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Spinal Cord Infarction


KEY FACTS

Terminology

  • Spinal cord ischemia/infarction

  • Secondary to vessel occlusion

    • Anterior spinal artery (ASA); T4-9 most vulnerable

    • Posterior spinal artery (PSA)

  • Hypotensive (cord “watershed” zone = central gray matter)

Imaging

  • MR with contrast, + diffusion

  • Cord hyperintensity on T2WI; central owl's-eye pattern

    • Central gray matter or entire cross-sectional area

    • Slight cord expansion in acute phase

Top Differential Diagnoses

  • Multiple sclerosis

  • Transverse myelitis

  • Acute disseminated encephalomyelitis/viral myelitis

  • Neuromyelitis optica

  • Type I dural fistula

  • Spinal cord neoplasm

  • Radiation myelopathy

Pathology

  • Most known causes related to aortic pathology

  • Other etiologies

    • Systemic hypotension, septicemia, disc embolism

    • Blunt trauma with dissection

    • Iatrogenic (transforaminal steroid injection, selective root block)

  • Up to 50% of cases have no known etiology

Clinical Issues

  • ASA: Abrupt-onset weakness, loss of sensation

  • PSA: Dorsal column dysfunction (loss of proprioception, vibration)

  • Rapid progression; maximum deficit within hours

  • Poor prognosis, with permanent disabling sequelae

  • Pain is frequent and disabling feature of cord infarct

Axial T2WI MR in this case of hypoxic-ischemic encephalopathy (HIE) shows typical “owl's eye” abnormal hyperintensity within the central gray matter from chronic spinal cord infarction.

Axial T1WI MR in case of severe HIE shows focal low signal within the central cord due to old infarction with myelomalacia.

Sagittal T2 MR shows slight hyperintensity in the distal thoracic cord
in this patient with acute onset of leg weakness. There is a geographic region of increased signal
in the superior aspect of the thoracic vertebral body due to concomitant cord and vertebral body infarcts.

Sagittal STIR MR shows the cord hyperintensity involving the mid and dorsal aspect of the thoracic cord
, along with the vertebral body infarction
. The classic anterior 2/3 of the cord involved is not always present.

TERMINOLOGY

Abbreviations

  • Spinal cord infarction (SCI)

  • Anterior spinal artery (ASA)

Synonyms

  • Spinal cord ischemia

Definitions

  • Cord infarction 2° to vessel occlusion (radicular artery)

IMAGING

General Features

  • Best diagnostic clue

    • Hyperintensity on T2WI within cord; central “owl's eye” pattern

  • Location

    • Distal 1/2 of thoracic cord → arterial border zone

  • Size

    • Usually > 1 vertebral body segment

  • Morphology

    • Central hyperintensity on T2WI, which involves central gray matter, more variable involvement of cord periphery

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