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Spinal Cord Infarct

Summary

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  • Acute onset of neurological deficits due to ischaemia of the spinal cord
  • Presents with sudden weakness, sensory loss, and autonomic dysfunction
  • Diagnosis relies on clinical presentation and MRI findings

Pathophysiology

  • Caused by interruption of blood supply to the spinal cord, leading to tissue ischaemia and necrosis
  • Common aetiologies:
    • Atherosclerosis of spinal arteries
    • Embolic events
    • Aortic dissection or surgery
    • Vasculitis
    • Hypotension or hypoperfusion states

Demographics

  • Rare condition, accounting for 1-2% of all strokes
  • More common in older adults (>60 years)
  • Slight male predominance
  • Risk factors:
    • Hypertension
    • Diabetes mellitus
    • Smoking
    • Hyperlipidaemia

Diagnosis

  • Clinical presentation:
    • Sudden onset of neurological deficits
    • Bilateral weakness or paralysis
    • Sensory loss below the level of infarction
    • Autonomic dysfunction (e.g., urinary retention, bowel incontinence)
  • Differential diagnosis:
    • Transverse myelitis
    • Spinal cord compression
    • Guillain-Barré syndrome
  • Laboratory tests:
    • CSF analysis to rule out infectious causes
    • Serum inflammatory markers

Imaging

  • MRI is the gold standard for diagnosis
    • T2-weighted and STIR sequences:
    • Hyperintense signal within the spinal cord
    • "Owl's eyes" appearance in axial views (central grey matter involvement)
    • Diffusion-weighted imaging (DWI):
    • Restricted diffusion in acute phase
    • Contrast-enhanced T1-weighted:
    • Minimal or no enhancement in acute phase
  • CT angiography:
    • Useful for identifying vascular abnormalities or aortic dissection
  • Spinal angiography:
    • May be considered in select cases to identify vascular malformations

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  • 40-year-old patient with a cardiac myopathy presented with sudden onset lower back pain and lower limb weakness.
  • MRI showed an anterior lower thoracic cord lesion causing diffusion restriction representing an anterior spinal artery infarct.

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  • A 50-year-old patient presented with sudden onset lower limb weakness and sensory disturbance.
  • MRI showed a longitudinally extensive dorsal cord lesion (right paramedian) lesion with diffusion restriction.
  • There was signal change and enhancement within the dorsal aspect of the T10 vertebral body.
  • Appearances are consistent with an infarct in the territory of a right posterior spinal artery.

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  • A 50-year-old patient presented with acute upper back pain and quadriparesis.
  • MRI showed a long segment lesion with diffusion restriction without contrast enhancement.
  • The involvement of the anterior half of the cord was typical of an acute cord infarct in the territory of the anterior spinal artery.

Treatment

  • Acute management:
    • Maintain adequate spinal cord perfusion
    • Blood pressure control
    • Antiplatelet therapy (e.g., aspirin)
  • Supportive care:
    • Respiratory support if needed
    • Bladder and bowel management
    • Prevention of pressure ulcers
  • Rehabilitation:
    • Physical therapy
    • Occupational therapy
    • Speech therapy (if cervical cord involvement)
  • Secondary prevention:
    • Risk factor modification
    • Anticoagulation in select cases (e.g., cardioembolic source)
  • Prognosis:
    • Variable, depending on the extent and location of infarction
    • Complete recovery in 10-20% of cases
    • Residual deficits common in severe cases

Differential diagnosis

Differential Diagnosis Differentiating Feature
Transverse myelitis Central cord T2 signal without anterior horn predilection; cord swelling and enhancement; may extend over multiple vertebral segments without DWI restriction
Multiple Sclerosis Short cord lesion (<2 vertebral segments); dorsolateral location; multiple periventricular and juxtacortical brain lesions; no restricted diffusion
Compressive myelopathy MRI shows structural compression from disc, osteophyte, or mass; deformity of cord contour; no restricted diffusion acutely
Spinal epidural abscess Rim-enhancing epidural collection displacing the thecal sac; restricted diffusion in the abscess cavity; cord oedema secondary to compression
Spinal cord tumour Intramedullary expansile mass with cord enlargement; heterogeneous enhancement; no restricted diffusion
Acute Disseminated Encephalomyelitis Bilateral white matter T2 lesions in brain and spinal cord; no cord restricted diffusion; no owl-eye or pencil-like DWI pattern