Anterior Spinal Cord Infarct in a Pediatric Patient and its Diagnostic Challenges
Tam Nguyen1, Alice Rhee1, Gregory Aaen2
1Loma Linda University, 2Loma Linda University School of Medicine
Objective:
To describe a case of anterior spinal cord infarct in a pediatric patient.
Background:
A 13-year-old previously healthy female developed acute onset of chest pain, back pain, and shortness of breath during soccer practice. Within 6 hours, she presented to the Emergency Department with bilateral leg weakness and inability to void. On exam, she was paraplegic with reduced lower extremity reflexes. Initial workup included a normal CT spine, MRI pan-spine and lumbar puncture.
Results:
Following IVIG course to empirically treat for acute inflammatory demyelinating polyneuropathy (AIDP), symptoms progressed with a T10 sensory level. Pain and temperature sensation were absent while vibration and proprioception were preserved. Repeat MRI spine with diffusion-weighted imaging (DWI) obtained one week later showed a longitudinal ventral cord signal abnormality from T1-T6, suggestive of anterior spinal artery infarct. Spinal angiogram showed angiographic signs of cervico-thoracic subacute infarct.
Conclusions:
Spinal cord infarction is rarely encountered in the pediatric population. It presents diagnostic challenges given variability in clinical presentation and shared features with other cord pathologies. Risk factors include recent aortic surgery, trauma and congenital heart disease; limited cases have been described in previously healthy children. The initial clinical history involving insidious, gradually progressive lower extremity weakness favored transverse myelitis or AIDP. However, the pattern of sensory findings in this case were characteristic for anterior spinal artery syndrome given relative preservation of dorsal column modalities. In our case, follow up DWI-MRI spine was obtained given high clinical suspicion despite the negative initial MRI. Previous literature has described variable sensitivity for MRI in diagnosing anterior spinal infarction within the first 24 hours. Our case highlights the importance of maintaining a broad differential diagnosis and recognizing clinical features of spinal artery pathology. With high clinical suspicion of spinal infarction, follow up imaging with DWI-MRI should be considered for establishing the diagnosis.