This condition is uncommon but usually presents with profound neurological signs and symptoms, and the prognosis is poor.
Epidemiology
As opposed to acute myelopathies 4,5, acute spinal cord ischemia syndrome represents only 5-8% of all strokes 7. The demographic of affected individuals will reflect the underlying cause, although generally, there are two peaks with different etiologies. The most common cause for the development of this condition in children is trauma or cardiac malformations 5. In adults, the most common cause is atherosclerosis, usually associated with other complications (e.g. thoracoabdominal aortic aneurysm, thromboembolism).
Clinical presentation
The majority of patients developed symptoms quickly, with maximal symptomatology reached within 12 hours for >50% of patients and within 72 hours for the vast majority of patients.
The initial symptoms include back pain (60-70%), loss of bladder control (60%) and bowel control (40%) 4,5. It may seem counter-intuitive, but the first symptom that is felt is usually sensory (60%) despite the anterior cord being most commonly involved 4,5.
However, a patient with a higher cord lesion will experience acute and severe neurological impairment with the inability to walk due to paraplegia and paraparesis, as well as quadriplegia or tetraplegia. Almost all patients have some sensory disturbance, and the majority of patients require urinary catheterization.
It is possible to classify neurological impairments into several distinct entities, although there is great variability in the nomenclature and description of these entities. There are two common patterns of spinal cord infarcts based on which spinal artery is involved, an approach that is perhaps simplistic, but most people would agree with.
Anterior spinal artery syndrome (most common)
- bilateral (due to single midline anterior spinal artery)
- paralysis below affected level (initially flaccid; later spastic)
- pain and temperature sensory loss
- relative sparing of proprioception and vibration (dorsal columns)
- incomplete
- anterior horn syndrome
- man-in-the-barrel syndrome if cervical
- Posterior spinal artery syndrome
- usually unilateral (due to paired posterior spinal arteries)
- complete sensory loss at the level of injury
- proprioception and vibration loss below level
- minimal, typically transient, motor symptoms
There are a number of less common presentations, which vary widely in terminology, including :
- central spinal cord infarct (often the result of severe hypotension)
- sulcal artery syndrome (resulting in a partial Brown-Sequard syndrome)
- complete transverse spinal cord infarction (aka transverse medullary infarction).