Authors: Zalewski NL et al.
JAMA Neurol 2018 Sep 24
Hyperacute or acute onset was the most consistent clinical symptom.
Spinal cord infarction is an underrecognized etiology of myelopathy that is sometimes misdiagnosed as transverse myelitis (NEJM JW Neurol Mar 2018 and Neurology 2018; 90:e96). Investigators reviewed data from 133 adults (median age, 60; interquartile range, 52–69) with spontaneous spinal cord infarction in the past decade at one institution.
Nadir was reached within 4 hours in 56% of patients, within 4 to 12 hours in 21%, within 12 to 24 hours in 14%, and beyond 24 hours in 10%. A stuttering or stepwise decline was more common with presentation past 8 hours. Selective pain and temperature sensory loss was present in 39%, severe back/limb pain in 72%, and one or more vascular risk factor in 76%. Lumbar puncture showed mild elevation in white cells in 8%, mild-to-moderate elevation of protein in 74%, and oligoclonal bands in only 2%. MRI was initially normal in 24% when performed in the first 24 hours. Diffusion abnormalities were noted in 19 of 29 patients, gadolinium enhancement in 37 of 96 patients, and focal cystic myelomalacia in 31 of 82 on follow-up. Vascular imaging revealed specific abnormalities, such as vessel dissections or occlusions, in 16 of 82 patients. Hypercoagulable profile was present in 7 of 63 patients tested. Common suspected mechanisms included atherosclerosis (68%), fibrocartilaginous embolism (14%), aortic dissection (5%), and hypercoagulability (4%).
Proposed diagnostic criteria include rapid onset within 12 hours, or stuttering onset if course is more than 12 hours, and no history of trauma or preceding progressive myelopathy. Supportive criteria include an intramedullary T2-weighted hyperintensity, diffusion abnormality, an attributable vascular abnormality on imaging, a noninflammatory cerebrospinal fluid profile, and no alternative diagnoses.
Spinal cord infarction can manifest with various myelopathic syndromes, but these usually reach nadir within several hours. A stuttering course may be seen with relatively longer presentations. A minority of patients presented with the classic syndrome of anterior spinal cord infarction. Diffusion imaging added to spinal cord imaging can help with the diagnosis. Vascular imaging and hypercoagulable work-up revealed the etiology in some patients. Spinal cord infarction remains a clinical diagnosis.