Acute spinal cord ischemic stroke; A rare but potentially devastating stroke emergency in young healthy adults

Introduction: Acute spinal cord infarction represents 1% of all strokes. The neurological presentation of spinal cord infarction is defined by vascular territory i.e. anterior or posterior spinal arteries. A broad spectrum of diseases can cause spinal cord infarction, most common cause is surgical repair or diseases of the thoracoabdominal aorta. MRI of the spine shows hyperintensities on T2WI, restricted diffusion on DWI and vertebral body infarction adjacent to a cord signal abnormality. Poor prognostic factors for recovery are severe impairment at presentation, female sex, advanced age, and lack of improvement in the first 24 hours. We describe clinical presentation, radiological findings and 3-month outcome of four patients who presented with ischemic spinal cord infarction. Methods: We retrospectively analysed our prospectively collected data and found four cases of spinal cord infarction for the period of May 2020 to April 2021. Total of 1,326 stroke patients (1125 i.e. 85% ischemic and 201 i.e. 15% haemorrhagic) were admitted in Hamad General Hospital. At our centre, spinal cord infarction accounts 0.30% of total stroke and 0.35% of ischemic strokes. We describe four young patients, presented with abrupt onset of focal neurologic deficit. Their MRI of the spine revealed hyperintensity signals in T2WI, restricted diffusion on DWI of spinal cord. Two patients had vertebral artery occlusion or dissection. One patient was discharged home and three patients underwent multidisciplinary rehabilitation program. Discussion: Spinal cord infarction may present with acute paraparesis or quadriparesis with devastating consequences. Blood flow to the spinal cord is influenced by perfusion pressure. The most common cause of spinal cord infarction in this case series was vertebral artery dissection or occlusion. Our case series suggests early recognition of spinal cord stroke, appropriate investigations and early treatment with further rehabilitation could improve patient outcome. Conclusion: Spinal cord infarction, a rare but devastating condition, represents 1% of all strokes but 0.3% of total strokes at our centre. Early recognition of spinal cord ischemia especially when presenting with abrupt onset focal neurological deficit, focus on underlying pathology with appropriate imaging and further investigations, secondary stroke prevention and rehabilitation are vital factors to improve neurological recovery. Future randomized trails are needed to establish the efficacy and safety of drug therapy including rt-PA in spinal cord infarction. Abbreviations: ASA: Anterior spinal artery; PSA: Posterior spinal artery; MRI: Magnetic resonance imaging; MRA: Magnetic resonance arteriogram; DWI: Diffusion weighted imaging; ICP: Intra-cranial pressure.

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Spinal Cord Infarction in the Region of the Posterior Spinal Artery After Embolization for Vertebral Artery Dissection

Operative Neurosurgery ◽

10.1093/ons/opy026 ◽

2018 ◽

Vol 15 (6) ◽

pp. 701-710 ◽

Cited By ~ 2

Author(s):

Wataro Tsuruta ◽

Tetsuya Yamamoto ◽

Go Ikeda ◽

Masayuki Sato ◽

Yoshiro Ito ◽

...

Keyword(s):

Spinal Cord ◽

Vertebral Artery ◽

Coil Embolization ◽

Univariate Analysis ◽

Posterior Inferior Cerebellar Artery ◽

Vertebral Artery Dissection ◽

Endovascular Surgery ◽

Artery Dissection ◽

Spinal Cord Infarction ◽

Posterior Spinal Artery

AbstractBACKGROUNDEndovascular surgery for vertebral artery dissections (VADs) carries the risk of spinal cord infarction (SCI). Although SCI in the region of the anterior spinal artery (ASA) has been reported, SCI in the region of the posterior spinal artery (PSA) is rare.OBJECTIVETo investigate PSA infarction after endovascular surgery for VAD.METHODSInfarction in the region of the PSA after endovascular surgery for VADs carried out in consecutive 21 cases was investigated. The variables of aneurysmal location, status, intra-aneurysmal thrombosis, antithrombotic therapy, and endovascular procedure were investigated in relation to the occurrence of spinal cord or brain stem infarction.RESULTSThirteen cases were unruptured aneurysms, and 8, ruptured aneurysms. The endovascular surgical method was internal trapping in 10 cases, stent-assisted coil embolization in 8 cases, and proximal occlusion (PO) in 3 cases. Periprocedural symptomatic infarction was detected in 4 of the 21 cases (19%): 3 SCIs and 1 lower medulla infarction, after 1 stent-assisted coil embolization and 3 PO. All 3 symptomatic SCIs were PSA infarction. On univariate analysis, the variables of posterior inferior cerebellar artery-involved-type, PO, and intraprocedural proximal flow arrest were significantly correlated with occurrence of PSA infarction.CONCLUSIONPSA infarction after endovascular surgery for VAD seems not to be a rare potential complication. Insufficiency of collateral blood flow and artery-to-artery embolism due to intraprocedural flow stagnation of the VA seem to be the possible mechanisms of PSA infarction in addition to previously reported mechanisms such as direct obliteration by the embolic materials and extended thrombosis of the VA stump.

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Spinal Cord Ischemia due to Vertebral Artery Dissection

Rivista di Neuroradiologia ◽

10.1177/197140090501800318 ◽

2005 ◽

Vol 18 (3) ◽

pp. 390-394

Author(s):

M. Bergui ◽

G. Ventilii ◽

F.M. Ferrio ◽

D.R. Daniele ◽

G.B. Bradač

Keyword(s):

Spinal Cord ◽

Differential Diagnosis ◽

Vertebral Artery ◽

Grey Matter ◽

Spinal Cord Ischemia ◽

Vertebral Artery Dissection ◽

Cervical Cord ◽

Artery Dissection ◽

Spinal Cord Infarction ◽

Central Regions

We reviewed clinical and neuroradiological findings in 37 consecutive patients with cervical cord infarction due to vertebral artery dissection diagnosed at our institution from 1996 to 2004. Four patients had clinical and neuroradiological findings consistent with spinal cord ischemia. Three patients had “pencil-like” infarction at C3-C5 level; one patient had an infarction of the anterior horns of the spinal grey matter at C3-C4 level. Symptoms were crural sensory deficit with mild tetraparesis and proximal strength deficit of the arms, respectively. Spinal cord infarction complicated vertebral artery dissection in about 10% of patients of our series. Infarctions involved the most central regions of the spinal cord, with relative sparing of the peripheral white matter tracts. Clinical and MRI pictures were almost typical, and consistent with a hemodynamic mechanism for the lesions. Vertebral artery dissection must be considered in the differential diagnosis in patients with cervical cord infarction.

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Endovascular treatment with tirofiban during the acute stage of cervical spinal cord infarction due to vertebral artery dissection

Journal of Spinal Cord Medicine ◽

10.1080/10790268.2017.1422880 ◽

2018 ◽

Vol 43 (1) ◽

pp. 130-133

Author(s):

Yuanling Wu ◽

Wenxian Li ◽

Xiaomei Xie ◽

Zhen Jing ◽

Weibiao Lu ◽

...

Keyword(s):

Spinal Cord ◽

Endovascular Treatment ◽

Vertebral Artery ◽

Cervical Spinal Cord ◽

Vertebral Artery Dissection ◽

Acute Stage ◽

Artery Dissection ◽

Spinal Cord Infarction

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Abstract 1122‐000032: Spinal Cord Infarction a Young Patient with a Hypoplastic Vertebral Artery

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000032 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Ammar Jum'ah ◽

Hassan Aboul Nour ◽

Daniel Miller

Keyword(s):

Risk Factors ◽

Spinal Cord ◽

Vertebral Artery ◽

Cervical Spinal Cord ◽

Vertebral Artery Dissection ◽

Vascular Risk Factors ◽

Cervical Cord ◽

Artery Dissection ◽

Spinal Cord Infarction ◽

Vascular Risk

Introduction : Rare presentation of disease processes is absolutely intriguing to the human mind. Spinal cord infarction is abundantly reported to be secondary to cardiological procedures, patients carrying multiple vascular risk factors and vertebral artery dissections. But for it to happen in a patient who is young, relatively healthy and without vascular risk factors is quite interesting. Herein, we present the case of a patient presented with bilateral upper extremity weakness, who has a hypoplastic right vertebral artery that has coincided with him being a professional gamer with exerting compression from video‐gaming posturing of “forward leaning with neck hyperextension”, resulting in cervical spinal cord infarction. Methods : Case report Results : Vertebral artery dissection was excluded by CTA and MRA. our hypothesis was that the patient is a professional gamer and his posture of leaning forward and neck hyper‐extension had a role in inducing his spinal cord infarction given the fact of him having a hypoplastic right vertebral artery. Conclusions : Vertebral artery disease is a well‐recognized cause of ischemia in the posterior cerebral circulation. Recently, however, cervical cord infarction, albeit being extremely rare, has been increasingly reported as a complication of vertebral artery diseases such as dissection. Awareness must be raised that such condition can also happen in the young population due to compression of the vertebral arteries, especially when one is hypoplastic.

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Restricted Diffusion in Spinal Cord Infarction Demonstrated by Magnetic Resonance Line Scan Diffusion Imaging

Stroke ◽

10.1161/strokeaha.111.624023 ◽

2012 ◽

Vol 43 (2) ◽

pp. 532-535 ◽

Cited By ~ 21

Author(s):

Raul G. Nogueira ◽

Rafael Ferreira ◽

P. Ellen Grant ◽

Stephan E. Maier ◽

Walter J. Koroshetz ◽

...

Keyword(s):

Spinal Cord ◽

Magnetic Resonance ◽

Resonance Line ◽

Diffusion Imaging ◽

Restricted Diffusion ◽

Spinal Cord Infarction ◽

Line Scan

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Unilateral right occipital condyle to C2 level spinal cord infarction associated with ipsilateral vertebral artery stenosis and contralateral vertebral artery dissection: a case report

Journal of Spinal Cord Medicine ◽

10.1179/107902610x12883422813543 ◽

2011 ◽

Vol 34 (1) ◽

pp. 118-121 ◽

Cited By ~ 5

Author(s):

Chin-Man Wang ◽

Wei-Lun Tsai ◽

Yang-Lan Lo ◽

Ji-Yih Chen ◽

Alice M-K Wong

Keyword(s):

Spinal Cord ◽

Case Report ◽

Vertebral Artery ◽

Vertebral Artery Dissection ◽

Artery Stenosis ◽

Occipital Condyle ◽

Artery Dissection ◽

Spinal Cord Infarction ◽

Vertebral Artery Stenosis

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Spinal cord infarction presenting as Brown-Séquard syndrome from spontaneous vertebral artery dissection: a case report and literature review

BMC Neurology ◽

10.1186/s12883-019-1559-0 ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 1

Author(s):

Yang-Yang Meng ◽

Le Dou ◽

Chun-Mei Wang ◽

De-Zheng Kong ◽

Ying Wei ◽

...

Keyword(s):

Risk Factors ◽

Spinal Cord ◽

Vertebral Artery ◽

Vertebral Artery Dissection ◽

Artery Dissection ◽

Spinal Cord Infarction ◽

Black Blood ◽

Middle Aged ◽

Aged Patients ◽

Brown Sequard Syndrome

Abstract Background Spinal cord infarction (SCI) is rarely caused by vertebral artery dissection (VAD), which is an important cause of posterior circulation stroke in young and middle-aged patients. We report the case of a middle-aged patient without obvious risk factors for atherosclerosis who had SCI from right VAD. Case presentation An otherwise healthy 40-year-old man presented with acute right-sided body weakness. Six days earlier, he had experienced posterior neck pain without obvious inducement. Neurologic examination revealed a right Brown-Séquard syndrome. Magnetic resonance imaging (MRI) of the head was normal. Further, cervical spine MRI showed spinal cord infarction (SCI) on the right at the C1-C3 level. Three-dimensional high-resolution MRI (3D HR-MRI) volumetric isotropic turbo spin echo acquisition (VISTA) scan showed evidence of vertebral artery dissection (VAD). The patient was significantly relieved of symptoms and demonstrated negative imaging findings after therapy with anticoagulation (AC) and antiplatelets (AP) for 3 months. Conclusions The possibility of vertebral artery dissection (VAD) should be considered in the case of young and middle-aged patients without obvious risk factors for atherosclerosis. Furthermore the VISTA black blood sequence plays an important role in the pathological diagnosis of vertebral artery stenosis. Early correct diagnosis and active therapy are crucial to the prognosis.

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