Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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December 4, 2014
Spinal Cord Infarct
- Spinal cord infarct is rare and accounts for only 1% of all strokes.
- Cervical spinal cord infarcts are exceptionally rare, given the cord's rich anastomotic arterial network. Arterial supply derives from the intracranial vertebral arteries (VAs) and posterior inferior cerebellar arteries (PICAs) in the upper cervical cord, and from radicular artery branches in the middle and lower cord. Radicular branches may arise from the cervical VAs and deep and ascending cervical arteries. Also, a rich anastomotic network exists with the ascending pharyngeal and occipital arteries.
- Causes of cervical cord infarction include atherosclerosis, vertebral artery occlusion or dissection, trauma, fibrocartilaginous embolism, cervical cord herniation, and surgery.
- Clinical Features: In most patients, the first neurological symptom is acute paraplegia or tetraparesis, and may be associated with acute pain.
- Key Diagnostic Features:
- Early-stage MRI shows a linear T2 hyperintensity in the ventral/central spinal cord (visible in about 50% of patients) involving gray matter and typically sparing its outer rim, with edema of the entire cord in a subacute phase followed by medullary atrophy in later stages.
- Variable enhancement after gadolinium injection or confluent hemorrhagic foci may be seen in the subacute stage, as seen in this case.
- Similar to brain ischemia, DWI shows the infarct at an early stage compared with T2WI, and helps in its differential diagnosis. Still, spinal cord DWI remains technically challenging due to local field inhomogeneities.
- DDx:
- Venous congestive edema (ie, dural AV fistula)
- Viral, postviral, or autoimmune myelitis
- Cord neoplasm
- Imaging may be indistinguishable from the various etiologies of “transverse myelitis”, but the acute onset of symptoms is the key for the diagnosis.
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