Spinal Cord Infarction: Definition and Management

brain mri

Spinal cord infarction is a condition in which the spinal cord does not receive enough (or any) blood for nourishment and oxygenation. It is therefore a spinal cord stroke (equivalent to stroke or stroke).

Spinal cord infarction is very rare compared to stroke. However, it may lead to major neurological deficitsIncluding for ou tetraplegia.

Find out more about this little-known condition with dreadful consequences!

Anatomy: vascularization of the spinal cord

Before defining what a spinal cord infarction is, it is important to briefly recall some anatomical bases on the vascularization of the spinal cord, because it is on the latter that the whole physiopathology of the disease rests.

The vascularization of the spinal cord is one of the most complex in the human body, as the number of arteries that contribute to it is so great. This is essentially ensured by:

  • Two lateral posterior (dorsal) spinal arteries

They come from the vertebral artery (itself issued from the subclavian artery, sometimes directly from the aorta) and vascularize the posterior third of the spinal cord giving a rich anastomotic network from which are born perforating arteries.

  • A middle anterior (ventral) spinal artery

 

They come from the branches of vertebral arteries and ensure the vascularization of anterior two-thirds of the spinal cord.

This artery gives off few afferent arteries at the upper cervical region, but it gives rise to a large caliber artery at the lower thoracic region called «Adamkiewicz's artery».

 

What is spinal cord infarction?

Spinal cord infarction is an interruption or decrease in the blood supply to the spinal cord. There are two main types:

Global ischemia

The interruption of vascularization is secondary to a state of systemic low flow, especially in the event of cardiac arrest, prolonged severe hypotension or massive bleeding, for example.

Spinal ischemia usually predominates at the level of the thoraco-lumbar region (least perfused areas).

Focal ischemia

Here, the ischemia is localized at the level of the territory of one of the arteries supplying the marrow. Most often it is Adamkiewicz's artery which is affected, or one of the arteries of the thoraco-lumbar hinge.

What are the causes of spinal cord infarction?

Many situations can cause a spinal cord infarction:

  • Certain pathologies of the aorta (the artery at the origin of all the arteries of the body): in particular atheroma (deposit of fats in the arterial walls), the aortic dissection (tearing of the inner layer of the aorta called "intima", it is an absolute emergency involving the vital prognosis in the very short term), iatrogenic aortic injury (following aortic surgery or other thoracoabdominal invasive procedure) …
  • Spinal artery occlusion: in certain illnesses infectious (tuberculosis, Lyme disease, shingles, fungal meningitis, etc.), inflammatory (sarcoidosis, lupus, Sjögren's disease, etc.), toxiques, hematological or original iatrogenic.
  • Vertebral artery occlusion: remember that the vertebral arteries supply the two posterior spinal arteries and the anterior spinal artery. Their occlusion (atheroma, dissection, etc.) is therefore responsible for a reduction in the blood flow that reaches these arteries supplying the spinal cord.
  • Occlusion of thoracic and lumbar intercostal arteries (iatrogenic) : these arteries supply the middle anterior spinal artery.
  • Hemodynamic failure: this includes all situations where the heart can no longer ensure sufficient blood flow to perfuse the body's cells. Such a situation can be observed in particular in the event of myocardial infarction (heart attack), some heart rhythm disorders (supraventricular tachycardia, ventricular fibrillation, etc.), massive bleeding with collapse (severe hypotension), severe dehydration… All of these conditions can be complicated spinal cord infarction, although the latter is in the background (given the extreme seriousness of these pathologies).

 

 

 

What are the symptoms of spinal cord infarction?

Spinal cord infarction is very rare compared to cerebral infarctions, and this, because of the smaller size of the spinal cord (compared to that of the brain), the wealth of anastomoses in its arterial network and the rarity of atheromatous damage in the medullary arteries.

In the rare cases where a spinal cord infarction occurs, various symptoms appear depending on the seat of ischemia and its expanse.

Classically, spinal cord infarction is manifested by a anterior spinal syndrome characterized by the occurrence of:

  • Spinal pain abrupt or rapidly progressive onset.
  • Paraplegia (paralysis of the lower limbs) or acute quadriplegia (paralysis of 4 limbs).
  • Sub-lesional disorder of thermoalgesic sensitivity: that is, an inability to feel pain, heat, or cold in any part of the body innervated by the segment of the spinal cord below under the lesion.
  • Sphincter disorders such as urinary or faecal incontinence.

other neurological symptoms whose nature, unilateral or bilateral nature and intensity depend on the seat and the extent of the ischemic territory of the spinal cord.

How is the diagnosis of spinal cord infarction made?

The diagnosis of spinal cord infarction is based on imagery, particularly MRI which allows, from the initial phase, to exclude certain differential diagnoses such as acute spinal cord compression.

However, whenever possible, the diagnosis of spinal cord infarction should not be a diagnosis of exclusion. He must rest a suggestive clinical picture and a number of direct and indirect signs on MRI.

Other tests may be performed to specify the cause of the spinal cord infarction, especially :

  • La lumbar puncture : it eliminates many differential diagnoses.
  • Transesophageal ultrasound: it allows the visualization of the aorta in search of an atheroma, a dissection, a coarctation, an aneurysm…
  • Spinal cord angiography: to visualize the arteries of the spinal cord and detect a possible occlusion.

What is the treatment for spinal cord infarction?

Unfortunately, no specific drug treatment has proven its effectiveness in the management of spinal cord infarction.

Therefore, the treatment of spinal cord infarction, regardless of the treatment of the cause, is symptomatic. Here are the highlights :

  • Re-education : physiotherapy is the mainstay of treatment in patients who have had a spinal cord infarction. It aims to limit motor disorders through the implementation of various passive and active exercises
  • Pressure sore prevention: daily skin care will be performed to avoid complications from prolonged bed rest.
  • Sphincter care: in order to avoid infectious complications, intermittent catheterizations can be carried out.

References

[1] D. Leys, C. Cordonnier, C. Masson, and J.-P. Pruvo, “Spinal cord infarcts”, EMC-Neurology, flight. 2, no 2, p. 163-174, 2005.

[2] G. Saliou, M. Théaudin, CJ-L. Vincent, and R. Souillard-Scemama, “Medullar Infarction”, in Practical guide to neurovascular emergencies, Springer, 2011, p. 165-170.

[3] C. Cordonnier, “Spinal arterial infarction: where are we in 2022? », Neurological Practice-FMC, flight. 13, no 1, p. 63-66, 2022.

[4] MA Mnaili and A. Bourazza, “Acute spinal cord infarction: an unrecognized diagnosis with a severe prognosis”, Pan African Medical Journal, flight. 31, no 1, 2018.

[5] K.Kim et al., “Mechanism of medullary infarction based on arterial territory involvement”, Journal of clinical neurology, flight. 8, no 2, p. 116-122, 2012.

[6] J. Stricker, R. Hourrez, RN Ikazabo, G. Bruninx, and P. Seeldrayers, “Cervical spinal cord infarction in a context of multi-level discopathy”, Rev Med Brux, flight. 35, p. 96‑8, 2014.

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