Spinal cord infarcts are rare, representing only 5-8% of acute myelopathies and 1-2% of strokes. They are poorly recognized, leading to frequent treatment of acute ischemia with steroids. Here we present three illustrative cases emphasizing the importance of expedient recognition of spinal cord stroke.
A 42-year-old presented with severe back pain preceding sudden onset of flaccid weakness of the lower extremities. Inflammatory findings on lumbar puncture triggered both post-stroke and steroid therapy before angiogram revealed causative L2 segmental artery thrombus, which did not change with integrilin infusion. Stat imaging of brain and spinal cord were negative but repeat imaging days later showed diffuse lower thoracic cord signal change on DWI and STIR most prominent below T10.
A 44-year-old presented with shooting neck pain followed by precipitous decline to arm diplegia. After initial imaging and lumbar puncture, she was pulsed with steroids and sent to rehab where repeat MRI revealed a small left C3 lesion. The extensive inflammatory workup remained negative and subsequent MRI revealed a lesion affecting grey matter and anterior horn from C4-7.
A 56-year-old experienced sudden-onset, severe left leg weakness but was initially treated only for newly diagnosed congestive heart failure. In follow-up, he had persistent leg weakness, hyperreflexia, and new urinary symptoms. Imaging revealed focal T2 hyperintensity ventrally within the cord at T5 and T8 and though initially referred for transverse myelitis workup, spinal cord infarct was eventually diagnosed.
Spinal cord strokes are known to produce mild inflammatory findings on lumbar puncture and frequently do not produce reliable MRI findings until 24-48 hours after the initial insult, leading to missed diagnoses and frequent treatment for inflammatory myelitis (i.e. steroids). These cases illustrate the importance of maintaining suspicion for stroke in appropriate presentations of acute-onset weakness that may reduce potential steroid-mediated exacerbation of ischemia.