Objective:

To describe spontaneous spinal cord infarct (SCI) in the setting of deep vein thrombosis (DVT) and patent foramen ovale (PFO).

Background:

SCIs constitute <1% of acute ischemic strokes and ~6% of acute myelopathies. Spontaneous SCI has been defined as an ischemic event occurring without an apparent triggering factor, e.g. trauma or medical procedures. Although the etiology of this condition is unclear, case reports suggest a potential link to PFO.

Design/Methods:

N/A

Results:

We present a 64-year-old female with a history of hypertension, obstructive sleep apnea, and morbid obesity who developed acute numbness, paresthesiae and weakness of the right arm while driving, progressing to the right leg and then the left side of her body within seconds. She pulled over, honked the horn, and  Emergency Medical Services were notified. In the Emergency Department, she had flaccid quadriplegia with areflexia and a C4 sensory level. Magnetic resonance imaging of neuraxis showed 3 small acute brain infarcts (right nodulus, left occipital cortex, right thalamus) and a C2-C6 longitudinal lesion with restricted diffusion. She had taken 4 commercial flights and 2 long-distance drives in the 10 days prior to her presentation. Venous ultrasound showed acute DVT in the right lower extremity on Day 3 of her hospitalization. Transesophageal echocardiogram  revealed an aneurysmal interatrial septum and a PFO with a small shunt at rest. Valsalva was not attempted. Exhaustive diagnostic workup including digital subtraction angiography, computerized tomography  of chest, abdomen and pelvis, cerebrospinal fluid studies, hypercoagulable tests, infectious and rheumatologic studies did not reveal other potential etiologies. Her RoPE score was only 5 but in the setting of concurrent DVT her PASCAL classification is PFO-probable stroke. She was treated with anticoagulation and PFO closure

Conclusions:

Paradoxical embolism is one of the pathophysiologic mechanisms of spontaneous SCI. Investigations for PFO and DVT should be considered when this condition is encountered.