To emphasize the clinical presentation, delayed MRI findings, and the importance of maintaining clinical suspicion in diagnosing and managing acute spinal cord infarction

Acute spinal cord infarction is a rare, life-threatening condition that presents differently from cerebral stroke. Unlike cerebral infarcts, which show rapid onset, spinal cord infarctions typically begin with acute pain and progress to neurological deficits over hours to days. MRI with diffusion-weighted imaging (DWI) and contrast is essential for diagnosis, although changes in T2 signal intensity or enhancement can be delayed, necessitating repeat imaging when clinical suspicion remains high.

A 42-year-old male with hypertension and tobacco use presented with acute bilateral lower extremity weakness, numbness, and urinary retention following sharp, radiating pain from the T6-T7 region. Initial differential diagnoses included spinal infarction, transverse myelitis, and vascular or inflammatory causes. An MRI without contrast, performed 4 hours after onset, was unremarkable. A second MRI with contrast and DWI, performed 11 hours later, also showed no abnormalities. CSF analysis revealed elevated white cells (12/uL, 74% neutrophils), high protein (109 mg/dL), and normal glucose, with negative infectious and autoimmune panels. Empiric antibiotics and pulse steroids were initiated. A repeat MRI, 75 hours post-onset, showed restricted diffusion in the lower thoracic cord, consistent with spinal cord infarction. Spinal angiography revealed a right L2 segmental artery dissection or thrombus affecting the anterior spinal artery. It was concluded that the above CSF findings were likely inflammatory response to spinal cord ischemia. The patient was started on dual antiplatelet therapy, transitioning to Clopidogrel monotherapy after 3 months.

This case highlights the importance of maintaining suspicion for spinal cord infarction, especially when initial MRI findings are negative. Repeat imaging is essential for diagnosis.