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The Ins and Outs of Spinal Cord Stroke

Monday January 13, 2003
Recovery from spinal cord stroke is variable, from no improvement to total recovery. One study showed that improvement within 24 hours correlated with the greatest degree of recovery.
Recovery from spinal cord stroke is variable, from no improvement to total recovery. One study showed that improvement within 24 hours correlated with the greatest degree of recovery.
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The devastating hallmark symptom of spinal cord stroke is the abrupt onset of paralysis. This may be preceded by back pain, diffuse aching which ascends from the feet to the abdomen, with weakness and numbness. Paraplegia or quadriplegia may occur in minutes, or hours. Sensory loss and urinary dysfunction, most often urinary retention, ensue.
Spinal cord infarction is caused by an interruption of blood flow anywhere from the aorta to the spinal arteries, or by severe systemic hypotension, or both. Symptoms are directly related to the location of the ischemia and infarct.
Blood Supply to the Spinal Cord
Radicular arteries of the spinal cord form a network to perfuse nerve roots near the vertebral foramina. Medullary arteries from the vertebral, subclavian, iliac arteries, and aorta branch to form a single anterior median spinal artery which perfuses the anterior cord. Also, from here, two posterior spinal arteries perfuse the posterior cord.
The cervical portion of the cord is supplied by the anterior spinal artery and many rich collateral vessels. The thoracic cord is supplied by the anterior spinal artery, but only a few collateral vessels are found at this level. This sparse blood supply is especially evident at the mid-thoracic level (T4-T9) and makes this area particularly vulnerable to vascular ischemia and infarction. The lumbar and sacral portions of the cord are supplied by the largest artery, the "great anterior radicular artery," known as the "artery of Adamkiewicz." This great artery merges with the anterior spinal artery. The central (sulcal) arteries supply the anterior 1/2 and posterior 1/3 of the cord and the central cord.
A cervical cord infarct will cause quadriplegia, urinary and bowel dysfunction, and sensory impairment below the level of the lesion. While a midthoracic infarct will cause paraplegia, urinary and bowel dysfunction, loss of pain and temperature, and flaccid weakness eventually followed by spasticity and hyperreflexia below the level of the lesion.
A lumbar and sacral infarct will cause paraplegia, sphincter symptoms, loss of cutaneous sensation, and flaccid weakness below the level of the lesion. And a central artery occlusion will present as Brown-Sequard syndrome, which appears as a partial infarction of the cord with loss of pain and temperature opposite the side of the lesion and motor paralysis on the same side. Thrombosis of spinal veins can also cause spinal cord infarction but are even less common than arterial lesions.
Any process or event that interrupts blood flow to the spinal cord can cause spinal ischemia and infarct. It is thought to occur more commonly in men with atherosclerosis of the aorta causing spontaneous occlusion of the aorta, and has been frequently associated with thoracic abdominal aneurysm repair. This may be related to the amount of time of cross clamping or ligation of collateral vessels intraoperatively. Emboli of cardiac origin, such as from bacterial endocarditis and atrial myxoma have been documented. In one study of nucleus pulposus embolism resulting in largely cervical cord infarct, 69% were female. Dissection of aortic aneurysms can cause shearing and occlusion of spinal vessels. Some other causes are vasculitis, angiographic contrast dye, vaccination, arteriovenous malformation repair, hypercoagulable states, and decompression sickness in which nitrogen bubbles occlude spinal arteries.
Differential Diagnosis
Many conditions may cause symptoms similar to spinal cord stroke, but have a slower, progressive onset. Some of these include acute transverse myelitis, multiple sclerosis, spinal tumor, meningitis, and metabolic myelopathies.
Diagnosis of spinal cord stroke is made primarily by clinical presentation of rapid onset of symptoms over hours or minutes, lack of preexisting systemic disease, findings of acute flaccid paralysis, decreased tendon reflexes, positive Babinski sign, and sphincter abnormalities. Laboratory and radiographic studies rule out compressive disorders of the spine, such as tumor, and a lumbar puncture may rule out infection or hemorrhage. CSF studies rule out transverse myelitis or multiple sclerosis. MRI can be a useful tool in diagnosing spinal infarct.
Prognosis and Treatment
Recovery is variable, from no improvement to total recovery. Treatment of spinal cord infarct is supportive. Maintenance of adequate blood pressure and prevention of complications due to immobility and bladder and bowel dysfunction is vital. Physical and occupational therapy are begun early in the course to help patients regain a maximal degree of independence. Psychological support and counseling are of paramount importance since a sudden onset of paralysis with uncertainty of recovery, is understandably viewed by the patient as a catastrophic event.
Patricia Agostino, RN, CEN, CCRN, is a staff nurse in ICU at Stamford Hospital, Stamford, CT.
References available upon request.