Vascular disorders of the spinal cord …

Elizabeth Anderson MD

Stroke & Vascular Disorders

Updated 12.03.2025
Released 06.17.1996
Expires For CME 12.03.2028

Vascular disorders of the spinal cord

Author: Elizabeth Anderson MD

See Contributor Disclosures

Editor: Steven R Levine MD

Cite this article

Vascular disorders of the spinal cord

In This Article

Quick Link

Introduction

Overview

Spinal cord vascular disorders are rare, though potentially devastating, conditions that require prompt recognition and treatment. These vascular disorders are heterogenous in origin, with pathologies involving both the arterial and venous vessels. Understanding the clinical hallmarks and potential etiologies are necessary to provide effective intervention and timely management. Most treatment strategies are reliant on a multidisciplinary team.

Key points

	• Spinovascular disorders are relatively rare and encompass a wide breadth of etiologic designations.
	• The majority of acute spinovascular processes have back or radicular pain.
	• Classic intramedullary spinal cord disorders follow well-defined neurovascular territories.
	• The etiologies of these conditions are heterogenous, including embolic, iatrogenic, hypotensive, ischemic, hemorrhagic, and congestive pathologies.
	• Treatment requires a multidisciplinary effort and may require an interventional approach.
	• Owing to the rarity of the disease, much is not robustly known on the outcomes of those with a spinovascular condition.

Historical note and terminology

Although the presence of a spinal epidural hematoma (termed “spinal apoplexy”) was possibly first described in 1682 by GJ Duverney, intramedullary spinovascular disease was not readily identified until the 1800s. According to Black, one can classify three time periods or epochs in the evolution of the classification of vascular spinal lesions: early observations (1860s to 1912), middle ages (1912 to 1960), and the modern era (1960 to present) (11). In 1817 and 1857, early cases reported spinovascular complications ranging from abdominal aortic aneurysm to the development of paraplegia (117). In 1881 and 1882, Polish pathologist Albert Adamkiewicz provided insight into the vascular anatomy of the spinal cord (74). His work allowed for further characterization of spinal cord vascular syndromes, including the first report of an anterior spinal artery syndrome in 1909 (122). In addition to large artery spinovascular complications, more intricate pathologies were identified. In 1912, Marie and Foix described the syndrome of "tephromalacie anterieure," or ischemic lesions in the anterior horn cells due to atherosclerotic disease (76). In 1926, Foix and Alajouanine subsequently described a congestive myelopathy from two cases of spinal dural arteriovenous fistulas (31). Embolization of spinal dural arteriovenous fistula was subsequently reported by Newton and Adams in 1968 (90). With the increasing interest in cardiovascular surgeries in the 1970s, reports emerged of incidences of anterior spinal cord syndrome related to hypoperfusion (118). More recent advances in neuroimaging have more readily identified spinovascular disorders, such as spinal dural arteriovenous fistula and stroke.

Clinical manifestations

Presentation and course

	• The symptoms of a spinovascular syndrome are highly reliant on the location and etiology of the condition.
	• Timing and onset of symptoms are of great importance in delineating etiology.

Ischemic processes

The clinical presentation varies depending on the vascular territory involved. The following vascular syndromes have been identified: anterior spinal artery syndrome, posterior spinal arteries syndrome, transverse infarction of the spinal cord, central cord infarction, venous infarction, transient spinal ischemia, and lacunar infarction.

Anterior spinal artery infarct. This syndrome is classically heralded by pain in approximately a third of individuals. If pain is present, it can be diffuse, radicular, or girdle-like in distribution and with both neuralgiform and throbbing qualities. Symptoms usually occur suddenly but may progress over minutes to hours, peaking at 12 hours (145). Unique to the spinal cord level involved, pain may mimic other conditions, such as cluster headaches in cervical cord infarcts and ischemic heart disease in thoracic cord infarcts (23; 62). However, it is important to differentiate that pain from an anterior spinal cord infarct will not affect proprioception, vibratory sense, or fine touch as these senses are controlled by a part of the spinal cord fed by the posterior spinal artery (140). Clinical features of an anterior spinal artery infarct are dependent on level and completeness of the infarct. Typically, lower motor neuron flaccid paralysis occurs with hyporeflexia, though over time, spasticity may occur depending on involvement of the anterior horn cells. Pain and temperature sensation may be lost beginning one to two levels below the infarct owing to the anatomy of the anterior fasciculus (143; 95). A “man-in-a-barrel” semiology has also been reported (09). Autonomic symptoms, such as bradycardia and incontinence, are common and depend on the spinal segments involved. Incomplete anterior spinal cord artery infarcts may lead to variable symptoms (124). Due to anatomical variations in spinal vasculature, partial Brown-Sequard syndromes (also known as hemi-cord myelopathy) may occur (58).

Transient spinal cord symptoms similar to a hemispheric transient ischemic attack may be a heralding sign of impending spinal cord infarct (25). Transient ischemia of the cervical cord may cause "drop attacks," whereas spinal cord claudication may occur in the lumbar region, leading to painless weakness of the lower extremities precipitated by effort and relieved by rest (128).

Posterior spinal artery infarct. These lesions are rare and are often difficult to recognize in a timely manner. Like anterior spinal artery infarcts, patients can have pain along the spine at the segment of injury. However, pain and sensory sensation will be otherwise preserved (140). Due to predominant dorsal column involvement, vibration and proprioception are absent below the level of the lesion, often on the ipsilateral side (140). Accompanying the expected dorsal column dysfunction is typically variable weakness and autonomic dysfunction, likely related to anterior anastomoses with the anterior spinal artery (123).

Complete segmental infarct. The syndrome is characterized by a segmental complete spinal infarct analogous to transverse myelitis. Depending on the segment involved, flaccid quadriplegia or quadriparesis and total loss of sensation below the lesion, as well as sphincter dysfunction, may occur.

Central cord infarction. Ischemia in the arterial border zone between anterior spinal and posterior spinal arteries may result in this type of clinical infarct. The picture, however, is believed to be clinically indistinguishable from anterior spinal artery syndrome (121). This type of infarct often occurs in the cervical cord, mostly occurring after a fall with hyperextension of the patient’s neck (140).

Venous infarction. Spinal venous infarcts are rare and often subacute. There may be some degree of motor and sensory loss but without a well-defined pattern. The level of sensory loss may not be as easily delineated as in arterial infarcts (121). Those with symptoms of portal venous hypertension may be more at risk (42).

Lacunar cord infarction. Though perhaps controversial and with some variability in the literature, another potential ischemic myelopathy is of lacunar origin presenting as a subacute progressive weakness referable to the anterior horns. Lacunar cord infarction is also referred to as "vascular myelopathy in old age." The usual findings are wasting and weakness of the small muscles of the hand as well as scattered pyramidal signs, mimicking motor neuron disease (29).

Hemorrhagic processes

Hematomyelia. Spontaneous hematomyelia (or nontraumatic intramedullary spinal cord hemorrhage) is a rare neurologic complication. Etiologies can include anticoagulant use, radiation-induced vasculopathy, inflammatory conditions (such as Covid-19), spinal arteriovenous malformations, spinal cord neoplasms, and trauma (08). The most common presentation is excruciating pain in the back of sudden onset, often with radicular radiation. Neurologic symptoms may occur acutely, subacutely or in a stepwise fashion (63).

Spinal epidural or subdural hematomas. Extramedullary hematomas are rare and often of unclear etiology, with an estimated incidence of 0.1 in 100,000 per year. Symptoms typically present as lower motor neuron symptoms, with hyporeflexia and flaccid paralysis, usually on a time scale of hours to several days or even months from initial onset of back pain. Potential etiologies include trauma, surgery, underlying arteriovenous malformations, use of anticoagulants, underlying coagulopathy, or vertebral hemangiomas (30).

Spinal subarachnoid hemorrhage. The presentation of spinal subarachnoid hemorrhage can be quite similar to spinal epidural and subdural hematomas. However, the constellation of sudden back pain, radicular pain, and meningeal irritation is more pathognomonic of subarachnoid hemorrhage (72).

Vascular anomalies

Spinal dural arteriovenous fistulas. Spinal dural arteriovenous fistulas are the most common spinal vascular anomaly (representing up to 70% of vascular shunts). They are defined as a fistulous connection without a nidus between a radicular artery and a radicular vein. The most common presenting symptom is subacute lower extremity weakness that worsens with exercise and occurs in a subacute or stepwise deteriorative manner (defined as Foix-Alajouanine syndrome) (80). Sensory and autonomic involvement are variable (86; 71).

Intramedullary fistulas. People with intradural fistulas frequently have an acute hemorrhagic presentation, though a progressive syndrome may be present. The arms are usually affected (cervicothoracic location) (108).

Cavernous malformations. Various terminology has been used to classify these malformations over the years, including cavernous malformation and slow flow venous malformation. By definition, they are classified by a compact focus of abnormal dilated vascular spaces without intervening neural tissue (80). These lesions are typically present in the thoracic cord and are present with an acute hemorrhage or as a subacute progressive or recurrent myelopathy (19).

Spinal aneurysms. Although often associated with other vascular anomalies (arteriovenous malformations or fistulas), about half of all spinal aneurysms occur in solidarity. Common presentations of spinal aneurysms occur in the setting of rupture, in which there are symptoms of sudden back pain and myelopathic symptoms. Although rare, spinal aneurysms can also result in thrombosis and distal emboli, resulting in distal infarct to the cord (80).

Prognosis and complications

Ischemic infarcts. The outcomes of an ischemic spinal cord infarct depend on location, severity, and etiology. Data on mortality estimations have fluctuated over the year across different studies, ranging from 5% to 23%. However, it is agreed that mortality is higher in periprocedural cases (in comparison to spontaneous infarcts) (37). Most with motor symptoms will need assistance with ambulation, though again, this depends on the severity and cause of the index event (22; 36). Rehabilitation has been shown to improve functional outcomes (89). Ideally, rehabilitation should begin as soon as possible (37).

Long-term complications include persistent pain in as many as 90% of patients, independent of motor function recovery. The frequency and intensity of pain after spinal cord infarction seem higher than with other myelopathies and may have an impact on the quality of life (144). Further, a myriad of complications may emerge, such as autonomic dysfunction with urinary and bowel incontinence leading to urinary tract infections or sepsis, autonomic dysreflexia, sexual dysfunction, pressure sores, deep venous thromboses, and pulmonary emboli as a result of immobility, and mental health dysfunction may occur (144; 111; 105).

Hemorrhagic processes. The prognosis of spinal epidural and subdural hematomas mainly depends on the preoperative neurologic status, anticoagulation use, cervical level, and involvement of the bladder autonomics (130). Surgical and interventional treatments are preferred to conservative measures (148). Rapid interventional treatment is favored for those with intramedullary hemorrhage or symptomatic medullary cavernoma (127). If patients have negligible or no neurologic impairment, conservative monitoring can be utilized (44).

Vascular anomalies. Unfortunately, spinal dural arteriovenous fistulas are difficult to diagnose, and those with this condition tend to have a long delay in diagnosis. Rapid identification of the fistula is imperative to forestall the progressive congestive myelopathy (53; 107). Outcomes are dependent on the time to treatment and severity of the symptoms.

Clinical vignette

A 57-year-old man with a history of smoking, coronary atherosclerotic disease, chronic obstructive pulmonary disease, and nephrolithiasis underwent emergency Dacron graft replacement of a dissecting abdominal aortic aneurysm between the renal and distal common iliac arteries. Postsurgically, the patient was noted to have flaccid paraplegia with absent reflexes and a pin-prick sensory level below the umbilicus. His vibration sense was intact at the knees and ankles. MRI of the thoracic cord demonstrated an extensive cord infarction.

Thoracic cord infarction (MRI)

This MRI of a 57-year-old man demonstrates an extensive cord infarction. (Contributed by Dr. Enrique Leira.)

Biological basis

• Vascular anatomy may help define a location of the insult but also define the potential etiology. A thorough history and review of events at the time of onset are key.

Etiology and pathogenesis

Segmental vessels. There are approximately 31 pairs of segmental vessels arising from different sources (in craniocaudal order): vertebral arteries, ascending cervical arteries, deep cervical arteries, superior intercostal artery, aorta, iliolumbar artery, and lateral sacral arteries (121). These segmental arteries then divide into anterior and posterior rami. The posterior rami enter the intervertebral foramen and constitute either the anterior or posterior (or both) radicular arteries. Radicular arteries are also known as medullary or radiculomedullary arteries (121).

Anterior radicular (medullary) arteries supply the anterior spinal artery, which acts as an anastomotic channel between them, and are distributed unevenly throughout the cord. The cervical-upper thoracic region is highly vascularized, whereas the midthoracic area (T4 to T8) is poorly perfused because it is supplied by a single small radicular artery known as the "arteria radicularis magna" or artery of Adamkiewicz (usually T5 to T7 level, but variable). This artery arises from the left side of the aorta and is known to have a tight hairpin turn. It is similar in appearance to the anterior radiculomedullary vein; however, the vein is larger and more tortuous (129). Posterior radicular (medullary) arteries are smaller in size. They supplement the posterior spinal arteries.

Longitudinal vessels. There are three longitudinal vessels: one anterior spinal artery and two posterior spinal arteries. The anterior spinal artery is an anastomotic channel that runs anteriorly in the midline. The anterior spinal artery constitutes the caudal continuation of the two vertebral arteries, at the level of the foramen magnum. It extends throughout the length of the cord in the anterior median fissure. The posterior spinal arteries run in the posterior lateral aspect of the cord. They usually originate from the vertebral arteries but occasionally come from the posterior inferior cerebellar arteries (128; 121).

Vasa coronae. These surface vessels originate from the anterior spinal artery and posterior spinal arteries, forming a vascular ring around the cord (121).

Penetrating vessels. They originate from the anterior spinal artery, posterior spinal arteries, and the vasa coronae to perfuse the central portions of the cord (121).

Central (sulcal) arteries. They are branches of the anterior spinal artery entering the cord through the anterior median fissure and give longitudinal branches. There are more than 200 sulcal arteries, which are unevenly distributed throughout the cord. These arteries mainly perfuse anterior horns, deep gray matter of posterior horn, and central white matter (121).

Posterior median septum arteries. These are branches of the posterior spinal arteries that supply the dorsal funiculi and the central gray matter. The remaining posterior one third of the cord is perfused by other penetrating branches of posterior spinal arteries (121).

Extrinsic veins. Spinal venous anatomy is more variable than its arterial counterpart. There are typically one or two anterior spinal veins and usually a single posterior spinal vein. In addition, posterolateral and anterolateral spinal veins form discontinuous channels.

Extrathecally, an internal venous plexus lies in the epidural space, and an external plexus drains the vertebral bodies (121).

Intrinsic veins. There are two anterior central veins (draining central white matter and medial anterior horn), two posterior central veins (median septum white matter and gray commissure), and an intrinsic venous drainage for the rest of the cord (121).

Spinal cord border zones. The lower thoracic and upper lumbar cord (T6 to L3) is considered the area most vulnerable to ischemia due to less vascular anastomoses compared with other levels. The artery of Adamkiewicz, essentially an end artery, is classically responsible for this segment’s perfusion (120).

In a transverse section, the anterior spinal artery territory (anterior two thirds) is believed to be more susceptible to ischemia than the posterior one third of the cord. The explanation may be the existence of more efficient functional anastomoses at the level of the posterior spinal arteries region (121).

The gray matter is considered more susceptible to ischemia than the white matter, probably due to the differences in metabolic demand (125).

Etiology of spinal cord infarcts. Spinal infarcts result from a heterogenous collection of pathologies and may be divided into non-iatrogenic, iatrogenic, venous infarcts, and spinal transient ischemic attack (See Table 1).

Table 1. Etiology of Spinal Cord Infarctions

Noniatrogenic etiologies
• Diabetic arteriopathy (128) • Atherosclerosis (113)
	- Associated renal transplants (15)
• Inflammatory or infectious
	- Syphilis (13) - Tuberculosis (13) - Arachnoiditis (13) - Herpes zoster (113) - HIV/varicella-zoster virus (56) - Pregnancy/varicella zoster virus reactivation (McNamara and Allworth 2016) - Coccidiomycosis (142) - Schistosomiasis (67) - Cryptococcal (13) - Mucormycosis (133) - Sarcoidosis (128) - Ankylosing spondylitis (66)
• Vasculitic
	- Systemic lupus erythematous (113) - Giant cell arteritis (38) - Panarteritis nodosa (121) - Postinfectious/vaccination? (113) - Granulomatous angiitis (39)
• Non-inflammatory arteriopathies dissection (eg, congenital afibrinogenemia) (61) • Cervical spondylosis (anterior spinal artery compression) (46) • Continuous hyperextension (Surfer myelopathy) (116) • Intervertebral foraminal disease (100) • Lumbar artery compression by the diaphragmatic crus (106) • Aortic disease
	- Dissecting aortic aneurysm (113) - Dissecting radicular artery aneurysms (Sato and Roccatagliata 2012) - Aortic occlusion/thrombosis (33) - Trauma (46) - Takayasu disease (88) - Marfan syndrome (141)
• Embolic
	- Nucleus pulposus embolism (48) - Fibrocartilagous embolism (98) - Caisson disease (decompression sickness) (113) - Atheromatous (121) - Paradoxical embolization (85) - Atrial myxoma (113) - Fibroelastoma (94) - Endocarditis (113)
• Hypoperfusional states (120)
	- Cardiac arrest (18) - Cardiac tamponade (68)
• Disc protrusion (13) • Vertebral artery lesions (128)
	- Cervical hyperextension injuries - Fractures with spine dislocation - Vertebral artery dissection (10)
• Tumor (128)
	- Radicular artery compression - Malignant melanotic schwannoma (146) - Vertebral body metastasis & cord compression (16)
• Recreational drugs
	- Heroin (73) - Cocaine (139) - Traumatic needle stick (54)
• Hypercoagulable states
	- Antiphospholipid syndrome (41) - Protein S deficiency (101) - Congenital afibrinogenemia (05)

• Anemia (18) • Sickle cell anemia (110) • Moyamoya disease (arterial fibrosis) (59) • Malignant histiocytosis (infiltrative) (28) • Malignancy (cholangiocarcinoma) (126) • Intravascular malignant lymphomatosis (IML) (70) • CADASIL (52) • Cryptogenic (84)
Iatrogenic causes
• Aortic surgery (risk increases if previous colectomy) (112)
	- Aortic coarctation - Aortic aneurysms
• Endovascular aortic repair (35) • Endovascular iliac artery dissecting aneurysm repair (35) • Gastrectomy (18) • Surgery for mesenteric vascular occlusion (06) • Thoracolumbar sympathectomy (50) • Coronary artery bypass surgery (109) • Retroperitoneal tumor resection (69) • Aortic bifemoral bypass (60) • Pneumonectomy (radicular artery ligation) (21) • Scoliosis surgery (radicular artery ligation) (21) • Thoracoplasty (radicular artery ligation) (21) • Intra-aortic balloon pump (119) • Hepatic transplantation (arterial reconstruction) (40) • Renal artery embolization • Pineal region tumor resection (positional?) (91) • Posterior fossa surgery (77) • Resection thoracic dumbbell neuroblastomas (12) • Anterior cervical fusion (04) • Drugs
	- Neoarsphenamine (121) - Epidural/spinal anesthesia (vasoconstriction?) (121) - Intrathecal phenol (47) - Zolmitriptan (132) - Carmustine and cisplatin (135) - Nitroglycerin (sudden hypotension) (45) - Sildenafil (134)

• Dural fistula embolization/surgery (if common vessels) (87) • Transposition of the great arteries (65) • Embolization of bronchial artery (17; 20) • Endovascular occlusion spinal dural arteriovenous malformation (78) • Epidural catheter placement (hyperlordosis) (02) • Central line placement (hemothorax) (138) • Cerebral angiography (07) • Peripheral angiography (14) • Coronary angiography (03) • Coronary angioplasty (131) • Transcatheter arterial chemoembolization of hepatocellular carcinoma (93) • Endoscopic ultrasound celiac plexus neurolysis (34) • Extracorporeal membrane oxygenation (64)
Venous infarction
• Sepsis (121) • Embolic (121)
	- Fibrocartilaginous (104; 01) - Caisson disease (121)
• Hypercoagulable states (113)
	- Associated to malignancies (121) - Acute pancreatitis (136)
• Intramedullary tumor (113) • Venous thrombosis (104) • Meningitis (79) • Endoscopic sclerotherapy for esophageal varices (42)
Spinal transient ischemic attack
• Paget disease (flow diversion to bone) (96) • Dural arteriovenous malformation (13) • Atherosclerosis (113)

Epidemiology

• Ischemic spinal infarcts are rare but may account for up to 1% of all ischemic strokes. Other types of spinovascular conditions are equally rare but have less data defining incidence.

Ischemic processes. The incidence of spinal cord infarction has been estimated to be 3.1 per 100,000 person-years, or about 5000 to 8000 cases each year in the United States, and may account for up to 1% to 2% of all ischemic strokes (103; 99; 147). Vascular surgery data show that a spinal cord infarct may occur in up to a third of people who undergo elective thoracoabdominal aneurysm repair (82).

Spinal venous infarctions are probably rarer than the arterial infarctions, although the exact frequency is unknown (121).

Hemorrhagic processes. Owing to the rarity of the condition, the incidence of spontaneous spinal hemorrhagic processes is not well reported. Post-procedural epidural and subdural hematomas are well documented in the surgical literature, with one study reporting roughly a 1% incidence (92). Risk factors for this subset of conditions includes surgical intervention, anticoagulant use, coagulopathy, and trauma (13). In some cases, congenital processes, such as cavernous malformation, are another risk factor.

Vascular anomalies. These conditions are rare, with an estimated incidence of 0.234 per 100,000 person years (43). Risk factors include congenital and genetic syndromes in younger adults (usually early adulthood) or posttraumatic and severe arthritic conditions in older adults (87; 102). Spinal cavernomas may occur in genetic syndromes, such as familial cavernomas, and as a complication of spinal radiation (75). Their prevalence has been estimated to be about 0.4% to 0.6%, with a rate of hemorrhage ranging from 1.4% to 6.8% (115).

Diagnostic workup

	• Spinal MRI, including T1, T2, hemosiderin sensitive sequences, and DWI, are recommended for noninvasively diagnosing a spinovascular condition.
	• Conventional arteriography remains the gold standard in diagnosing spinovascular anomalies.

The evaluation for an acute spinal cord infarction includes neuroimaging studies to exclude the presence of an acute extrinsic spinal cord compression or an intraspinal mass. An MRI of the spinal cord should provide the needed information.

Spinal cord infarction (MRI)

This MRI is from a 76-year-old man. Short arrows indicate peripheral enhancement of central gray matter. Long arrows indicate peripheral enhancement of cord, probably near watershed zone between sulcal and perforating arteries. (U...

A series on the use of MRI offered a diagnostic high yield; approximately 93% of T2-weighted images detect the ischemic lesion at the time of the onset of symptoms (32). T1-weighted images are less reliable because 70% appear isointense at onset and only 18% are hypointense. Diffusion-weighted MRI may be useful for the detection of early ischemic cord lesions, though the size of the spinal cord may limit robust determination (137). Classic T2 hyperintense findings of an anterior spinal artery distribution infarct include “owl-eyes” and “pencil-like” hyperintensity patterns (143). Signs of vertebral body infarction on MRI are a useful radiological marker of spinal cord infarction associated with fibrocartilaginous embolism (27).

Admitting laboratory tests should include a comprehensive metabolic, infectious, and autoimmune screening. CSF analysis should be completed if concern arises for an alternative diagnostic etiology to ischemia.

Intramedullary mass at cervical cord (MRI)

T2-weighted sagittal image shows a low T2-signal intramedullary mass at cervical cord. Note multiple serpiginous flow-voids on the back of the spinal cord. (Contributed by Dr. Gaurang Shah.)
Ring enhancing nodule (MRI)

Post-contrast T1-weighted sagittal image shows a ring enhancing nodule (clotted aneurysm on angiogram) with a rim of faint T1-signal border situated superior to it, outlining the acute bleed. Note the flow-voids compatible with hy...
Intramedullary bleed (MRI)

T2-weighted axial image shows the area of intramedullary bleed with a string of flow-voids. (Contributed by Dr. Gaurang Shah.)

Overall, three criteria must be met for a diagnosis of spinal cord ischemia to be made. First, there must be rapid progression of severe symptoms, with a peak to symptoms within 12 hours. Second, MR imaging must exclude compression and support spinal cord ischemia as the underlying cause. Finally, CSF findings must exclude inflammation as a potential cause (147).

Spinal dural arteriovenous fistula may be apparent on sagittal MRI T2 sequences due to the presence of flow voids. A T1 hypointense but T2 hyperintense pattern along three to seven vertebral body lengths additionally suggests a spinal dural arteriovenous fistula (51). However, the gold standard in diagnosis remains a conventional arteriogram (87).

Spinal arteriovenous malformation (myelogram)

The malformation is characterized by dilated and tortuous tangles of vessels. (Contributed by Dr. Sherman Stein.)
Spinal arteriovenous malformation (arteriogram)

This study demonstrates the feeding artery (arrow) of this malformation, as well as a large venous aneurysm superiorly. (Contributed by Dr. Sherman Stein.)
Spinal arteriovenous fistula (angiogram)

Digital subtraction angiography images in the AP (A, B) and lateral (C) projection of a selective thyrocervical trunk injection demonstration of an arterial aneurysm (white arrowhead) and multiple dilated arterial afferents that d...
Spinal arteriovenous fistula (MRI)

Sagittal MR images of the cervical cord demonstrates the intramedullary lesion on the T1 precontrast (A), T1 post-contrast (B) and T2 weighted images (C). Angiography confirmed that this lesion was consistent with an aneurysm. Mar...

Management

	• Treatment of an acute spinal infarct depends on the etiology, though the use of antithrombotics, permissive hypertension, and lowering intrathecal pressures may aid in augmenting spinal blood flow.
	• Intravenous thrombolytics may be beneficial in the acute management of an ischemic spinal cord stroke.
	• Collaboration with neurointerventional and neurosurgical teams are important for the treatment of spinovascular anomalies.

Owing to the rarity of spinovascular conditions, there is no specific approved treatment for acute spinal cord infarctions. Intravenous rtPA has been used anecdotally, but the safety and efficacy are not known (26). Additionally, treatment by intravenous thrombolysis is contraindicated in those with aortic dissection or those who have an index major surgical intervention, further limiting the sample size. Difficulty identifying ischemia and potential candidates within the 4.5-hour time window also limits the potential patient candidacy pool (147). The use of permissive hypertension and lower intrathecal pressures through a lumbar drain have shown some theoretical success.

Spinal cord infarcts that are referable to conventional cardiovascular risk factors should be optimized medically with the aid of statin therapy, antihyperglycemics, and antithrombotic medications.

Spinal epidural and subdural hematomas should be decompressed emergently. Occasionally, fresh frozen plasma needs to be given to correct underlying coagulopathies.

Spinal dural and intramedullary arteriovenous malformations can be treated by excision, surgically eliminating the transmission of arterial pressure into the venous system of the cord. Surgical interruption of the intradural draining vein can provide a cure due to retrograde thrombosis. Embolization of these lesions is an alternative (87).

Symptomatic cavernous malformations may benefit from surgery, but there are not enough data about the natural history of these lesions (81).

Outcomes

Much is not known on the outcomes of treatment of a spinal cord infarct because the majority of documentation are case reports. Surgical treatment of spinovascular anomalies is well-documented, with a success rate of over 90% in treating spinal arteriovenous malformation via venous disconnection; however, this ultimately depends on the level of disability preoperatively and the experience of the surgeon (24). Additionally, a meta-analysis of spinal cord infarct from a malignancy found 12-month survival to be 16.3%, likely owing to the aggressiveness of the underlying malignancy but also the functional limitations imposed by the infarct (97).

Media

References

01: Al-Farsi SA, Al-Abri H, Al-Ajmi E, Al-Asmi A. Spinal cord infarct due to fibrocartilaginous embolism in an adolescent boy: a case report and literature review. Cureus 2023;15(4):e37319. PMID 37041852
02: Amoiridis G, Wohrle JC, Langkafel M, et al. Spinal cord infarction after surgery in a patient in the hyperlordotic position. Anesthesiology 1996;84:228-30. PMID 8572339
03: Aramburu O, Mesa C, Arias JL, Izquierdo G, Perez-Cano R. Spinal cord infarctions as a complication of coronary angiography. Rev Neurol 2000;30:651-4. PMID 10859745
04: Baba H, Tomita K, Kawagishi T, Imura S. Anterior spinal artery syndrome. Int Orthop 1993;17(6):353-6. PMID 8163309
05: Bas DF, Oguz KK, Yavuz K, Topcuoglu MA. Spinal cord infarction in congenital afibrinogenemia: a case report and review of the literature. J Stroke Cerebrovasc Dis 2009;18(4):298-303. PMID 19560685
06: Bbairaktari A, Kokolaki M, Vafiadou M. Spinal cord infarction following surgery for mesenteric vascular occlusion. Minerva Anestesiol 2007;73(12):651-3. PMID 18046296
07: Bejjani GK, Rizkallah RG, Tzortidis F, Mark AS. Cervical spinal cord injury during cerebral angiography with MRI confirmation: case report. Neuroradiology 1998;40:51-3. PMID 9493190
08: Belete Y, Kuma A, Anegagregn A, Girma A. Catastrophic neurological collapse following push-up exercise: a rare case of spontaneous hematomyelia causing acute paraplegia in a healthy young adult. Clin Case Rep 2025;13(7):e70633. PMID 40655455
09: Berg D, Mullges W, Koltzenburg M, Bendszus M, Reiners K. Man-in-the-barrel syndrome caused by cervical spinal cord infarction. Acta Neurol Scand 1998;97:417-9. PMID 9669478
10: Bergqvist CA, Goldberg HI, Thorarensen O, Bird SJ. Posterior cervical spinal cord infarction following vertebral artery dissection. Neurology 1997;48:1112-5. PMID 9109913
11: Black P. Spinal vascular malformations: an historical perspective. Neurosurg Focus 2006;21(6):E11. PMID 17341044
12: Boglino C, Martins AG, Ciprandi G, Sousinha M, Inserra A. Spinal cord vascular injuries following surgery of advanced neuroblastoma: an unusual catastrophic complication. Med Pediatr Oncol 1999;32:349-52. PMID 10219336
13: Bogousslavsky J, Caplan LR. Spinal stroke syndromes from "stroke syndromes." Cambridge Univ Pr, 1995:395-402.
14: Bozkurt AK, Aydingoz O, Yuceyar L, Tanriverdi S. Anterior spinal artery syndrome after peripheral angiography of the lower limbs. Spinal Cord 2003;41(8):473-4. PMID 12883547
15: Bruno A, Adams HP Jr. Neurologic problems in renal transplant recipients. Neurol Clin 1988;6(2):305-25. PMID 3047543
16: Chan S, Leow WQ. Sudden collapse due to medullary and cervical cord infarction-an unusual presentation of hepatocellular carcinoma. J Forensic Sci 2019;64(3):925-9. PMID 30352122
17: Cheng SJ, Hsueh IH, Po HL, Huang JK, Yang FS. Watershed infarction of spinal cord after the embolization of bronchial artery: a case report. Chin Med J 1996;57:293-6. PMID 8705883
18: Cheshire WP, Santos CC, Massey EW, Howard JF. Spinal cord infarction: etiology and outcome. Neurology 1996;47:321-30. PMID 8757000
19: Clark AJ, Wang DD, Lawton MT. Spinal cavernous malformations. Handb Clin Neurol 2017;143:303-8. PMID 28552154
20: Cynamon J. Revisiting spinal cord infarction after bronchial artery embolization. J Vasc Interv Radiol 2023;34(7):1260-1. PMID 36963614
21: Dawson D, Potts F. Acute non-traumatic myelopathies. Neurol Clin 1991;9:585-603. PMID 1921948
22: de la Barrera S, Barca-Buyo A, Montoto-Marqués A, Ferreiro-Velasco ME, Cidoncha-Dans M, Rodriguez-Sotillo A. Spinal cord infarction: prognosis and recovery in a series of 36 patients. Spinal Cord 2001;39(10):520-25. PMID 11641795
23: de la Sayette V, Schaeffer S, Coskun O, Leproux F, Defer G. Cluster headache-like attack as an opening symptom of a unilateral infarction of the cervical cord: persistent anaesthesia and dysaesthesia to cold stimuli. J Neurol Neurosurg Psychiatry 1999;66(3):397-400. PMID 10084543
24: Ehresman J, Catapano JS, Branoski JF, Jadhav AP, Ducruet AF, Albuquerque FC. Treatment of spinal arteriovenous malformation and fistula. Neurosurg Clin N Am 2022;33(2):193-206. PMID 35346451
25: English SW, Rabinstein AA, Flanagan EP, Zalewski NL. Spinal cord transient ischemic attack. Neurol Clin Pract 2020;10(6):480-3. PMID 33520410
26: Etgen T, Hocherl C. Repeated early thrombolysis in cervical spinal cord ischemia. J Thromb Thrombolysis 2016;42(1):142-5. PMID 26762860
27: Faig J, Busse O, Salbeck R. Vertebral body infarction as a confirmatory sign of spinal cord ischemic stroke: report of three cases and review of the literature. Stroke 1998;29:239-43. PMID 9445357
28: Falguera M, Pac M, Domingo A, et al. Malignant histiocytosis: review of the entity apropos of 2 cases with seldom seen clinical manifestations. Med Clin (Barc) 1987;89(3):115-8. PMID 3626649
29: Fieschi C, Gottlieb A, De Carolis V. Ischemic lacunae in the spinal cord of arteriosclerotic subjects. J Neurol Neurosurg Psychiatry 1985;33(2):138-46. PMID 5443471
30: Figueroa J, DeVine JG. Spontaneous spinal epidural hematoma: literature review. J Spine Surg 2017;3(1):58-63. PMID 28435919
31: Foix C, Alajouanine T. La myélite nécrotique subaigue. Rev Neurol 1926;2:1-42.
32: Fortuna A, Ferrante L, Acqui M, Trillo G. Spinal cord ischemia diagnosed by MRI. Case report and review of the literature. J Neuroradiol 1995;22(2):115-22. PMID 7629569
33: Fujigaki Y, Kimura M, Shimizu T, et al. Acute aortic thrombosis associated with spinal cord infarction in nephrotic syndrome. Clin Invest 1992;70(7):606-10. PMID 1392431
34: Fujii L, Clain JE, Morris JM, Levy MJ. Anterior spinal cord infarction with permanent paralysis following endoscopic ultrasound celiac plexus neurolysis. Endoscopy 2012;44 Suppl 2 UCTN:E265-6. PMID 22814912
35: Gao Z, Zhao K, Pan H, Chen K, Zheng J. Spinal cord ischemia following EVAR of a unilateral Iliac artery dissecting aneurysm: a case report. Ann Vasc Surg 2019;59:306. PMID 30684624
36: Ge L, Arul K, Stoner M, Mesfin A. Etiology and outcomes of spinal cord infarct: a case series from a level 1 trauma center. Global Spine J 2020;10(6):735-40. PMID 32707011
37: Gharios M, Stenimahitis V, El-Hajj VG, et al. Spontaneous spinal cord infarction: a systematic review. BMJ Neurology Open 2024;6(1):e000754. PMID 38818241
38: Gibb WR, Urry PA, Lees AJ. Giant cell arteritis with spinal cord infarction and basilar artery thrombosis. J Neurol Neurosurg Psychiatry 1985;48:945-8. PMID 4045490
39: Giovanini MA, Eskin TA, Mukherji SK, Mickle JP. Granulomatous angiitis of the spinal cord, case report. Neurosurgery 1994;34(3):540-3. PMID 8190233
40: Goss JA, Seu P, Shackleton CR, Busuttil RW. Lower extremity paralysis after use of the supraceliac aorta for hepatic arterial reconstruction of the transplanted liver. Transplantation 1997;63:163-4. PMID 9000681
41: Hasegawa M, Yamashita T, Ikeda K, Fujishima Y, Yamazaki M. Spinal cord infarction associated with primary antiphospholipid syndrome in a young child: case report. J Neurosurg 1993;79(3):446-50. PMID 8360745
42: Heller SL, Meyer JR, Russell EJ. Spinal cord venous infarction following endoscopic sclerotherapy for esophageal varices. Neurology 1996;47(4):1081-5. PMID 8857750
43: Hiramatsu M, Ishibashi R, Suzuki E, et al. Incidence and clinical characteristics of spinal arteriovenous shunts: hospital-based surveillance in Okayama, Japan. J Neurosurg Spine 2021;36(4):670-7. PMID 34715647
44: Hsu CJ, Lin PZ, Ju DT, Hueng DY, Tseng KY. Prognostic factors and treatment efficacy in spontaneous spinal epidural hematoma: a single center experience and literature review. In Vivo 2024;38(5):2415-24. PMID 39187334
45: Huang TC, Hwang JJ, Yip PK, Liu HM. Hypotensive spinal cord infarction associated with vertebral body infarction after treatment with short-acting antihypertensive agent. J Formos Med Assoc 2005;104:607-10. PMID 16193186
46: Hughes JT. Spinal cord infarction due to aortic trauma. Br Med J 1964;2:356. PMID 14160229
47: Hughes JT. Thrombosis of the posterior spinal arteries: a complication of an intrathecal injection of phenol. Neurology 1970;20:659-64. PMID 5467888
48: Hughes JT. Venous infarction of the spinal cord. Neurology 1971;21:794-800. PMID 5106295
49: Hughes JT, Brownell B. Cervical spondylosis complicated by spinal artery thrombosis. Neurology 1964;14:1073-7. PMID 14239093
50: Hughes JT, MacIntyre AG. Spinal cord infarction occurring during thoraco-lumbar sympathectomy. J Neurol Neurosurg Psychiatry 1963;26:418-21. PMID 14066633
51: Hurst RW, Grossman RI. Peripheral spinal cord hypointensity on T2-weighted MR images: a reliable imaging sign of venous hypertensive myelopathy. Am J Neuroradiol 2000;21:781-6. PMID 10782797
52: Hutchinson M, O'Riordan J, Javed M, et al. Familial hemiplegic migraine and autosomal dominant arteriopathy with leukoencephalopathy (CADASIL). Ann Neurol 1995;38(5):817-24. PMID 7486874
53: Jablawi F, Schubert GA, Dafotakis M, Pons-Kuhnemann J, Hans FJ, Mull M. Long-term outcome of patients with spinal dural arteriovenous fistula: the dilemma of delayed diagnosis. AJNR Am J Neuroradiol 2020;41(2):357-63. PMID 31919141
54: Joseph G, Santosh C, Marimuthu R, Fraser MH, McLean AN. Spinal cord infarction due to a self-inflicted needle stick injury. Spinal Cord 2004;42:655-8. PMID 15326468
55: Kemp CM, Feng Z, Aftab M, Reece TB. Preventing spinal cord injury following thoracoabdominal aortic aneurysm repair: the battle to eliminate paraplegia. JTCVS Tech 2021;8:11-15. PMID 34401794
56: Kenyon LC, Dulaney E, Montone KT, Goldberg HI, Liu GT, Lavi E. Varicella-Zoster ventriculo-encephalitis and spinal cord infarction in a patient with AIDS. Acta Neuropathol 1996;92:202-5. PMID 8841667
57: Keyhani K, Miller CC 3rd, Estrera AL, Wegryn T, Sheinbaum R, Safi HJ. Analysis of motor and somatosensory evoked potentials during thoracic and thoracoabdominal aortic aneurysm repair. J Vasc Surg 2009;49(1):36-41. PMID 18829232
58: Kim SY, Lee K, Sohn SY. A case of Brown-Sequard syndrome caused by spinal cord infarction. Journal of Neurocritical Care 2022;15(1):76-7.
59: Kiriakov VA, Odinokova VA. Moya-moya syndrome in disorders of spinal circulation. Sov Med 1989;6:72-5. PMID 2799498
60: Kouki S, Labben E, Abdullah NB. Acute spinal cord infarction after aortobifemoral bypass. Neurol India 2017;65(5):1128-30. PMID 28879909
61: Laufs H, Weidauer S, Heller C, Lorenz M, Neumann-Haefelin T. Hemi-spinal cord infarction due to vertebral artery dissection in congenital afibrinogenemia. Neurology 2004;63:1522-3. PMID 15505182
62: Lee DW, Choi YH. Spinal cord infarction mimicking ischemic heart disease. Clin Exp Emerg Med 2017;4(2):109-12. PMID 28717781
63: Leep Hunderfund AN, Wijdicks EFM. Intramedullary spinal cord hemorrhage (hematomyelia). Rev Neurol Dis 2009;6(2):E54-61. PMID 19587631
64: Le Guennec L, Shor N, Levy B, et al. Spinal cord infarction during venoarterial-extracorporeal membrane oxygenation support. J Artif Organs 2020;30:1-6. PMID 32474793
65: Lemke RP, Idiong N, Al-Saedi S, et al. Spinal cord infarct after arterial switch associated with an umbilical artery catheter. Ann Thorac Surg 1996;62:1532-4. PMID 8893606
66: Li W, Guo J, Wang L, Zhang T, Li T. Acute spinal cord infarction secondary to ankylosing spondylitis: a case report and literature review. Front Neurol 2023;14:1221810. PMID 37808493
67: Liblau R, Chiras J, Orssaud C, Dormont D, Duclos H, Gentilini M. Spinal infarction in the anterior spinal territory with possible relation to bilharziasis. Rev Neurol 1991;147(8-9):605-8. PMID 1962071
68: Lin CC, Chen SY, Lan C, Ting-Fang Shih T, Lin MC, Lai JS. Spinal cord infarction caused by cardiac tamponade. Am J Phys Med Rehabil 2002;81:68-71. PMID 11807337
69: Linz SM, Charbonnet C, Mikhail MS, et al. Spinal artery syndrome masked by postoperative epidural analgesia. Can J Anaesth 1997;44:1178-81. PMID 9398958
70: Liu H, Koyanagi I, Chiba H, et al. Spinal cord infarct as the initial clinical presentation of intravascular malignant lymphomatosis. J Clin Neurosci 2009;16(4):570-3. PMID 19200739
71: Maimon S, Luckman Y, Strauss I. Spinal dural arteriovenous fistula: a review. Adv Tech Stand Neurosurg 2016;(43):111-37. PMID 26508408
72: Maiti TK, Bir SC, Nanda A. Spinal subarachnoid hemorrhage and aneurysms. Handb Clin Neurol 2017;143:215-23. PMID 28552143
73: Malik MM, Woolsey RM. Acute myelopathy following intravenous heroin: a case report. J Am Paraplegia Soc 1991;14(4):182-3. PMID 1960535
74: Manjila S, Haroon N, Parker B, Xavier AP, Guthikonda M, Rengachary SS. Albert Wojciech Adamkiewicz (1850–1921): unsung hero behind the eponymic artery. Neurosurg Focus 2009;26(1):E2. PMID 19119888
75: Maraire JN, Abdulrauf SI, Berger S, Knisely J, Awad IA. De novo development of a cavernous malformation of the spinal cord following spinal axis radiation. Case report. J Neurosurg 1999;90(2 Suppl):234-38. PMID 10199254
76: Marie P, Foix C. L’atrophie isolae non progressive des petits muscles de la main. In frequence relative et pathogenie. Tephromalacie anterieure. Polyomyelite, nevrite radicul 1912.
77: Martinez-Lage JF, Almagro MJ, Izura V, Serrano C, Ruiz-Espejo AM, Sánchez-Del-Rincón I. Cervical spinal cord infarction after posterior fossa surgery: a case-based update. Childs Nerv Syst 2009;25(12):1541-6. PMID 19590878
78: Mascalchi M, Cosottini M, Ferrito G, Salvi F, Nencini P, Quilici N. Posterior spinal artery infarct. AJNR Am J Neuroradiol 1998;19:361-3. PMID 9504495
79: Mathew P, Todd NV, Hadley DM, Adams JH. Spinal cord infarction following meningitis. Br J Neurosurg 1993;7(6):701-4. PMID 8161436
80: McCarty J, Chung C, Samant R, et al. Vascular pathologic conditions in and around the spinal cord. Radiographics 2024;44(9):e240055. PMID 39207926
81: McCormick PC. Spinal vascular malformations. Semin Neurol 1993;13(4):349-58. PMID 8146485
82: McGarvey ML, Cheung AT, Szeto W, Messe SR. Management of neurologic complications of thoracic aortic surgery. J Clin Neurophysiol 2007;24(4):336-43. PMID 17938602
83: McNamara JF, Paterson DL, Allworth A, Presneill J, O'Connell P, Henderson R, Paterson DL. Reactivation of varicella zoster virus associated with anterior spinal cord stroke in pregnancy. Infect Dis (Lond) 2016;48(9):705-7. PMID 27207607
84: Monteiro L, Leite I, Pinto JA, Stocker A. Spontaneous thoracolumbar spinal cord infarction: report of six cases. Acta Neurol Scand 1992;86(6):563-6. PMID 1481641
85: Mori S, Sadoshima S, Tagawa K, Iino K, Fujishima M. Massive spinal cord infarction with multiple paradoxical embolism: a case report. Angiology 1993;44(3):251-6. PMID 8442536
86: Muralidharan R, Saladino A, Lanzino G, Atkinson JL, Rabinstein AA. The clinical and radiological presentation of spinal dural arteriovenous fistula. Spine (Phila Pa 1976) 2011;36(25):E1641-7. PMID 21336239
87: Muraszco KM, Oldfield EH. Vascular malformations of the spinal cord and dura. Neurosurg Clin N Am 1990;1(3):631-52. PMID 2316162
88: Nair KR, Bhaskaran R, Retnakumari S, Madhusoodana M. Ischemic myelopathy in Takayasu's disease. J Assoc Physicians India 1985;33(11):735-6. PMID 2869023
89: New PW, McFarlane CL. Retrospective case series of outcomes following spinal cord infarction. Eur J Neurol 2012;19(9):19(9):1207-12. PMID 22435357
90: Newton TH, Adams JE. Angiographic demonstration and nonsurgical embolization of spinal cord angioma. Radiology 1968;91(5):873-6. PMID 5687792
91: Nitta H, Yamashita J, Nomura M, Igarashi N. Cervical spinal cord infarction after surgery for a pineal region choriocarcinoma in the sitting position: case report. Neurosurgery 1997;40:1082-5. PMID 9149270
92: Park JH, Park S, Choi SA. Incidence and risk factors of spinal epidural hemorrhage after spine surgery: a cross-sectional retrospective analysis of a national database. BMC Musculoskelet Disord 2020;21(1):324. PMID 32450822
93: Park SJ, Kim CH, Kim JD, et al. Spinal cord injury after conducting transcatheter arterial chemoembolization for costal metastasis of hepatocellular carcinoma. Clin Mol Hepatol 2012;18(3):316-320. PMID 23091813
94: Pello SJ, Ashkenazi A. Spinal cord infarction in a woman with cardiac fibroelastoma. Neurologist 2011;17:47-8. PMID 21192195
95: Pikija S, Kunz AB, Nardone R, et al. Spontaneous spinal cord infarction in Austria: a two-center comparative study. Ther Adv Neurol Disord 2022;15:17562864221076321. PMID 35299778
96: Porrini AA, Maldonado Cocco JA, Garcia Morteo O. Spinal artery steal syndrome in Paget's disease of the bone. Clin Exp Rheumatol 1987;5(4):377-8. PMID 3440335
97: Puente-Hernandez M, Rivero-de-Aguilar A, Varela-Lema L. Cancer-associated spinal cord infarction: a systematic review and analysis of survival predictors. J Neurol Sci 2023;446:120580. PMID 36764185
98: Quinn JN, Breit H, Dafer RM. Spinal cord infarction due to fibrocartilaginous embolism: a report of 3 cases. J Stroke Cerebrovasc Dis 2019;28(6):e66-7. PMID 30930242
99: Qureshi AI, Afzal MR, Suri MFK. A population-based study of the incidence of acute spinal cord interaction. J Vasc Interv Neurol 2017;9(4):44-8. PMID 28702119
100: Ram S, Osman A, Cassar-Pullicino VN, Short DJ, Masry WE. Spinal cord infarction secondary to intervertebral foraminal disease. Spinal Cord 2004;42:481-4. PMID 15249926
101: Ramelli GP, Wyttenbach R, von der Weid N, Ozdoba C. Anterior spinal artery syndrome in an adolescent with protein S deficiency. J Child Neurol 2001;16:134-5. PMID 11292220
102: Renowden SA, Molyneux AJ. Case report: spontaneous thrombosis of a spinal dural AVM (Foix-Alajouanine syndrome)--magnetic resonance appearance. Clin Radiol 1993;47(2):134-6. PMID 8435961
103: Rigney L, Cappelen-Smith C, Sebire D, Beran RG, Cordato D. Nontraumatic spinal cord ischaemic syndrome. J Clin Neurosci 2015;22(10):1544-9. PMID 26154150
104: Roa KR, Donnenfeld H, Chusid JG, Valdez S. Acute myelopathy secondary to spinal venous thrombosis. J Neurol Sci 1982;56(1):107-13. PMID 7143024
105: Robertson CE, Brown RD Jr, Wijdicks EF, Rabinstein AA. Recovery after spinal cord infarcts: long-term outcome in 115 patients. Neurology 2012;78(12):114-21. PMID 22205760
106: Rogopoulos A, Benchimol D, Paquis P, Mahagne MH, Bourgeon A. Lumbar artery compression by the diaphragmatic crus: a new etiology for spinal cord ischemia. Ann Neurol 2000;48:261-4. PMID 10939580
107: Ronald AA, Yao B, Winkelman RD, Piraino D, Masaryk TJ, Krishnaney AA. Spinal dural arteriovenous fistula: diagnosis, outcomes, and prognostic factors. World Neurosurg 2020;144:e306-15. PMID 32858225
108: Rosenblum B, Oldfield EH, Doppman JL, Di Chiro G. Spinal arteriovenous malformations: a comparison of dural arteriovenous fistulas and intradural AVM’s in 81 patients. J Neurosurg 1987;67(6):795-802. PMID 3681418
109: Rossi D, Goodwin D, Cruzzavala J. Spinal cord infarction following coronary artery bypass grafting surgery. WV Med J 2008;104(6):24-5. PMID 19006901
110: Rothman SM, Nelson JS. Spinal cord infarction in a patient with sickle cell anemia. Neurology 1990;13(6):463-7.
111: Sakakibara R, Yamaguchi C, Uchiyama T, et al. Pelvic autonomic dysfunction without paraplegia: a sequel of spinal cord stroke. Eur Neurol 2008;60(2):97-100. PMID 18552497
112: Salam AA, Sholkamy SM, Chaikof EL. Spinal cord ischemia after abdominal aortic procedures: is previous colectomy a risk factor. J Vasc Surg 1993;17(6):1108-10. PMID 8505791
113: Sandson TA, Friedman JH. Spinal cord infarction: report of 8 cases and review of the literature. Medicine 1989;68(5):282-92. PMID 2677596
114: Sato K, Roccatagliata L, Depuydt S, Rodesch G. Multiple aneurysms of thoracic spinal cord arteries presenting with spinal infarction and subarachnoid hemorrhage: case report and literature review. Neurosurgery 2012;71(5):E1053-8. PMID 23086108
115: Sekar A, Raj ARP. Spinal cavernoma. In: Endovascular and neurovascular surgery for spinal vascular malformations. Springer, Singapore, 2024:207-15.
116: Shuster A, Franchetto A. Surfer's myelopathy-an unusual cause of acute spinal cord ischemia: a case report and review of the literature. Emerg Radiol 2011;18(1):57-60. PMID 20963461
117: Silver JR. History of infarction of the spinal cord. J Hist Neurosci 2003;12(2):144-53. PMID 12953617
118: Silver JR, Buxton PH. Spinal stroke. Brain 1974;97:539-50. PMID 4417652
119: Singh BM, Fass AE, Pooley RW, Wallach R. Paraplegia associated with intraaortic balloon pump counterpulsation. Stroke 1983;14:983-6. PMID 6659004
120: Singh U, Silver JR, Welply NC. Hypotensive infarction of the spinal cord. Paraplegia 1994;32(5):314-22. PMID 8058348
121: Sliwa JA, Maclean IC. Ischemic myelopathy: a review of spinal vasculature and related clinical syndromes. Arch Phys Med Rehabil 1992;73(4):365-72. PMID 1554311
122: Spiller WG. Thrombosis of the cervical anterior median spinal artery; syphilitic acute anterior poliomyelitis. The Journal of Nervous and Mental Disease 1909;36(10):601-13.
123: Struhal W, Seifert-Held T, Lahrmann H, Fazekas F, Grisold W. Clinical core symptoms of posterior spinal artery ischemia. Eur Neurol 2011;65(4):183-6. PMID 23189729
124: Sturzenegger M. Spinal stroke syndromes. In: Stroke syndromes. Bogousslavsky J, Caplan LR, editors. Cambridge: Cambridge University Press, 2001: 691-704.
125: Tator CH. Update on the pathophysiology and pathology of acute spinal cord injury. Brain Pathol 1995;5(4):407-13. PMID 8974623
126: Thar YY, Tun AM, Huang T, Bordia S, Guevara E. Spinal cord infarct as a presentation of cholangiocarcinoma with metastases. Ann Transl Med 2015;3(20):320. PMID 26697480
127: Tong X, Deng X, Li H, Du Z, Xu Y. Clinical presentation and surgical outcome of intramedullary spinal cord cavernous malformations. J Neurosurg Spine 2012;16(3):308-14. PMID 22195607
128: Toole J. Cerebrovascular diseases. In: Spinal cord vascular anatomy and diseases. New York: Raven, 1990:519-34.
129: Vargas MI, Gariani J, Sztajzel R, et al. Spinal cord ischemia: practical imaging tips, pearls, and pitfalls. AJNR Am J Neuroradiol 2015;36(5):825-30. PMID 25324492
130: Vastani A, Mirza AB, Lavrador JP, et al. Risk factor analysis and surgical outcomes of acute spontaneous spinal subdural hematoma. An institutional experience of four cases and literature review. World Neurosurg 2021;146:384-97. PMID 33223130
131: Vatankulu MA, Kayrak M, Alihanoglu Y, Salli A, Ulgen MS. A rare but serious complication of percutaneous coronary intervention: spinal cord embolism. J Spinal Cord Med 2010;33(1):85-9. PMID 20397450
132: Vijayan N, Peacock JH. Spinal cord infarction during use of zolmitriptan: a case report. Headache 2000;40:57-60. PMID 10759907
133: von Pohle WR. Disseminated mucormycosis presenting with lower extremity weakness. Eur Respir J 1996;9:1751-3. PMID 8866605
134: Walden JE, Castillo M. Sildenafil-Induced Cervical Spinal Cord Infarction. AJNR Am J Neuroradiol 2012;33(3):E32-3. PMID 21903916
135: Wang MY, Arnold AC, Vinters HV, Glasgow BJ. Bilateral blindness and lumbosacral myelopathy associated with high-dose carmustine and cisplatin therapy. Am J Ophthalmol 2000;130:367-8. PMID 11020424
136: Wei SC, Kao JH, Lee WY, Lin JT, Wang TH. Acute pancreatitis complicated by infarction of the spleen and spinal cord. J Formos Med Assoc 1997;96:754-7. PMID 9308332
137: Weidauer S, Dettmann E, Krakow K, Lanfermann H. Diffusion-weighted MRI of spinal cord infarction: description of two cases and review of the literature. Nervenarzt 2002;73:999-1003. PMID 12376890
138: Williams A, Little M, Gibbs J, Warwicker P, Farrington K. Spinal cord infarction following central-line insertion. Renal Failure 2003;25(2):327-9. PMID 12739841
139: Williamson J, Bonello M, Simpson M, Jacob A. Spinal cord infarction after cocaine use. Pract Neurol 2017;17(1):51-2. PMID 27872170
140: Wiszniewska M, Sankowska M. Spinal cord ischemia-from diagnosis to treatment. Postep Psychiatr Neurol 2024;33(2):93-7. PMID 39119546
141: Wityk RJ, Zanferrari C, Oppenheimer S. Neurovascular complications of marfan syndrome: a retrospective, hospital-based study. Stroke 2002;33:680-4. PMID 11872887
142: Wrobel CJ, Rothrock J. Coccidioidomycosis meningitis presenting as anterior spinal artery syndrome. Neurology 1992;42(9):1840. PMID 1513482
143: Yadav N, Pendharkar H, Kulkarni GB. Spinal cord infarction: clinical and radiological features. J Stroke Cerebrovasc Dis 2018;27(10):2810-21. PMID 30093205
144: Young RR, Woolsey RM. Diagnosis and management of disorders of the spinal cord. Philadelphia: WB Saunders, 1995:51-4, 65-6.
145: Zalewski NL, Rabinstein AA, Krecke KN. Characteristics of spontaneous spinal cord infarction and proposed diagnostic criteria. JAMA Neurol 2019;76(1):56-63. PMID 30264146
146: Zaninovich O, Ramey W, Eldersveld J, Kasoff WS. Malignant melanotic Schwannian tumor presenting with spinal cord infarction due to occlusion of the artery of Adamkiewicz: case report and review of the literature. World Neurosurg 2019;128:422-5. PMID 31108251
147: Zedde M, De Falco A, Zanferrari C, et al. Spinal cord infarction: clinical and neuroradiological clues of a rare stroke subtype. J Clin Med 2025;15(14):1293. PMID 40004823
148: Zhong W, Chen H, You C, Li J, Liu Y, Huang S. Spontaneous spinal epidural hematoma. J Clin Neurosci 2011;18(11):1490-94. PMID 21920757

Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Author

Elizabeth Anderson MD

Dr. Anderson of NYC Health and Hospitals/Kings County has no relevant financial relationships to disclose.
See Profile

Editor

Steven R Levine MD

Dr. Levine of the SUNY Health Science Center at Brooklyn has no relevant financial relationships to disclose.
See Profile

Former Authors

Enrique C Leira MD
Eric Goldstein MD

Patient Profile

Age range of presentation: Age range depends on etiology, eg, fibrocartilaginous emboli are more common in young adults, whereas spinovascular insufficiency is more common in older adults. This topic covers nearly the entire lifespan.
Sex preponderance: No sex preponderance
Heredity: None
Population groups selectively affected: Post-operative
Occupation groups selectively affected: Surfers and those who recurrently hyperextend their necks

ICD & OMIM codes

ICD-10: Vascular myelopathies: G95.1
ICD-11: Other specified non-compressive vascular myelopathies: 8B43.Y

Non-compressive vascular myelopathies, unspecified: 8B43.Z
OMIM: CADASIL: #125310

Cerebral cavernous malformation syndrome: #116860

Hereditary hemorrhagic telangiectasia: #175050

This is an article preview.
Start a Free Account
to access the full version.

Nearly 3,000 illustrations, including video clips of neurologic disorders.
Every article is reviewed by our esteemed Editorial Board for accuracy and currency.
Full spectrum of neurology in 1,200 comprehensive articles.
Listen to MedLink on the go with Audio versions of each article.

Questions or Comment?

MedLink, LLC

3525 Del Mar Heights Rd, Ste 304
San Diego, CA 92130-2122

Toll Free (U.S. + Canada): 800-452-2400

US Number: +1-619-640-4660

Support: service@medlink.com

Editor: editor@medlink.com

ISSN: 2831-9125

Vascular disorders of the spinal cord

Associated Disorders

familial cerebral cavernous malformation syndrome
hereditary hemorrhagic telangiectasia
Cobb syndrome

Differential Diagnosis

autoimmune conditions
infectious myelitis
Guillain-Barre–related syndromes

Also Relevant

Aortic diseases: neurologic complications
Cavernous malformations
Cerebral arteriopathies

Clinical Categories

Stroke & Vascular Disorders

	• Preventing an ischemic spinal infarct relies on the same strategies as secondary stroke prevention.
	• Intraoperative monitoring and careful monitoring of vital signs are important in preventing iatrogenic spinal cord infarcts during aortic interventions.

Vascular disorders of the spinal cord

Cite this article

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Ischemic processes

Hemorrhagic processes

Vascular anomalies

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Table 1. Etiology of Spinal Cord Infarctions

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Associated or underlying disorders

Diagnostic workup

Management

Outcomes

Special considerations

Pregnancy

Anesthesia

Media

References

Contributors

Author

Editor

Former Authors

Patient Profile

ICD & OMIM codes

This is an article preview. Start a Free Account to access the full version.

Questions or Comment?

Also in This Category

Neoplastic and infectious aneurysms

Aortic atherosclerosis and stroke

Stroke associated with cerebral angiography

Sneddon syndrome

Cerebral venous thrombosis

Fibromuscular dysplasia

Brainstem hemorrhage

Cavernous malformations

This is an article preview.
Start a Free Account
to access the full version.