Acute Quadriparesis in a Smoker

A 51-year-old woman was seen for evaluation of transverse myelitis. Pertinent medical history included hypertension, hyperlipidemia, and 50 pack-years of cigarette smoking. Two months earlier, she was shopping and suddenly had excruciating pain in her upper back. Two hours later, severe weakness of both hands developed abruptly. Over the next 8 hours, severe paraparesis and urinary retention developed, with inability to lift legs against gravity, and she reported a T1 sensory level. Review of the outside magnetic resonance imaging noted key imaging findings, including initially normal magnetic resonance imaging within the first 12 hours of symptom presentation, and subsequent magnetic resonance imaging on day 3 showing anterior pencil-like hyperintensity on sagittal view and anterior U- or V-shaped pattern on axial view (termed U/V pattern), without associated gadolinium enhancement. Diffusion-weighted imaging was not obtained. Given the rapid, severe deficits with pain, spinal cord infarction was considered most likely, and the magnetic resonance imaging findings were typical. Magnetic resonance angiography of the neck with T1-fat-saturated views was obtained and did not show dissection. Laboratory evaluation showed a low-density lipoprotein value of 124 mg/dL and hemoglobin A1c of 6.2%. The patient was diagnosed with probable spontaneous spinal cord infarction on the basis of diagnostic criteria. The patient was counselled on smoking cessation, started on an aspirin and statin regimen, and followed up by a primary care provider for management of vascular risk factors. Residual neuropathic pain was treated with high doses of gabapentin. Importantly, unnecessary additional immunotherapy was avoided by establishing the correct diagnosis. Spontaneous spinal cord infarctions are an underrecognized cause of acute myelopathy. Spinal cord infarctions generally occur in older persons, with most cases associated with typical vascular risk factors, arterial dissection, and fibrocartilaginous embolism; historically, cases were often secondary to syphilis.