Acute ischemic myelopathy treated with intravenous thrombolysis: Four new cases and literature review

Abstract

Background Intravenous thrombolysis is a well-established treatment of ischemic stroke within 4.5 h. However, its effectiveness in acute ischemic myelopathy is unknown. Purpose We describe a series of four acute ischemic myelopathy patients treated with intravenous thrombolysis within 4.5 h and review the current literature to explore this treatment feasibility, potential safety, and efficacy. Methods We reviewed all routinely collected clinical, radiological, and follow-up data of patients with a final acute ischemic myelopathy diagnosis who received acute intravenous thrombolysis in our stroke network. We also reviewed thrombolyzed acute ischemic myelopathy patients in the literature. Results Four patients (three women) aged 57 to 83 years presented with acute uni- or bilateral extremity paresis, considered initially as cerebral strokes in two of them. After excluding contraindications by brain imaging in three, spinal computed tomography in one and confirmation of acute ischemic myelopathy on spinal magnetic resonance imaging in one patient, intravenous thrombolysis was administered at 135, 190, 240, and 245 min accordingly. Subacute diffusion-weighted imaging-magnetic resonance imaging confirmed acute ischemic myelopathy in all but one patient. Favorable outcome was achieved in two patients rapidly and in three patients at three-month follow-up. We identified seven other thrombolyzed acute ischemic myelopathy patients in the literature, who showed variable recovery and no hemorrhagic complications. Conclusions With appropriate acute imaging, intravenous thrombolysis after acute ischemic myelopathy is feasible and potentially safe within 4.5 h. Given the potential of benefit of thrombolysis in acute ischemic myelopathy, this treatment warrants further efficacy and safety studies.

Spinal Cord Infarction: A Single Center Experience and the Usefulness of Evoked Potential as an Early Diagnostic Tool

“…Unlike the case of cerebral infarctions, an acute phase thrombolytic treatment protocol has not been standardized for SCI. Several case reports and ongoing clinical trials have been released, and a common emphasis in the reports is that acute thrombolytic treatment could be performed in a timely manner only if an accurate diagnosis is made prior to treatment (50)(51)(52)(53). Therefore, should a systematic acute phase treatment process be established in the future, the importance of an accurate early diagnosis of SCI will be emphasized even more.…”

Evaluation and Management of Acute Myelopathy

“…26 In patients with high suspicion for spontaneous SCI, empiric thrombolysis can be considered within the first few hours from onset and in the absence of major contraindications. 133 For drug-related myelitis, treatment withdrawal should be evaluated, with additional immunotherapy for the immune-mediated forms (e.g., TNF-α/immune checkpoint inhibitor-related). In patients with cancer who develop immune-mediated complications from checkpoint inhibitors, the risk/benefit of drug withdrawal should be carefully weighed.…”

Extended Window Thrombolysis in Acute Spinal Cord Ischemia

“…Due to the rarity and challenges in the timely recognition of acute ischemic myelopathy, no robust data are available to guide the therapeutic timeframe. IVT has been shown to be effective and safe in at least 13 case reports, when given within 4.5 h. 2,4 The vast majority of cases remain untreated even when presenting relatively early. In contrast to cerebral stroke, spinal cord infarction symptoms are often preceded or accompanied by acute pain and can develop over a longer period of time.…”

“…3 The time window for treatment of SCI is extrapolated from acute ischemic stroke trials. To our knowledge, all reported cases of SCI had thrombolytic therapy administered within 4.5 h. 2 Herein, we present a case of acute SCI treated with IVT administered beyond the suggested time window.…”

“…1 To date, there are no randomized trials to guide therapy. Most literature related to acute treatment of SCI is based on case reports and involves either intravenous thrombolysis 2 (IVT) or intra-arterial thrombolysis. 3 The time window for treatment of SCI is extrapolated from acute ischemic stroke trials.…”