Spinal stroke is a rare type of stroke accounting for less than 1% of all strokes. It results from an acute disruption of blood supply to the spinal cord, causing ischemia and neurological deficits. The spinal cord receives its blood supply from the anterior spinal artery and dual posterior spinal arteries. Etiologies of spinal stroke include vertebral artery dissection, arteriosclerosis, embolism, hypotension, and vasculitis. Clinical features appear rapidly within 30-45 minutes and include radicular pain and neurological deficits depending on the affected territory. MRI is important for diagnosis, particularly vertebral body infarction. There is no established effective therapy, but prognosis varies with age and severity, with many patients experiencing some improvement over time.

1. Spinal Stroke
Ade Wijaya, MD – February 2019

2. Introduction
 Rare; less than 1 % of all strokes
 Extensive vascular collateral network
 Acute disruption of the spinal cord blood supply resulting in ischemia, infarction
and acute spinal cord dysfunction with related clinical neurological deficits linked
to the blood supply territory of the affected
Romi F, Naess H. Spinal cord infarction in clinical neurology: a review of characteristics and long-term prognosis in comparison to cerebral infarction. European neurology. 2016;76(3-4):95-8.
Weidauer S, Nichtweiß M, Hattingen E, Berkefeld J. Spinal cord ischemia: aetiology, clinical syndromes and imaging features. Neuroradiology. 2015 Mar 1;57(3):241-57.

3. Anatomy
 Anterior spinal artery (ASA)
 Dual posterior spinal arteries (PSA)
 Dual posterolateral spinal arteries (PLSA)
The spinal arteries in turn receive their blood supply from different regional arteries:
C1–T3 is supplied by the vertebral arteries
T3–T7 receives a branch from the intercostal arteries
T8 to the medullary conus is supplied by the Adamkiewicz artery and in some cases there is
a medullary conus artery arising from the internal iliac artery
Romi F, Naess H. Spinal cord infarction in clinical neurology: a review of characteristics and long-term prognosis in comparison to cerebral infarction. European neurology. 2016;76(3-4):95-8.
Weidauer S, Nichtweiß M, Hattingen E, Berkefeld J. Spinal cord ischemia: aetiology, clinical syndromes and imaging features. Neuroradiology. 2015 Mar 1;57(3):241-57.

5. Etiology
 Spontaneous and traumatic uni- or bilateral vertebral
artery (VA) dissection
 Arteriosclerosis or cardiac embolic occlusion of the VA
 Hypotension, e.g. due to cardiac failure
 Drugs
 Fibrocartilaginous embolism into the radiculomedullar
artery
 Vasculitis, e.g. panarteriitis nodosa, antiphospholipid
antibody syndrome, neurosyphilis, systemic lupus
erythematosus, sickle cell disease
 Varicella zoster virus vasculopathies
 Cocaine misuse
 In the elderly especially, aortic diseases like
arteriosclerosis, aortic dissections and aortic aneurysm
repair
 Spinal decompression sickness after diving
 Chiropractic manipulation
 Diagnostic and therapeutic interventional
blockades of cervical or lumbar nerve roots,
 Scoliosis operation of the spine
 Complication of intracranial endovascular
intervention
 Intravascular malignant lymphomatosis
 Subarachnoid haemorrhage
 Meningococcal meningitis
 “Surfer’s myelopathy”
Weidauer S, Nichtweiß M, Hattingen E, Berkefeld J. Spinal cord ischemia: aetiology, clinical syndromes and imaging features. Neuroradiology. 2015 Mar 1;57(3):241-57.

6. Clinical Features
 30 to 45 min going along with radicular, e.g. belt-like acute pain representing the
overture of this severe neurological disease
Weidauer S, Nichtweiß M, Hattingen E, Berkefeld J. Spinal cord ischemia: aetiology, clinical syndromes and imaging features. Neuroradiology. 2015 Mar 1;57(3):241-57.

7. Differential Diagnosis
Weidauer S, Nichtweiß M, Hattingen E, Berkefeld J. Spinal cord ischemia: aetiology, clinical syndromes and imaging features. Neuroradiology. 2015 Mar 1;57(3):241-57.

8. Treatment and Prognosis
 Treatment: supportive and treatment of the risk factors
 Younger patients and men usually present with more severe spinal cord strokes in the
initial phase
 A week after ictus, however, men tend to improve more rapidly than women in terms of
less severe disability scores in relation to their initial neurological deficits
 Long-term mortality (9%) in spinal cord infarction patients is associated with higher age,
severity of deficits in the acute phase and peripheral vascular disease
 Many spinal cord infarction patients experience significant improvement with time. Up
to half of the patients who were unable to walk 1 week after spinal cord infarction onset
are able to walk on follow-up
 Up to 79% of spinal cord infarction patients report chronic pain on follow-up
Romi F, Naess H. Spinal cord infarction in clinical neurology: a review of characteristics and long-term prognosis in comparison to cerebral infarction. European neurology. 2016;76(3-4):95-8.

9. Summary
 No well-established effective therapy
 Acute onset ( < 4 hours )
 Diagnostically challenging
 MRI
 The occurrence of vertebral body infarction is of particular value for a positive
diagnosis of spinal cord ischemia