Sonia Bellara1, Robert Sacks1, Hyunah Choi1, Elizabeth Chernyak2, Nuri Jacoby2, Steven Levine1
1SUNY Downstate Medical Center, 2Maimonides Medical Center
Background:
Spinal infarcts in the setting of anatomical variants with absent arteries of Lazorthes and Adamkiewicz are rare and seldom reported.
Design/Methods:
We report a healthy twenty-two-year-old man who presented after severe neck pain following strenuous weight lifting, with bilateral arm followed by leg weakness, and respiratory failure requiring intubation. Initial exam was significant for absent movement in the arms and decreased movement in the left > right leg, a C3 sensory level, and hyporeflexia.
MRI cervical/thoracic/lumbar spine with and without gadolinium revealed an extensive, thin, anterior, non-enhancing T2 hyperintensity from the craniocervical junction to T7. CSF analysis was unremarkable. He was started on steroids and plasmapheresis for possible NMOSD though anterior spinal artery infarct was high in the differential. Repeat MRI was DWI positive with ADC correlate. A spinal angiogram revealed the absence of intracranial vertebral artery, PICA, a. of Lazorthes, and a. of Adamkiewicz. Steroids and plasmapheresis were discontinued after anti-MOG and NMO antibodies were negative.
Results:
This patient’s presentation exemplifies the challenge of determining whether the underlying etiology is demyelinating versus ischemic. Given that the patient's symptoms developed in the setting of strenuous weight lifting, the diagnosis of spinal cord infarct is likely. The most probable mechanism is dissection and occlusion of the vertebral artery with subsequent occlusion of the anterior spinal artery. The anatomic variants seen in the spinal angiogram may have worsened the presentation due to fewer collaterals present. Another mechanism which was considered, although less likely, was fibrocartilaginous embolism. During the hospital course the patient regained motor function in the legs and some function in the arms but continued to require mechanical ventilation.
Conclusions:
Acute intramedullary ischemia should be considered in younger patients without vascular risk factors if the clinical presentation and diagnostic work-up are suggestive, even when a thrombus or dissection is not seen on angiogram.