Imaging Characteristics, Clinical Presentation, and Prognosis of Spinal Cord Infarction

Imaging Characteristics, Clinical Presentation, and Prognosis of Spinal Cord Infarction | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Imaging Characteristics, Clinical Presentation, and Prognosis of Spinal Cord Infarction Narihito Nagoshi, Yasuhiro Kamata, Toshiki Okubo, Masahiro Ozaki, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6730915/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Study design : Retrospective cohort study. Introduction : Spinal cord infarction is a rare condition, and many aspects of its pathophysiology remain unclear. The purpose of this study is to conduct a comprehensive analysis of the clinical symptoms, imaging changes, and prognosis of spinal cord infarction to elucidate its pathophysiology. Setting : The multiple institutions in Japan. Methods : We retrospectively analyzed the clinical course and imaging findings of 19 patients diagnosed with spinal cord infarction at affiliated institutions between 2012 and 2022, based on medical records. Prognosis was assessed using the modified Rankin Scale (mRS), with a favorable outcome defined as the ability to walk independently (mRS 0–3) at discharge. Results : The study cohort consisted of 15 male and 4 female patients, with a mean age of 62.7±18.4 years. Eleven patients were iatrogenic following cardiac surgery and epidural anesthesia. Among eight patients who underwent diffusion-weighted imaging (DWI) within two days of onset, five exhibited hyperintensity at the infarcted site. Clinically, 12 patients presented with anterior spinal artery syndrome, five with Brown-Séquard syndrome, and two with transverse infarction. A favorable prognosis at discharge was observed in six patients, five of whom had Brown-Séquard syndrome, showing a significant association between a good prognosis and Brown-Séquard syndrome (p < 0.01). Conclusions : DWI in MRI can aid in the early diagnosis of spinal cord infarction immediately after onset. Additionally, the findings suggest that patients with Brown-Séquard syndrome have a favorable prognosis for gait ability. Health sciences/Medical research/Outcomes research Health sciences/Diseases/Neurological disorders/Spinal cord diseases Figures Figure 1 INTRODUCTION Spinal cord infarction is a rare condition, accounting for approximately 6% of spinal cord diseases and 0.3–1.0% of all ischemic strokes [ 1 ]. Etiologies include spontaneous onset, traumatic vascular dissection, hypotension, atherosclerosis, abdominal aortic aneurysm repair, and epidural anesthesia [ 2 – 8 ]. Spinal cord infarction typically presents acutely, often manifesting as sudden-onset paralysis, necessitating immediate medical intervention. Despite its clinical significance, there are no established diagnostic criteria for spinal cord infarction, making definitive diagnosis challenging. In clinical practice, the condition is generally diagnosed when a patient exhibits relatively rapid-onset spinal neurological deficits, with corresponding intramedullary lesions on magnetic resonance imaging (MRI) at the affected spinal level, while excluding other possible differential diagnoses. However, MRI findings in the hyperacute phase may not show signal changes, with T2-weighted hyperintensity typically appearing 2–9 days post-onset [ 9 ]. Diffusion-weighted imaging (DWI) has been proposed as a potential tool for early detection, yet its utility remains limited due to the small size of the spinal cord and difficulties in identifying signal abnormalities [ 10 , 11 ]. Furthermore, there are no standardized treatment guidelines for spinal cord infarction, resulting in considerable variability in management across institutions, with treatment strategies being tailored to individual cases. Despite this lack of consensus, some patients exhibit favorable neurological recovery [ 12 ]. Robertson et al. has reported that patients with mild paralysis at onset are more likely to experience neurological recovery [ 13 ]. However, the causal relationship between the underlying pathophysiology of spinal cord infarction and the improvement of paralysis remains unclear. The present study aims to comprehensively investigate the clinical manifestations, imaging characteristics, and prognostic factors of spinal cord infarction, to elucidate its underlying pathophysiology. METHODS Study Participants and Clinical Data Collection This retrospective observational study included 19 patients diagnosed with spinal cord infarction at the three hospitals between 2012 and 2022. The diagnostic criteria for spinal cord infarction are as follows: 1. Acute onset, 2. No history of trauma, 3. Presence of neurological deficits associated with spinal cord dysfunction, such as motor paralysis, sensory disturbance, or urinary dysfunction, 4. Evidence of spinal cord lesions on spinal MRI, 5. Absence of compressive lesions of the spinal cord. Clinical data collected included age, sex, smoking history, underlying diseases, etiology, presence of back pain, and infraction type. The modified Rankin Scale (mRS) [ 14 ] was used to evaluate disability at the nadir of symptoms and at follow-up. Patients who could walk without assistance were classified as the good prognosis group (mRS: 0–3), while those who could not walk without assistance were classified as the poor prognosis group (mRS: 4–6) [ 15 ]. A comparative evaluation was conducted as an additional sub-analysis by categorizing spinal cord infarction into iatrogenic and non-iatrogenic groups. MRI examinations were performed between 2 hours to 25 days after the onset of clinical symptoms. The standardized imaging protocol included native axial and sagittal T1- and T2-weighted scans. All patient data is shown in Supplemental Table 1. Statistical Methods Continuous variables and frequencies are presented as means ± standard deviations (SDs) and the categorical variables as percentages. Differences between the groups were examined using the chi-square analysis and the Mann- Whitney U test. Statistical significance was defined as a P value of < 0.05. Data were analyzed with statistical package for social science (SPSS) Statistics, version 28.0.1.0 (IBM Corp., Armonk, NY). Ethics Statement All the patients provided written informed consent, and the study protocol was approved by the institutional review board prior to data collection and analysis (approval number 20110142). The corresponding author assumes complete responsibility for maintaining the integrity of the data and ensuring the accuracy of the data analysis. RESULTS Characteristics of Patients with Spinal Infarction Table 1 summarizes the demographics for 19 patients, including 15 men (78.9%) and four women (21.1%), 62.7 ± 18.4 years old on average. Five patients (26.3%) were smokers. One patient (5.3%) had hyperlipidemia, six patients (31.6%) had hypertension, and four patients (21.1%) had diabetes as underlying conditions. The etiology included 8 patients of cardiovascular surgery (42.1%), 3 patients of epidural anesthesia (15.8%), and 8 patients of unknown cause (42.1%). Five patients had back pain at the time of onset. The infarctions were categorized into three types: anterior spinal artery (ASA) syndrome (n = 12), Brown–Séquard syndrome (n = 5), and transverse infarction (n = 2). Six patients (31.6％) were able to walk independently, corresponding to an mRS of 3 or less. MRI Findings Table 2 summarizes the characteristics of imaging findings. The average time from onset to MRI was 4.2 ± 5.8 days. The level of spinal infarction was cervical in 1 patient (5.3％), upper thoracic in 9 patients (47.4％), and lower thoracic in 9 patients (47.4％). The localization of spinal infarction was ventral in 12 patients (63.2％), lateral funiculus in 3 patients (15.8％), ventral and lateral funiculus in 1 patient (5.3％), lateral funiculus and dorsal in 1 patient (5.3％), and transverse in 2 patients (10.5％). The average spinal length of the infarction was 2.7 ± 1.9 vertebral bodies. In all cases, a high-signal area was observed on T2-weighted imaging during the follow-up examination. Among the patients, eight underwent DWI within two days of onset. Of these, five (62.5%) exhibited signal changes in the infarcted area on DWI. Comparison Between the Good and Poor Prognosis Groups In the prognostic analysis of walking ability, six patients were classified into the good prognosis group (mRS 0–3), while 13 patients were categorized into the poor prognosis group (mRS 4–6). The age, sex, etiology, the time to MRI, the length of lesions, and the localization of the infarct did not differ between the two groups. However, in the good prognosis group, five patients (83.3%) presented with Brown–Séquard syndrome, whereas 11 patients (84.6%) in the poor prognosis group exhibited ASA syndrome, demonstrating a statistically significant difference (p < 0.01). Comparison Between the Iatrogenic and Non-iatrogenic Groups As shown in Table 1, eight patients of spinal cord infarction occurred following cardiovascular surgery, and three patients were observed after epidural anesthesia. These 11 patients were classified as iatrogenic spinal cord infarction and compared with eight patients of infarction of unknown etiology. Significant differences were observed between the two groups in age (72.2 ± 11 years vs. 49.8 ± 19.1 years; p = 0.01) and gender (percentage of male patients: 100% vs. 50.0%; p = 0.02). The time to MRI, the length of intramedullary lesions, the localization of the infarct, prognosis, and infraction type did not differ between the two groups (Table 4). Representative Case Case 4: A 19-year-old female reported a sensation of discomfort in both lower limbs and weakness in the right lower limb, which began one day prior without any apparent cause. Her medical history included atrial septal defect and tricuspid regurgitation, for which she underwent surgery during childhood. However, she had no recent history of trauma or infectious symptoms. She had no diabetes, and her blood pressure was normal. A neurological examination revealed that her consciousness and speech were normal. Cranial nerve examination showed no abnormalities. According to the Manual Muscle Test (MMT) scale, muscle strength was 5/5 distal to the deltoid muscles in both upper limbs, 3-4/5 distal to the iliopsoas muscle in the right lower limb, and 5/5 in the contralateral lower limb. There was decreased vibratory sensation in both lower limbs and reduced temperature and pain sensation distal to the right ankle. Clinical tests, including hematological, biochemical, and immunological examinations, were all within normal ranges. Head computed tomography and MRI showed no apparent abnormalities. On the second day after onset, thoracic spine T2-weighted MRI revealed no abnormalities, but a high-signal lesion was observed at the T4 level on axial DWI (Figure 1a and 1b). On the sixth day after onset, T2-weighted MRI of the thoracic spine revealed a high-signal lesion at the same location where the signal change was previously observed on the second-day DWI (Figure 1c). Based on these findings, a diagnosis of spinal cord infarction presenting as Brown-Séquard syndrome was made. The patient underwent anti-edema therapy from the first day after onset and anticoagulant therapy from the second day. By the fifth day, the previously weakened muscle strength had improved, with only residual sensory dullness on the right sole. She was discharged ambulatory with the mRS score of 1. DISCUSSION In this study, we investigated factors associated with gait prognosis in 19 patients with spinal cord infarction. The results indicated that patients who retained the ability to walk exhibited a significantly higher prevalence of Brown-Séquard syndrome. In contrast, those who experienced complete loss of gait function more frequently exhibited infarction of the anterior spinal artery or transverse infarction. Additionally, we assessed differences between iatrogenic and non-iatrogenic cases; however, no significant differences were observed in infarction level, infarction type, or functional recovery. These findings suggest that, regardless of the underlying cause of spinal cord infarction, the prognosis of neurological function is primarily determined by the affected vasculature and the extent of damage to its corresponding perfusion territory. Consistent with previous reports [ 1 ], our study also found that ASA syndrome was the most common infarction type, observed in 12 out of 19 cases. ASA syndrome results from impaired or obstructed blood flow in the artery supplying the anterior two-thirds of the spinal cord, leading to sudden onset of paraplegia or quadriplegia, dissociative sensory loss, and bladder or rectal dysfunction. In contrast, Brown-Séquard syndrome is a condition that occurs when one side of the spinal cord is affected, characterized by ipsilateral pyramidal tract signs and deep sensory impairment, along with contralateral loss of pain and temperature sensation. This pathology primarily involves unilateral damage, often resulting in paralysis of only one lower limb. Consequently, gait function is relatively preserved in these patients. Therefore, in this study, patients with Brown-Séquard syndrome exhibited better neurological functional outcomes. Robertson et al. also reported that patients classified as American Spinal Injury Association Impairment Scale (AIS) C or D at the time of onset retained ambulatory function thereafter [ 13 ]. In our study, patients with Brown-Séquard syndrome were ambulatory and were considered to correspond to AIS C or D. Therefore, our finding is consistent with their research, supporting the favorable neurological prognosis for ambulation. In this study, DWI was performed within two days of onset in eight cases, of which five cases (62.5%) demonstrated signal changes. DWI is widely used for the evaluation of acute cerebral infarction and has also been reported to be useful for the early diagnosis of spinal cord infarction [ 16 – 19 ]. Our findings support this notion, as more than half of the cases in which early DWI imaging was performed exhibited signal changes, suggesting its diagnostic utility. However, only eight cases (42.1%) underwent the DWI, while the remaining cases were not evaluated at an early stage. This highlights the need for proactive acquisition of DWI sequences as part of MRI when spinal cord infarction is suspected, rather than merely performing MRI alone. Nevertheless, a few cases in the current study did not exhibit signal changes in DWI, raising concerns about the difficulty of early diagnosis in such cases. Regarding the spinal level of onset, in our study, only one case originated in the cervical spine, while the remaining 18 cases (94.7%) occurred in the thoracic spine. Although previous reports have shown some variation in the incidence, they consistently identify the thoracic spine as the most frequently affected region (ranging from 56.5–70%) [ 4 , 20 ], aligning with our findings. The predominance of thoracic involvement has been attributed to anatomical characteristics. The arterial supply of the human spinal cord consists of a single anterior spinal artery and two posterior spinal arteries. The diameter of the anterior spinal artery decreases caudally from the T4 level and increases distally from the confluence of the artery of Adamkiewicz [ 21 ], which may contribute to the higher frequency of thoracic involvement. Furthermore, in our study, 11 cases were iatrogenic, occurring after cardiovascular surgery or epidural anesthesia. Given that many medical interventions are performed at the thoracic level, this factor may have contributed to the relatively high incidence of thoracic onset in our cohort. In this study, the iatrogenic causes of spinal cord infarction were identified as postoperative complications of cardiovascular surgery and epidural anesthesia. Spinal cord infarction following cardiovascular surgery, particularly after abdominal aortic aneurysm repair or aortic dissection surgery, has been relatively well-documented. It has been reported that spinal cord infarction in this context can occur either immediately or in a delayed manner [ 22 , 23 ]. Immediate infarction results from intraoperative spinal ischemia, leading to irreversible spinal cord damage. While this can be caused by embolism or other persistent ischemic events, even transient ischemia exceeding a critical duration can result in irreversible damage. Delayed injury, on the other hand, has been attributed to postoperative occlusion of nutritional arteries (such as occlusion of reconstructed arteries or progressive thrombosis of the false lumen in aortic dissection), spinal cord edema-induced elevation of intraspinal pressure, and hemodynamic deterioration leading to reduced spinal cord perfusion pressure. In contrast, reports of spinal cord infarction following epidural anesthesia are scarce. Some studies have hypothesized that spinal cord ischemia in this setting may be associated with intraoperative hypotension [ 24 ], the neurotoxicity of local anesthetics [ 25 ], or vasospasm induced by local anesthetics containing epinephrine. However, no definitive causal relationship has been established. In our study, there were no significant differences in infarct extent, location, infarction type, or prognosis between iatrogenic and non-iatrogenic cases of spinal cord infarction. These findings suggest that differences in the etiology of spinal cord infarction may have minimal impact on its pathological characteristics. Several limitations should be described in the present study. First, this study included a relatively small cohort of 19 patients with spinal cord infarction, which limits the statistical power and generalizability of the findings. A larger sample size would be necessary to draw more definitive conclusions and improve the robustness of the statistical analyses. Second, the study was conducted at a single institution in Japan, which may limit the generalizability of the findings to other populations and healthcare settings. Multicenter studies involving diverse patient demographics and medical practices would enhance the applicability of the results. Third, as a retrospective observational study, this research is subject to inherent biases, including incomplete medical records and variations in diagnostic approach. A prospective study design would allow for more standardized data collection and minimize potential biases. And finally, the study was unable to address treatment-related aspects due to insufficient documentation in medical records. Additionally, the treatment strategies and initiation timing varied among cases, preventing a comprehensive analysis of their impact on neurological outcomes. Despite these limitations, the present study is the first to identify the type of vascular insufficiency due to infarction as a key factor influencing neurological outcomes following spinal cord infarction. Based on these findings, it may be possible to estimate the clinical condition and functional prognosis of the patients with spinal cord infarction. CONCLUSIONS In this study, we analyzed the clinical features, MRI findings, and prognosis of 19 cases of spinal cord infarction. Our findings indicate that DWI on MRI can facilitate early diagnosis immediately after onset in certain patients. While the underlying etiology was not associated with neurological prognosis, the infarction pattern at onset served as a prognostic indicator. These findings are expected to contribute to further understanding of the pathophysiology of spinal cord infarction. Declarations Acknowledgements We would like to express our deepest gratitude to all the institutions that have cooperated with us. In preparing this manuscript, ChatGPT (OpenAI) and Grammarly (Grammarly Inc.) were used for grammar refinement and typographical error correction. These tools were employed exclusively to improve clarity and readability, without modifying the scientific content or interpretation of the findings. Author Contribution Y.K., T.O., M.O., S.S., K.T., T.I., K.S., M.M., M.N., K.W., and N.N. designed the study; Y.K. and N.N. performed the experiments and analyzed the data; N.N. supervised the experiments; Y.K. and N.N. wrote the manuscript. Source of Funding None. Ethical Approval All the patients provided written informed consent, and the study protocol was approved by the institutional review board prior to data collection and analysis (approval number 20110142). The first author assumes complete responsibility for maintaining the integrity of the data and ensuring the accuracy of the data analysis. Conflicts of Interest The authors declare that there are no relevant conflicts of interest. References Vargas MI, Gariani J, Sztajzel R, Barnaure-Nachbar I, Delattre BM, Lovblad KO, Dietemann JL. Spinal cord ischemia: practical imaging tips, pearls, and pitfalls. AJNR Am J Neuroradiol 2015; 36: 825–830. Sandson TA, Friedman JH. Spinal cord infarction. Report of 8 cases and review of the literature. Medicine (Baltimore) 1989; 68: 282–292. Meng YY, Dou L, Wang CM, Kong DZ, Wei Y, Wu LS, et al. Spinal cord infarction presenting as Brown-Séquard syndrome from spontaneous vertebral artery dissection: a case report and literature review. 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Additional Declarations There is a duality of interest Supplementary Files XXXXXXXXXXXXXXXSpinalCordXXXXXXTable1.docx Table 1 XXXXXXXXXXXXXXXSpinalCordXXXXXXTable2.docx Table 2 XXXXXXXXXXXXXXXSpinalCordXXXXXXTable3.docx Table 3 XXXXXXXXXXXXXXXSpinalCordXXXXXXTable4.docx Table 4 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6730915","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":465228255,"identity":"c7f6d1db-0cce-44ce-983a-1c3780f69ff5","order_by":0,"name":"Narihito 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08:31:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6730915/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6730915/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84199058,"identity":"36a7f16a-3871-49ef-aecb-81a28d69c6c6","added_by":"auto","created_at":"2025-06-09 08:13:28","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":179578,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMRI findings in Case 4\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea DWI on MRI from day 1 showed thoracic cord hyperintensity at T4 (arrow).\u003c/p\u003e\n\u003cp\u003eb T2-weighted MRI from day 1 showed no signal changes in the thoracic cord at T4.\u003c/p\u003e\n\u003cp\u003ec T2-weighted MRI from day 6 showed thoracic cord hyperintensity at T4 (arrow).\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6730915/v1/bab5cc62f31dd78334f87a41.jpg"},{"id":85502815,"identity":"0edb3af9-2435-49c1-91e7-3f8577afacd0","added_by":"auto","created_at":"2025-06-26 14:55:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":719509,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6730915/v1/886482c9-fce8-4615-9889-20ddabd12558.pdf"},{"id":84199053,"identity":"a63f4883-a42b-4786-9fee-b2c149d6041e","added_by":"auto","created_at":"2025-06-09 08:13:28","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":37362,"visible":true,"origin":"","legend":"\u003cp\u003eTable 1\u003c/p\u003e","description":"","filename":"XXXXXXXXXXXXXXXSpinalCordXXXXXXTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6730915/v1/f8821e62f1e904a824cf5350.docx"},{"id":84199055,"identity":"1125ff21-f5d2-492f-a7eb-00f82897fc94","added_by":"auto","created_at":"2025-06-09 08:13:28","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":37039,"visible":true,"origin":"","legend":"\u003cp\u003eTable 2\u003c/p\u003e","description":"","filename":"XXXXXXXXXXXXXXXSpinalCordXXXXXXTable2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6730915/v1/97f13724eaa8cf229a851333.docx"},{"id":84199864,"identity":"73e1d31b-1cd1-4331-9cd7-46b166cbf9d9","added_by":"auto","created_at":"2025-06-09 08:21:28","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":38700,"visible":true,"origin":"","legend":"\u003cp\u003eTable 3\u003c/p\u003e","description":"","filename":"XXXXXXXXXXXXXXXSpinalCordXXXXXXTable3.docx","url":"https://assets-eu.researchsquare.com/files/rs-6730915/v1/67841d78c1d0fe16bc96a720.docx"},{"id":84199056,"identity":"3e9fef23-7472-4834-89a2-14228c244341","added_by":"auto","created_at":"2025-06-09 08:13:28","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":38589,"visible":true,"origin":"","legend":"Table 4","description":"","filename":"XXXXXXXXXXXXXXXSpinalCordXXXXXXTable4.docx","url":"https://assets-eu.researchsquare.com/files/rs-6730915/v1/6aecead3a945c0cf972e0255.docx"}],"financialInterests":"There is a duality of interest","formattedTitle":"Imaging Characteristics, Clinical Presentation, and Prognosis of Spinal Cord Infarction","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSpinal cord infarction is a rare condition, accounting for approximately 6% of spinal cord diseases and 0.3\u0026ndash;1.0% of all ischemic strokes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Etiologies include spontaneous onset, traumatic vascular dissection, hypotension, atherosclerosis, abdominal aortic aneurysm repair, and epidural anesthesia [\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Spinal cord infarction typically presents acutely, often manifesting as sudden-onset paralysis, necessitating immediate medical intervention.\u003c/p\u003e \u003cp\u003eDespite its clinical significance, there are no established diagnostic criteria for spinal cord infarction, making definitive diagnosis challenging. In clinical practice, the condition is generally diagnosed when a patient exhibits relatively rapid-onset spinal neurological deficits, with corresponding intramedullary lesions on magnetic resonance imaging (MRI) at the affected spinal level, while excluding other possible differential diagnoses. However, MRI findings in the hyperacute phase may not show signal changes, with T2-weighted hyperintensity typically appearing 2\u0026ndash;9 days post-onset [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Diffusion-weighted imaging (DWI) has been proposed as a potential tool for early detection, yet its utility remains limited due to the small size of the spinal cord and difficulties in identifying signal abnormalities [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Furthermore, there are no standardized treatment guidelines for spinal cord infarction, resulting in considerable variability in management across institutions, with treatment strategies being tailored to individual cases. Despite this lack of consensus, some patients exhibit favorable neurological recovery [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Robertson et al. has reported that patients with mild paralysis at onset are more likely to experience neurological recovery [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, the causal relationship between the underlying pathophysiology of spinal cord infarction and the improvement of paralysis remains unclear.\u003c/p\u003e \u003cp\u003eThe present study aims to comprehensively investigate the clinical manifestations, imaging characteristics, and prognostic factors of spinal cord infarction, to elucidate its underlying pathophysiology.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Participants and Clinical Data Collection\u003c/h2\u003e \u003cp\u003eThis retrospective observational study included 19 patients diagnosed with spinal cord infarction at the three hospitals between 2012 and 2022. The diagnostic criteria for spinal cord infarction are as follows: 1. Acute onset, 2. No history of trauma, 3. Presence of neurological deficits associated with spinal cord dysfunction, such as motor paralysis, sensory disturbance, or urinary dysfunction, 4. Evidence of spinal cord lesions on spinal MRI, 5. Absence of compressive lesions of the spinal cord. Clinical data collected included age, sex, smoking history, underlying diseases, etiology, presence of back pain, and infraction type. The modified Rankin Scale (mRS) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] was used to evaluate disability at the nadir of symptoms and at follow-up. Patients who could walk without assistance were classified as the good prognosis group (mRS: 0\u0026ndash;3), while those who could not walk without assistance were classified as the poor prognosis group (mRS: 4\u0026ndash;6) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A comparative evaluation was conducted as an additional sub-analysis by categorizing spinal cord infarction into iatrogenic and non-iatrogenic groups.\u003c/p\u003e \u003cp\u003eMRI examinations were performed between 2 hours to 25 days after the onset of clinical symptoms. The standardized imaging protocol included native axial and sagittal T1- and T2-weighted scans. All patient data is shown in Supplemental Table\u0026nbsp;1.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStatistical Methods\u003c/h3\u003e\n\u003cp\u003eContinuous variables and frequencies are presented as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (SDs) and the categorical variables as percentages. Differences between the groups were examined using the chi-square analysis and the Mann- Whitney U test. Statistical significance was defined as a \u003cem\u003eP\u003c/em\u003e value of \u0026lt;\u0026thinsp;0.05. Data were analyzed with statistical package for social science (SPSS) Statistics, version 28.0.1.0 (IBM Corp., Armonk, NY).\u003c/p\u003e\n\u003ch3\u003eEthics Statement\u003c/h3\u003e\n\u003cp\u003eAll the patients provided written informed consent, and the study protocol was approved by the institutional review board prior to data collection and analysis (approval number 20110142). The corresponding author assumes complete responsibility for maintaining the integrity of the data and ensuring the accuracy of the data analysis.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eCharacteristics of Patients with Spinal Infarction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 summarizes the demographics for 19 patients, including 15 men (78.9%) and four women (21.1%), 62.7 ± 18.4 years old on average. Five patients (26.3%) were smokers. \u0026nbsp;One patient (5.3%) had hyperlipidemia, six patients (31.6%) had hypertension, and four patients (21.1%) had diabetes as underlying conditions. The etiology included 8 patients of cardiovascular surgery (42.1%), 3 patients of epidural anesthesia (15.8%), and 8 patients of unknown cause (42.1%).\u0026nbsp;\u0026nbsp;Five patients had back pain at the time of onset. The infarctions were categorized into three types: anterior spinal artery (ASA) syndrome (n = 12),\u0026nbsp;Brown–Séquard syndrome (n = 5), and transverse infarction (n = 2). Six patients (31.6％) were able to walk independently, corresponding to an mRS of 3 or less.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMRI Findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 summarizes the characteristics of imaging findings. The average time from onset to MRI was 4.2 ± 5.8 days. The level of spinal infarction was cervical in 1 \u0026nbsp;patient (5.3％), upper thoracic in 9 patients\u0026nbsp;(47.4％), and lower thoracic in 9 patients\u0026nbsp;(47.4％). The localization of spinal infarction was\u0026nbsp;ventral\u0026nbsp;in 12 patients\u0026nbsp;(63.2％),\u0026nbsp;lateral funiculus\u0026nbsp;in 3\u0026nbsp;patients\u0026nbsp;(15.8％),\u0026nbsp;ventral and lateral funiculus\u0026nbsp;in 1 patient\u0026nbsp;(5.3％),\u0026nbsp;lateral funiculus and dorsal\u0026nbsp;in 1\u0026nbsp;patient\u0026nbsp;(5.3％), and\u0026nbsp;transverse\u0026nbsp;in 2 patients\u0026nbsp;(10.5％). The average spinal length of the infarction was 2.7 ± 1.9 vertebral bodies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;In all cases, a high-signal area was observed on T2-weighted imaging during the follow-up examination. Among the patients, eight underwent DWI within two days of onset. Of these, five (62.5%) exhibited signal changes in the infarcted area on DWI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison Between the Good and Poor Prognosis Groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the prognostic analysis of walking ability, six patients were classified into the good prognosis group (mRS 0–3), while 13 patients were categorized into the poor prognosis group (mRS 4–6). The age, sex, etiology, the time to MRI, the length of lesions, and the localization of the infarct did not differ between the two groups. However, in the good prognosis group, five patients (83.3%) presented with Brown–Séquard syndrome, whereas 11 patients (84.6%) in the poor prognosis group exhibited ASA syndrome, demonstrating a statistically significant difference (p \u0026lt; 0.01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison Between the Iatrogenic and Non-iatrogenic Groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table 1, eight patients of spinal cord infarction occurred following cardiovascular surgery, and three patients were observed after epidural anesthesia. These 11 patients were classified as iatrogenic spinal cord infarction and compared with eight patients of infarction of unknown etiology. \u0026nbsp;Significant differences were observed between the two groups in age (72.2 ± 11 years vs. 49.8 ± 19.1 years; p = 0.01) and gender (percentage of male patients: 100% vs. 50.0%; p = 0.02). The time to MRI, the length of intramedullary lesions, the localization of the infarct, prognosis, and infraction type did not differ between the two groups (Table 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRepresentative Case\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCase 4: A 19-year-old female reported a sensation of discomfort in both lower limbs and weakness in the right lower limb, which began one day prior without any apparent cause. Her medical history included atrial septal defect and tricuspid regurgitation, for which she underwent surgery during childhood. However, she had no recent history of trauma or infectious symptoms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eShe had no diabetes, and her blood pressure was normal. A neurological examination revealed that her consciousness and speech were normal. Cranial nerve examination showed no abnormalities. According to the Manual Muscle Test (MMT) scale, muscle strength was 5/5 distal to the deltoid muscles in both upper limbs, 3-4/5 distal to the iliopsoas muscle in the right lower limb, and 5/5 in the contralateral lower limb. There was decreased vibratory sensation in both lower limbs and reduced temperature and pain sensation distal to the right ankle. Clinical tests, including hematological, biochemical, and immunological examinations, were all within normal ranges. Head computed tomography and MRI showed no apparent abnormalities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn the second day after onset, thoracic spine T2-weighted MRI revealed no abnormalities, but a high-signal lesion was observed at the T4 level on axial DWI (Figure 1a and 1b). On the sixth day after onset, T2-weighted MRI of the thoracic spine revealed a high-signal lesion at the same location where the signal change was previously observed on the second-day DWI (Figure 1c). Based on these findings, a diagnosis of spinal cord infarction presenting as Brown-Séquard syndrome was made.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe patient underwent anti-edema therapy from the first day after onset and anticoagulant therapy from the second day. By the fifth day, the previously weakened muscle strength had improved, with only residual sensory dullness on the right sole. She was discharged ambulatory with the mRS score of 1.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this study, we investigated factors associated with gait prognosis in 19 patients with spinal cord infarction. The results indicated that patients who retained the ability to walk exhibited a significantly higher prevalence of Brown-S\u0026eacute;quard syndrome. In contrast, those who experienced complete loss of gait function more frequently exhibited infarction of the anterior spinal artery or transverse infarction. Additionally, we assessed differences between iatrogenic and non-iatrogenic cases; however, no significant differences were observed in infarction level, infarction type, or functional recovery. These findings suggest that, regardless of the underlying cause of spinal cord infarction, the prognosis of neurological function is primarily determined by the affected vasculature and the extent of damage to its corresponding perfusion territory.\u003c/p\u003e \u003cp\u003eConsistent with previous reports [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], our study also found that ASA syndrome was the most common infarction type, observed in 12 out of 19 cases. ASA syndrome results from impaired or obstructed blood flow in the artery supplying the anterior two-thirds of the spinal cord, leading to sudden onset of paraplegia or quadriplegia, dissociative sensory loss, and bladder or rectal dysfunction. In contrast, Brown-S\u0026eacute;quard syndrome is a condition that occurs when one side of the spinal cord is affected, characterized by ipsilateral pyramidal tract signs and deep sensory impairment, along with contralateral loss of pain and temperature sensation. This pathology primarily involves unilateral damage, often resulting in paralysis of only one lower limb. Consequently, gait function is relatively preserved in these patients. Therefore, in this study, patients with Brown-S\u0026eacute;quard syndrome exhibited better neurological functional outcomes. Robertson et al. also reported that patients classified as American Spinal Injury Association Impairment Scale (AIS) C or D at the time of onset retained ambulatory function thereafter [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In our study, patients with Brown-S\u0026eacute;quard syndrome were ambulatory and were considered to correspond to AIS C or D. Therefore, our finding is consistent with their research, supporting the favorable neurological prognosis for ambulation.\u003c/p\u003e \u003cp\u003eIn this study, DWI was performed within two days of onset in eight cases, of which five cases (62.5%) demonstrated signal changes. DWI is widely used for the evaluation of acute cerebral infarction and has also been reported to be useful for the early diagnosis of spinal cord infarction [\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Our findings support this notion, as more than half of the cases in which early DWI imaging was performed exhibited signal changes, suggesting its diagnostic utility. However, only eight cases (42.1%) underwent the DWI, while the remaining cases were not evaluated at an early stage. This highlights the need for proactive acquisition of DWI sequences as part of MRI when spinal cord infarction is suspected, rather than merely performing MRI alone. Nevertheless, a few cases in the current study did not exhibit signal changes in DWI, raising concerns about the difficulty of early diagnosis in such cases.\u003c/p\u003e \u003cp\u003eRegarding the spinal level of onset, in our study, only one case originated in the cervical spine, while the remaining 18 cases (94.7%) occurred in the thoracic spine. Although previous reports have shown some variation in the incidence, they consistently identify the thoracic spine as the most frequently affected region (ranging from 56.5\u0026ndash;70%) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], aligning with our findings. The predominance of thoracic involvement has been attributed to anatomical characteristics. The arterial supply of the human spinal cord consists of a single anterior spinal artery and two posterior spinal arteries. The diameter of the anterior spinal artery decreases caudally from the T4 level and increases distally from the confluence of the artery of Adamkiewicz [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], which may contribute to the higher frequency of thoracic involvement. Furthermore, in our study, 11 cases were iatrogenic, occurring after cardiovascular surgery or epidural anesthesia. Given that many medical interventions are performed at the thoracic level, this factor may have contributed to the relatively high incidence of thoracic onset in our cohort.\u003c/p\u003e \u003cp\u003eIn this study, the iatrogenic causes of spinal cord infarction were identified as postoperative complications of cardiovascular surgery and epidural anesthesia. Spinal cord infarction following cardiovascular surgery, particularly after abdominal aortic aneurysm repair or aortic dissection surgery, has been relatively well-documented. It has been reported that spinal cord infarction in this context can occur either immediately or in a delayed manner [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Immediate infarction results from intraoperative spinal ischemia, leading to irreversible spinal cord damage. While this can be caused by embolism or other persistent ischemic events, even transient ischemia exceeding a critical duration can result in irreversible damage. Delayed injury, on the other hand, has been attributed to postoperative occlusion of nutritional arteries (such as occlusion of reconstructed arteries or progressive thrombosis of the false lumen in aortic dissection), spinal cord edema-induced elevation of intraspinal pressure, and hemodynamic deterioration leading to reduced spinal cord perfusion pressure. In contrast, reports of spinal cord infarction following epidural anesthesia are scarce. Some studies have hypothesized that spinal cord ischemia in this setting may be associated with intraoperative hypotension [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], the neurotoxicity of local anesthetics [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], or vasospasm induced by local anesthetics containing epinephrine. However, no definitive causal relationship has been established. In our study, there were no significant differences in infarct extent, location, infarction type, or prognosis between iatrogenic and non-iatrogenic cases of spinal cord infarction. These findings suggest that differences in the etiology of spinal cord infarction may have minimal impact on its pathological characteristics.\u003c/p\u003e \u003cp\u003eSeveral limitations should be described in the present study. First, this study included a relatively small cohort of 19 patients with spinal cord infarction, which limits the statistical power and generalizability of the findings. A larger sample size would be necessary to draw more definitive conclusions and improve the robustness of the statistical analyses. Second, the study was conducted at a single institution in Japan, which may limit the generalizability of the findings to other populations and healthcare settings. Multicenter studies involving diverse patient demographics and medical practices would enhance the applicability of the results. Third, as a retrospective observational study, this research is subject to inherent biases, including incomplete medical records and variations in diagnostic approach. A prospective study design would allow for more standardized data collection and minimize potential biases. And finally, the study was unable to address treatment-related aspects due to insufficient documentation in medical records. Additionally, the treatment strategies and initiation timing varied among cases, preventing a comprehensive analysis of their impact on neurological outcomes. Despite these limitations, the present study is the first to identify the type of vascular insufficiency due to infarction as a key factor influencing neurological outcomes following spinal cord infarction. Based on these findings, it may be possible to estimate the clinical condition and functional prognosis of the patients with spinal cord infarction.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eIn this study, we analyzed the clinical features, MRI findings, and prognosis of 19 cases of spinal cord infarction. Our findings indicate that DWI on MRI can facilitate early diagnosis immediately after onset in certain patients. While the underlying etiology was not associated with neurological prognosis, the infarction pattern at onset served as a prognostic indicator. These findings are expected to contribute to further understanding of the pathophysiology of spinal cord infarction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our deepest gratitude to all the institutions that have cooperated with us. In preparing this manuscript, ChatGPT (OpenAI) and Grammarly (Grammarly Inc.) were used for grammar refinement and typographical error correction. These tools were employed exclusively to improve clarity and readability, without modifying the scientific content or interpretation of the findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eY.K., T.O., M.O., S.S., K.T., T.I., K.S., M.M., M.N., K.W., and N.N. designed the study; Y.K. and N.N. performed the experiments and analyzed the data; N.N. supervised the experiments; Y.K. and N.N. wrote the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource of Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the patients provided written informed consent, and the study protocol was approved by the institutional review board prior to data collection and analysis (approval number 20110142). The first author assumes complete responsibility for maintaining the integrity of the data and ensuring the accuracy of the data analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no relevant conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eVargas MI, Gariani J, Sztajzel R, Barnaure-Nachbar I, Delattre BM, Lovblad KO, Dietemann JL. Spinal cord ischemia: practical imaging tips, pearls, and pitfalls. AJNR Am J Neuroradiol 2015; 36: 825\u0026ndash;830.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSandson TA, Friedman JH. Spinal cord infarction. Report of 8 cases and review of the literature. Medicine (Baltimore) 1989; 68: 282\u0026ndash;292.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeng YY, Dou L, Wang CM, Kong DZ, Wei Y, Wu LS, et al. Spinal cord infarction presenting as Brown-S\u0026eacute;quard syndrome from spontaneous vertebral artery dissection: a case report and literature review. BMC Neurol 2019; 19: 321.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeidauer S, Nichtweiss M, Lanfermann H, Zanella FE. Spinal cord infarction: MR imaging and clinical features in 16 cases. Neuroradiology 2002; 44: 851\u0026ndash;857.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkuno S, Touho H, Ohnishi H, Karasawa J. Cervical infarction associated with vertebral artery occlusion due to spondylotic degeneration: case report. Acta Neurochir (Wien) 1998; 140: 981\u0026ndash;985.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuh WT, Marsh EE, 3rd, Wang AK, Russell JW, Chiang F, Koci TM, Ryals TJ. MR imaging of spinal cord and vertebral body infarction. AJNR Am J Neuroradiol 1992; 13: 145\u0026ndash;154.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerg P, Kaufmann D, van Marrewijk CJ, Buth J. Spinal cord ischaemia after stent-graft treatment for infra-renal abdominal aortic aneurysms. Analysis of the Eurostar database. Eur J Vasc Endovasc Surg 2001; 22: 342\u0026ndash;347.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKobayashi K, Narimatsu N, Oyoshi T, Ikeda T, Tohya T. Spinal cord infarction following epidural and general anesthesia: a case report. JA Clin Rep 2017; 3: 42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoher TJ, Bassetti CL, L\u0026ouml;vblad KO, Stepper FP, Sturzenegger M, Kiefer C, et al. Diffusion-weighted MRI in acute spinal cord ischaemia. Neuroradiology 2003; 45: 557\u0026ndash;561.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHundsberger T, Th\u0026ouml;mke F, Hopf HC, Fitzek C. Symmetrical infarction of the cervical spinal cord due to spontaneous bilateral vertebral artery dissection. Stroke 1998; 29: 1742.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThurnher MM, Bammer R. Diffusion-weighted MR imaging (DWI) in spinal cord ischemia. Neuroradiology 2006; 48: 795\u0026ndash;801.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalvador de la Barrera S, Barca-Buyo A, Montoto-Marqu\u0026eacute;s 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: 520\u0026ndash;525.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobertson CE, Brown RD, Jr., Wijdicks EF, Rabinstein AA. Recovery after spinal cord infarcts: long-term outcome in 115 patients. Neurology 2012; 78: 114\u0026ndash;121.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurn JP. Reliability of the modified Rankin Scale. Stroke 1992; 23: 438.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePowers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50: e344-e418.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBammer R. Basic principles of diffusion-weighted imaging. Eur J Radiol 2003; 45: 169\u0026ndash;184.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLansberg MG, Albers GW, Beaulieu C, Marks MP. Comparison of diffusion-weighted MRI and CT in acute stroke. Neurology 2000; 54: 1557\u0026ndash;1561.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurdette JH, Ricci PE, Petitti N, Elster AD. 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South Med J 1990; 83: 695\u0026ndash;697.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6730915/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6730915/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e: Retrospective cohort study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: Spinal cord infarction is a rare condition, and many aspects of its pathophysiology remain unclear. The purpose of this study is to conduct a comprehensive analysis of the clinical symptoms, imaging changes, and prognosis of spinal cord infarction to elucidate its pathophysiology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting\u003c/strong\u003e: The multiple institutions in Japan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: We retrospectively analyzed the clinical course and imaging findings of 19 patients diagnosed with spinal cord infarction at affiliated institutions between 2012 and 2022, based on medical records. Prognosis was assessed using the modified Rankin Scale (mRS), with a favorable outcome defined as the ability to walk independently (mRS 0–3) at discharge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The study cohort consisted of 15 male and 4 female patients, with a mean age of 62.7±18.4 years. Eleven patients were iatrogenic following cardiac surgery and epidural anesthesia. Among eight patients who underwent diffusion-weighted imaging (DWI) within two days of onset, five exhibited hyperintensity at the infarcted site. Clinically, 12 patients presented with anterior spinal artery syndrome, five with Brown-Séquard syndrome, and two with transverse infarction. A favorable prognosis at discharge was observed in six patients, five of whom had Brown-Séquard syndrome, showing a significant association between a good prognosis and Brown-Séquard syndrome (p \u0026lt; 0.01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: DWI in MRI can aid in the early diagnosis of spinal cord infarction immediately after onset. Additionally, the findings suggest that patients with Brown-Séquard syndrome have a favorable prognosis for gait ability.\u003c/p\u003e","manuscriptTitle":"Imaging Characteristics, Clinical Presentation, and Prognosis of Spinal Cord Infarction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-09 08:13:24","doi":"10.21203/rs.3.rs-6730915/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9574c2fd-067a-481a-adc2-fcaec2e3902d","owner":[],"postedDate":"June 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":49386046,"name":"Health sciences/Medical research/Outcomes research"},{"id":49386047,"name":"Health sciences/Diseases/Neurological disorders/Spinal cord diseases"}],"tags":[],"updatedAt":"2025-07-14T13:41:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-09 08:13:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6730915","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6730915","identity":"rs-6730915","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}