“Crescent Moon” Sign in Complete Brown-Sequard Syndrome Caused by Spinal Cord Infarction
Daniel Moreno-Zambrano1, Ricardo Martinez1, Rafael Martinez2, Roberto Sanchez3, Ariol Labrada3
1Department of Neurology, Larkin Community Hospital, 2Escuela de Medicina, Universidad de Ciencia Medicas “Faustino Perez Hernandez” de Sancti Spiritus, 3Department of Neurology, Palmetto General Hospital
Objective:
To report a novel “Crescent Moon” sign in magnetic resonance imaging (MRI) in a rare case of complete Brown-Sequard Syndrome (BSS) caused by Spinal Cord Infarction (SCI).
Background:
SCI is uncommon and typically injures the anterior spinal artery (ASA) territory; posterior spinal artery (PSA) territory involvement is very rare. In the cervical spinal cord, the ASA branches off the vertebral arteries; the PSA from the posterior inferior cerebellar or vertebral arteries. SCI rarely causes BSS. When provoked, it manifests with a partial presentation consisting of ipsilateral hemiparesis, contralateral spinothalamic deficit, and sparing proprioception. In such cases, the pathogenesis is sulcal artery occlusion that spares the posterior column. We describe a novel “Crescent Moon” sign in MRI associated with complete BSS in SCI after vertebral artery occlusion (VAO). The likely mechanism was right ipsilateral ASA and PSA territory ischemia secondary to VAO.
Design/Methods:
A 74-year-old male with a history of smoking, hypertension, hyperlipidemia, head and neck radiation after mouth and pharyngeal cancer developed sudden onset right-sided weakness and left-sided numbness. Examination showed right-sided hemiplegia and proprioception loss, with left-sided temperature and pain sensation loss, compatible with BSS localizing to the right hemicord at the C2 level.
Results:
Plain and perfusion CT-Brain were unremarkable. Head and neck CTA revealed right VAO. Axial MRI view of the cervical spine showed a “Crescent Moon” shaped area of restricted diffusion in DWI and ADC sequences consistent with C1-C3 right hemicord acute ischemic infarct. After stroke work-up, it was determined the etiology was VAO secondary to progressive stenosis triggered by radiotherapy. The patient was acutely treated with mean arterial pressure augmentation, followed by dual antiplatelet, statins, and physical therapy.
Conclusions:
The “Crescent Moon” MRI pattern is associated with complete Brown-Sequard syndrome in SCI. To our knowledge, this sign has not been previously reported in the literature.