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Spinal Cord Stroke

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Its preventive measures include decreasing the risk factors and maintaining enough spinal cord perfusion pressure during and after the operation. Radiologists always apply different MRI protocols for the diagnosis of both ischemic and hemorrhagic spinal stroke.[1][2] Treatment for spinal cord stroke is mainly determined by the symptoms and the causes of the disease. For ischemic spinal stroke patients, antiplatelet and corticosteroids might be used to reduce the risk of blood clot. For hemorrhagic spinal stroke patients, rapid surgical decompression is applied to minimize the neurological injuries.[3] Patients may spend years for the significant recovery after the spinal cord stroke.[4]

Prevention

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Risk factors

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Modifiable risk factors that contribute to the common strokes such as hypertension and heart disease, are found less common in the formation of spinal cord stroke. On the other hand, diabetes mellitus, peripheral artery disease, smoking and cholesterol are associated more with such disease.[4] Prevention and treatment of these modifiable risk factors could reduce the likelihood of spinal cord stroke.

Intraoperative strategy

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As the high difficulty for the detection during operation, somatosensory evoked potential monitoring or motor evoked potential monitoring is necessary to early detect the spinal cord ischemia in anesthetized patient for quick intervention.[5][6] Cerebrospinal fluid drainage is always used to decrease intraspinal pressure and increase blood flow to the spinal cord to avoid hypotension, thus reducing the risk of spinal cord ischemia.[6]

Postoperative strategy

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The aims of postoperative management are to maintain enough spinal cord perfusion pressure, and make serial neurologic assessments to detect the disease. Similar as in the intraoperative strategy, increasing the spinal cord perfusion as an immediate intervention may increase the chance for a successful treatment.[7] Neurological examination should be conducted after anesthesia to test the motor function of the low extremity of patients. By using this method to detect whether patients have spinal cord ischemia, doctors could decide whether rapid treatment should be provided.[5]

 
Owl-eyes sign exhibits bilaterally symmetric circular to ovoid foci of T2-weighted signals in anterior horn cells.

Diagnosis

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Spinal stroke could be easily misdiagnosed because of its rarity.[8] The doctor will first assess the clinical symptoms of the patient, such as paralysis, sensory loss and urinary and bowel dysfunction, to determine whether it is possible for the spinal stroke. After that, different MRI imaging protocols will be used, including axial and sagittal T1 and T2-weighted sequences and diffusion-weighted imaging (DWI).

Ischemic spinal cord stroke

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As the non-contrast CT and spine CT angiography are ineffective in imaging modalities, doctors use MRI to confirm the diagnosis. MRI findings, including pencillike hyperintensities on T2-weighted sagittal images and “owl’s eyes” or “snake eyes” sign on T2 axial images, indicating the infarction is predominately in the watershed area of the gray matter of ventral horn (ASA infarct).[8] Also, posterior paramedian triangular hyperintensity in T2 hyperintensity indicates PSA infarct. On a T1 sequence, we may also observe a cord expansion and a decreased signal.[9] However, traditional MRI may show no abnormality especially for those patients in the acute phase.[2] DWI is very sensitive for early detection of spinal cord infarction and shows a typical high signal intensity.[10]

Hemorrhagic spinal cord stroke

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On axial imaging at the level of the denticulate ligaments, the inverted Mercedes-Benz sign denotes the form taken on by a spinal subdural hematoma.

To identify the hematoma in the spinal cord, MRI with and without gadolinium enhancement is the preferred choice.[3] CT is also used to identify the hemorrhage and provide evidence for pathological analysis. Complete spinal MRI with MR angiography is used when patients with subarachnoid hemorrhage without the intracranial etiology.[11] As the evaluation of the need for intradural interrogation is important, it is necessary to differentiate between subdural and epidural hematomas. Based on the location of the hematoma, use both axial and sagittal images of MRI to identify the boundary between hematoma and fat.[1] An inverted Mercedes-Benz sign shows the spinal subdural hematoma on the axial image.[12]

Treatment

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Given the rarity and heterogeneity of the spinal cord stroke, symptomatic treatment of associated complications is applied, which is based on patients' own circumstances.

Ischemic spinal cord stroke

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Although some literature suggest that thrombolysis could be the treatment for ischemic spinal stroke, the associated risks are unknown due to the scarce data.[13] If the cause is global hypoperfusion, maintaining enough blood pressure to maintain adequate spinal perfusion is needed.[9] Also, anticoagulation and antiplatelet agents have been prescribed to prevent vascular occlusion or embolism.[2] Corticosteroids are prescribed in situations of vasculitis or aortitis.[9]

Hemorrhagic spinal cord stroke

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Surgical decompression

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The goal of treatment in an acute situation is to relieve pressure on the spinal cord. To limit neurological injury, surgical decompression should be undertaken as soon as possible.[14] Several case studies show a substantial link between the time from bleeding to surgical decompression and neurological outcome, with the greatest results coming from individuals who had surgery within 12 hours after symptom onset.[15]

Administration of large dose corticosteroids
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While waiting for surgery, high-dose corticosteroids were administered in the acute phase. It could reduce edema and secondary cord compression.[16]

Reversal of anticoagulation
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As anticoagulation treatment with warfarin or heparin has been linked to spontaneous hematomyelia, reversal anticoagulation is used to reduce the risk of bleeding by using suitable antidotes. Protamine is used to reverse heparin and low molecular-weight heparin. Vitamin K is a reversal agent for warfarin.[17]

Prognosis

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It is possible that spinal cord ischemia patients have a full recovery. Although the mortality rate after spinal cord ischemia is relatively high (23%), 58% of the survivors were ambulating with or without gait assistance at their final follow-up appointment. Patients with total paraplegia and sensory loss at nadir can, however, progress significantly over months to years.[18]

  1. ^ a b Kirsch, E.; Gratzl, O.; Mindermann, Th.; Hausmann, O.; Rad, E. (Mar 2001). "Coagulopathy Induced Spinal Intradural Extramedullary Haematoma: Report of Three Cases and Review of the Literature". Acta Neurochirurgica. 143 (2): 135–140. doi:10.1007/s007010170118. ISSN 0001-6268.
  2. ^ a b c Zalewski, Nicholas L.; Rabinstein, Alejandro A.; Krecke, Karl N.; Brown, Robert D.; Wijdicks, Eelco F. M.; Weinshenker, Brian G.; Kaufmann, Timothy J.; Morris, Jonathan M.; Aksamit, Allen J.; Bartleson, J. D.; Lanzino, Giuseppe (2019-01-01). "Characteristics of Spontaneous Spinal Cord Infarction and Proposed Diagnostic Criteria". JAMA Neurology. 76 (1): 56. doi:10.1001/jamaneurol.2018.2734. ISSN 2168-6149. PMC 6440254. PMID 30264146.{{cite journal}}: CS1 maint: PMC format (link)
  3. ^ a b Shaban, Amir; Moritani, Toshio; Al Kasab, Sami; Sheharyar, Ali; Limaye, Kaustubh S.; Adams, Harold P. (June 2018). "Spinal Cord Hemorrhage". Journal of Stroke and Cerebrovascular Diseases. 27 (6): 1435–1446. doi:10.1016/j.jstrokecerebrovasdis.2018.02.014.
  4. ^ a b Romi, Fredrik; Naess, Halvor (2016). "Spinal Cord Infarction in Clinical Neurology: A Review of Characteristics and Long-Term Prognosis in Comparison to Cerebral Infarction". European Neurology. 76 (3–4): 95–98. doi:10.1159/000446700. ISSN 0014-3022.
  5. ^ a b Cheung, Albert T.; López, Jaime R. (2021), Cheng, Davy C.H.; Martin, Janet; David, Tirone (eds.), "Spinal Cord Ischemia Monitoring and Protection", Evidence-Based Practice in Perioperative Cardiac Anesthesia and Surgery, Cham: Springer International Publishing, pp. 323–343, doi:10.1007/978-3-030-47887-2_28, ISBN 978-3-030-47886-5, retrieved 2022-03-27
  6. ^ a b Epstein, NancyE (2018). "Cerebrospinal fluid drains reduce risk of spinal cord injury for thoracic/thoracoabdominal aneurysm surgery: A review". Surgical Neurology International. 9 (1): 48. doi:10.4103/sni.sni_433_17. ISSN 2152-7806. PMC 5843969. PMID 29541489.{{cite journal}}: CS1 maint: PMC format (link) CS1 maint: unflagged free DOI (link)
  7. ^ Keith, Charles J.; Passman, Marc A.; Carignan, Martin J.; Parmar, Gaurav M.; Nagre, Shardul B.; Patterson, Mark A.; Taylor, Steven M.; Jordan, William D. (Jan 2012). "Protocol implementation of selective postoperative lumbar spinal drainage after thoracic aortic endograft". Journal of Vascular Surgery. 55 (1): 1–8. doi:10.1016/j.jvs.2011.07.086. ISSN 0741-5214.
  8. ^ a b Vuong, Shawn M.; Jeong, William J.; Morales, Humberto; Abruzzo, Todd A. (Oct 2016). "Vascular Diseases of the Spinal Cord: Infarction, Hemorrhage, and Venous Congestive Myelopathy". Seminars in Ultrasound, CT and MRI. 37 (5): 466–481. doi:10.1053/j.sult.2016.05.008.
  9. ^ a b c Yadav, Nishtha; Pendharkar, Hima; Kulkarni, Girish Baburao (Oct 2018). "Spinal Cord Infarction: Clinical and Radiological Features". Journal of Stroke and Cerebrovascular Diseases. 27 (10): 2810–2821. doi:10.1016/j.jstrokecerebrovasdis.2018.06.008.
  10. ^ Weidauer, Stefan; Nichtweiß, Michael; Hattingen, Elke; Berkefeld, Joachim (March 2015). "Spinal cord ischemia: aetiology, clinical syndromes and imaging features". Neuroradiology. 57 (3): 241–257. doi:10.1007/s00234-014-1464-6. ISSN 0028-3940.
  11. ^ Lawton, Michael T.; Vates, G. Edward (2017-07-20). "Subarachnoid Hemorrhage". New England Journal of Medicine. 377 (3): 257–266. doi:10.1056/NEJMcp1605827. ISSN 0028-4793. PMID 28723321.
  12. ^ Kobayashi, Kazuyoshi; Imagama, Shiro; Ando, Kei; Nishida, Yoshihiro; Ishiguro, Naoki (Nov 2017). "Acute non-traumatic idiopathic spinal subdural hematoma: radiographic findings and surgical results with a literature review". European Spine Journal. 26 (11): 2739–2743. doi:10.1007/s00586-017-5013-y. ISSN 0940-6719.
  13. ^ Lee, K.; Strozyk, D.; Rahman, C.; Lee, L.K.; Fernandes, E.M.; Claassen, J.; Badjatia, N.; Mayer, S.A.; Pile-Spellman, J. (2010). "Acute Spinal Cord Ischemia: Treatment with Intravenous and Intra-Arterial Thrombolysis, Hyperbaric Oxygen and Hypothermia". Cerebrovascular Diseases. 29 (1): 95–98. doi:10.1159/000259618. ISSN 1421-9786.
  14. ^ Akpınar, Aykut; Celik, Bahattin; Canbek, Ihsan; Karavelioğlu, Ergun (2016). "Acute Paraplegia due to Thoracic Hematomyelia". Case Reports in Neurological Medicine. 2016: 1–3. doi:10.1155/2016/3138917. ISSN 2090-6668.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  15. ^ Lawton, Michael T.; Porter, Randall W.; Heiserman, Joseph E.; Jacobowitz, Ronald; Sonntag, Volker K. H.; Dickman, Curtis A. (July 1995). "Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological outcome". Journal of Neurosurgery. 83 (1): 1–7. doi:10.3171/jns.1995.83.1.0001. ISSN 0022-3085.
  16. ^ Bracken, Michael B (2012-01-18). "Steroids for acute spinal cord injury". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd001046.pub2. ISSN 1465-1858.
  17. ^ Frontera, Jennifer A.; Lewin III, John J.; Rabinstein, Alejandro A.; Aisiku, Imo P.; Alexandrov, Anne W.; Cook, Aaron M.; del Zoppo, Gregory J.; Kumar, Monisha A.; Peerschke, Ellinor I. B.; Stiefel, Michael F.; Teitelbaum, Jeanne S (2015-12-29). "Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage". Neurocritical Care. 24 (1): 6–46. doi:10.1007/s12028-015-0222-x. ISSN 1541-6933.
  18. ^ Robertson, C. E.; Brown, R. D.; Wijdicks, E. F. M.; Rabinstein, A. A. (2012-01-10). "Recovery after spinal cord infarcts: Long-term outcome in 115 patients". Neurology. 78 (2): 114–121. doi:10.1212/WNL.0b013e31823efc93. ISSN 0028-3878. PMC 3466672. PMID 22205760.{{cite journal}}: CS1 maint: PMC format (link)
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