Spinal cord infarction: Clinical and imaging insights from the periprocedural setting

Zalewski, Nicholas L.; Rabinstein, Alejandro A.; Krecke, Karl N.; Brown, Robert D.; Wijdicks, Eelco F. M.; Weinshenker, Brian G.; Doolittle, Derrick A.; Flanagan, Eoin P.

doi:10.1016/j.jns.2018.03.029

Cited by 31 publications

(38 citation statements)

References 33 publications

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“…Also, imaging timing could not be standardized in this retrospective study and can impact the presence or absence of a T2-lesion and its length. 3,[23][24][25][26] Other gadolinium enhancement patterns (e.g., ventral subpial enhancement in a braid-like pattern in sarcoid myelopathy) 21,27 or unenhanced T2-patterns (e.g., bright spotty lesions with AQP4-IgG seropositive NMOSD, cap sign in ependymoma) 28,29 have also been associated with myelopathies, but assessment of such cases was not undertaken in this study.…”

Section: Evaluation Of Neuroimaging Alone Is Insufficient For Diagnosismentioning

confidence: 99%

Utility of MRI Enhancement Pattern in Myelopathies With Longitudinally Extensive T2 Lesions

et al. 2021

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ObjectiveTo determine if MRI gadolinium enhancement patterns in myelopathies with longitudinally-extensive T2-lesions can be reliably distinguished and assist in diagnosis.MethodsWe retrospectively identified 74 Mayo Clinic patients (1/1/1996–12/31/2019) fulfilling the following criteria: 1) Clinical myelopathy; 2) MRI spine available; 3) Longitudinally-extensive T2-hyperintensity (≥3 vertebral segments); and 4) Characteristic gadolinium enhancement pattern associated with a specific myelopathy etiology. Thirty-nine cases with alternative myelopathy etiologies, without previously described enhancement patterns, were included as controls. Two independent readers, educated on enhancement patterns, reviewed T2-weighted and post-gadolinium T1-weighted images and selected the diagnosis based on this knowledge. These were compared to the true diagnoses and agreement was measured with Kappa coefficient.ResultsAmong all cases and controls (n=113), there was excellent agreement for diagnosis using post-gadolinium images (Kappa, 0.76) but poor agreement with T2-weighted characteristics alone (Kappa, 0.25). A correct diagnosis was more likely when assessing post-gadolinium image characteristics than with T2-weighted images alone (Rater 1: 100/113 [88%] vs 61/113 [54%] correct, p<0.0001; Rater 2: 95/113 [84%] vs 68/113 [60%] correct, p<0.0001). Of the 74 with characteristic enhancement patterns, 55 (74%) were assigned an alternative incorrect or non-specific diagnosis when originally evaluated in clinical practice, 12 (16%) received immunotherapy for non-inflammatory myelopathies, and 2 (3%) underwent unnecessary spinal cord biopsy.ConclusionsMisdiagnosis of myelopathies is common. The gadolinium enhancement patterns characteristic of specific diagnoses can be identified with excellent agreement between raters educated on this topic. This study highlights the potential diagnostic utility of enhancement patterns in myelopathies with longitudinally-extensive T2-lesions.

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Section: Evaluation Of Neuroimaging Alone Is Insufficient For Diagnosismentioning

confidence: 99%

Utility of MRI Enhancement Pattern in Myelopathies With Longitudinally Extensive T2 Lesions

et al. 2021

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“…Periprocedural Spinal Cord Infarction SCI has long been recognized as a complication of aortic surgery, but SCI can also complicate a variety of other procedures. [14][15][16] Open or endovascular thoracic aortic aneurysm or dissection repair remain the most common contributors, with SCI complicating repair in <1% of cases in a large retrospective series, 17 but others generally reporting a more frequent rate of ischemia ($2-7%). 18,19 The etiology in surgical cases not directly involving the aorta or its branches is felt to be related to vessel trauma, systemic hypotension, baseline peripheral arterial disease with concurrent hypotension, embolism, or epidural injection with local vasoactive (epinephrine) medication (►Table 1).…”

Section: Arterial Ischemiamentioning

confidence: 99%

“…While most cases involve a clinical nadir in the immediate postprocedural setting (80%), delayed symptom onset days after the procedure can be seen. 16 Deficits from periprocedural SCI are typically bilateral and severe (two-thirds para-or quadriplegic), 16 but less severe, incomplete, and asymmetric presentations can be seen. Emergent imaging (high-quality CT or MRI spine) should be performed to rule out spinal epidural hematoma or other mechanisms such as decompensation of cord compression from spondylosis during anesthesia.…”

Section: Arterial Ischemiamentioning

confidence: 99%

“…Close analysis of MRI in periprocedural SCI has provided important understanding of findings in spontaneous SCI cases. 16,20 It is particularly important to recognize that MRI within the first day can be normal despite severe deficits, a variety of T2-hyperintensity patterns can be seen, and gadolinium enhancement of the SCI and adjacent nerves roots often occurs subacutely. 16 Diagnostic criteria for both periprocedural and spontaneous SCI have been proposed to help make an accurate diagnosis (►Table 2).…”

Section: Arterial Ischemiamentioning

confidence: 99%

“…16,20 It is particularly important to recognize that MRI within the first day can be normal despite severe deficits, a variety of T2-hyperintensity patterns can be seen, and gadolinium enhancement of the SCI and adjacent nerves roots often occurs subacutely. 16 Diagnostic criteria for both periprocedural and spontaneous SCI have been proposed to help make an accurate diagnosis (►Table 2). 20 Treatment strategies for spinal cord ischemia aim at increasing cord perfusion with blood pressure augmentation (e.g., goal mean arterial pressure > 90 mm Hg, or increase by 10-20 mm Hg increments observing for benefit) and cerebrospinal fluid (CSF) drainage (e.g., drain 10 cc every 2-4 hours, goal CSF pressure 8-12 mm Hg depending on response).…”

Section: Arterial Ischemiamentioning

confidence: 99%

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Vascular Spinal Cord Disorders

English

Zalewski

2021

Semin Neurol

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Vascular disorders of the spinal cord are uncommon yet under-recognized causes of myelopathy. Etiologies can be predominantly categorized into clinical and radiographic presentations of arterial ischemia, venous congestion/ischemia, hematomyelia, and extraparenchymal hemorrhage. While vascular myelopathies often produce significant morbidity, recent advances in the understanding and recognition of these disorders should continue to expedite diagnosis and proper management, and ideally improve patient outcomes. This article comprehensively reviews relevant spinal cord vascular anatomy, clinical features, radiographic findings, treatment, and prognosis of vascular disorders of the spinal cord.

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Characteristics of Spontaneous Spinal Cord Infarction and Proposed Diagnostic Criteria

et al. 2019

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IMPORTANCE Spinal cord infarction (SCI) is often disabling, and the diagnosis can be challenging without an inciting event (eg, aortic surgery). Patients with a spontaneous SCI are often misdiagnosed as having transverse myelitis. Diagnostic criteria for SCI are lacking, hindering clinical care and research. OBJECTIVE To describe the characteristics of spontaneous SCI and propose diagnostic criteria. DESIGN, SETTING, AND PARTICIPANTS An institution-based search tool was used to identify patients evaluated at Mayo Clinic, Rochester, Minnesota, from January 1997 to December 2017 with a spontaneous SCI. Patients provided written consent to use their records for research. Participants were 18 years and older with a diagnosis of spontaneous SCI (n = 133), and controls were selected from a database of alternative myelopathy etiologies for validation of the proposed diagnostic criteria (n = 280). MAIN OUTCOMES AND MEASURES A descriptive analysis of SCI was performed and used to propose diagnostic criteria, and the criteria were validated. RESULTS Of 133 included patients with a spontaneous SCI, the median (interquartile range) age at presentation was 60 (52-69) years, and 101 (76%) had vascular risk factors. Rapid onset of severe deficits reaching nadir within 12 hours was typical (102 [77%]); some had a stuttering decline (31 [23%]). Sensory loss occurred in 126 patients (95%), selectively affecting pain/temperature in 49 (39%). Initial magnetic resonance imaging (MRI) spine results were normal in 30 patients (24%). Characteristic MRI T2-hyperintense patterns included owl eyes (82 [65%]) and pencil-like hyperintensity (50 [40%]); gadolinium enhancement (37 of 96 [39%]) was often linear and located in the anterior gray matter. Confirmatory MRI findings included diffusion-weighted imaging/apparent diffusion coefficient restriction (19 of 29 [67%]), adjacent dissection/occlusion (16 of 82 [20%]), and vertebral body infarction (11 [9%]). Cerebrospinal fluid showed mild inflammation in 7 of 89 patients (8%). Diagnostic criteria was proposed for definite, probable, and possible SCI of periprocedural and spontaneous onset. In the validation cohort (n = 280), 9 patients (3%) met criteria for possible SCI, and none met criteria for probable SCI. CONCLUSIONS AND RELEVANCE This large series of spontaneous SCIs provides clinical, laboratory, and MRI clues to SCI diagnosis. The diagnostic criteria proposed here will aid clinicians in making the correct diagnosis and ideally improve future care for patients with SCI. The validation of these criteria supports their utility in the evaluation of acute myelopathy.

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Spinal cord infarction: Clinical and imaging insights from the periprocedural setting

Cited by 31 publications

References 33 publications

Utility of MRI Enhancement Pattern in Myelopathies With Longitudinally Extensive T2 Lesions

Utility of MRI Enhancement Pattern in Myelopathies With Longitudinally Extensive T2 Lesions

Vascular Spinal Cord Disorders

Characteristics of Spontaneous Spinal Cord Infarction and Proposed Diagnostic Criteria

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