Characteristics of Spontaneous Spinal Cord Infarction and Proposed Diagnostic Criteria.

Importance: Spinal cord infarction (SCI) is often disabling, and the diagnosis can be challenging without an inciting event (eg, aortic surgery). Patients with a spontaneous SCI are often misdiagnosed as having transverse myelitis. Diagnostic criteria for SCI are lacking, hindering clinical care and research. Objective: To describe the characteristics of spontaneous SCI and propose diagnostic criteria. Design, Setting, and Participants: An institution-based search tool was used to identify patients evaluated at Mayo Clinic, Rochester, Minnesota, from January 1997 to December 2017 with a spontaneous SCI. Patients provided written consent to use their records for research. Participants were 18 years and older with a diagnosis of spontaneous SCI (n = 133), and controls were selected from a database of alternative myelopathy etiologies for validation of the proposed diagnostic criteria (n = 280). Main Outcomes and Measures: A descriptive analysis of SCI was performed and used to propose diagnostic criteria, and the criteria were validated. Results: Of 133 included patients with a spontaneous SCI, the median (interquartile range) age at presentation was 60 (52-69) years, and 101 (76%) had vascular risk factors. Rapid onset of severe deficits reaching nadir within 12 hours was typical (102 [77%]); some had a stuttering decline (31 [23%]). Sensory loss occurred in 126 patients (95%), selectively affecting pain/temperature in 49 (39%). Initial magnetic resonance imaging (MRI) spine results were normal in 30 patients (24%). Characteristic MRI T2-hyperintense patterns included owl eyes (82 [65%]) and pencil-like hyperintensity (50 [40%]); gadolinium enhancement (37 of 96 [39%]) was often linear and located in the anterior gray matter. Confirmatory MRI findings included diffusion-weighted imaging/apparent diffusion coefficient restriction (19 of 29 [67%]), adjacent dissection/occlusion (16 of 82 [20%]), and vertebral body infarction (11 [9%]). Cerebrospinal fluid showed mild inflammation in 7 of 89 patients (8%). Diagnostic criteria was proposed for definite, probable, and possible SCI of periprocedural and spontaneous onset. In the validation cohort (n = 280), 9 patients (3%) met criteria for possible SCI, and none met criteria for probable SCI. Conclusions and Relevance: This large series of spontaneous SCIs provides clinical, laboratory, and MRI clues to SCI diagnosis. The diagnostic criteria proposed here will aid clinicians in making the correct diagnosis and ideally improve future care for patients with SCI. The validation of these criteria supports their utility in the evaluation of acute myelopathy.

Cerebrospinal fluid homovanillic acid in cerebral infarction.

Cerebrospinal fluid (CSF) homovanillic acid (HVA) concentration was measured in 39 consecutive cases of hemispheric infarction, 7 cases of brainstem infarction, and in 16 controls. The CSF-HVA level was 38 +/- 15 ng/ml (mean +/- S.D.) in the control patients, 15 +/- 6 ng/ml in patients with brainstem infarcts, and 49 +/- 41 ng/ml in those with hemispheric infarcts. The CSF-HVA levels were decreased in brainstem infarct cases (p less than 0.001) and greatly scattered in patients with hemispheric infarcts (range 4--207 ng/ml) when compared to controls. The decrease of levels of CSF-HVA in brainstem infarct cases may reflect interference with the dopaminergic pathways. CSF-HVA values in hemispheric infarction could not be related to the acuteness, location, nor severity of the lesion. The broad range of CSF-HVA values may be due to the interaction of multiple, as yet unknown factors. These findings suggest that dopamine metabolism is altered in many cases with acute brain infarction.

Infarction of the spinal cord as a complication of pneumococcal meningitis. Case report.

Spinal cord infarction in association with pneumococcal meningitis has not been previously recognized. The case is reported of a 5 1/2-year-old boy who had Streptococcus pneumoniae meningitis complicated by the sudden onset of flaccid paraplegia and loss of all sensory modalities below the level of T-2. At operation, the spinal cord was pale and enveloped by dense adhesions, suggesting compromise of the arterial vasculature with concomitant infarction.

Cerebrospinal fluid creatine phosphokinase in acute subarachnoid hemorrhage.

The author measured the level of creatine phosphokinase (CPK) in 35 cerebrospinal fluid (CSF) specimens from 30 patients with acute subarachnoid hemorrhage, and correlations were sought with 17 other clinical and laboratory parameters. Elevations of CSF CPK have no diagnostic specificity. However, they do dhow a statistically significant correlation with the existence of any destructive process in cerebral tissue (hydrocephalus, infarction, intraparenchymal hemorrhage, or intraventricular clot). Yet arterial spasm without infarction does not raise the CSF CPK level. During the preoperative management of ruptured aneurysms and vascular malformations, a significant elevation of the CSF CPK level can thus provide a clue to the presence or significance of one or more of these destructive processes.

[The prognostic value of the lactate concentration and lactate/pyruvate ratio in cerebrospinal fluid following acute cerebral circulatory disorders]. / Prognosticheskoe znachenie soderzhaniia laktata i otnosheniia laktat/piruvat v spinomozgovoi zhidkosti pri ostrykh narusheniiakh mozgovogo krovoobrashcheniia

The study was conducted in 80 patients with ischaemic and 29 with haemorrhagic cerebral stroke. Lactate, pyruvate, the lactate/pyruvate ratio and glucose were determined in the arterial blood and lumbar CSF. A high prognostic value of the CSF lactate content was found in cases of ischaemic stroke. According to the data obtained, an elevation of the CSF lactate concentration above 4.0 mEq/l should be considered life-threatening. Haemorrhagic stroked was found to be accompanied by a reduced CSF glucose level and an elevated lactate content, as well as by a significant proportional elevation of the lactate and red blood cells count in the CSF. The conducted calculations demonstrated that 1/4 to 1/3 of the CSF lactate is formed at the expense of the glycolytic metabolism in the CSF erythrocytes. This constitutes the main reason of the discordance between the CSF lactate content in haemorrhagic stroke and the routine criteria of prognosis in ischaemic stroke. The lactate/pyruvate ratio in the CSF is of no prognostic importance in both forms of cerebral stroke.

Spinal cord infarction: MRI and MEP findings in three cases.

We report findings of magnetic resonance imaging (MRI) in three patients with spinal cord ischemia. While myelography was normal in all three patients, MRI found pathological signal increase on the T2-weighted images in each case. Signal changes in T1-weighted images of hemorrhagic infarction were seen in one patient, and gadolinium-DTPA enhancement because of a disturbed blood-tissue barrier was noted in another. Motor evoked potentials after transcortical magnetic stimulation showed normal latencies with very low amplitudes as a sign of axonal loss in ischemia of the spinal cord.

Cerebrospinal fluid in cerebral hemorrhage and infarction.

Cerebrospinal fluid (CSF) abnormalities were correlated with pathological diagnoses in 61 patients with autopsy-verified intracerebral hemorrhage or cerebral infarction. Lumbar punctures were performed within one week of onset of symptoms. The CSF color and red blood cell counts were the most useful CSF parameters in differentiating between intracerebral hemorrhage and cerebral infarction. In 75% of the patients with intracerebral hemorrhage, the CSF was either grossly bloody or xanthochromic; in 25%, the CSF was clear. In patients with cerebral infarction, the CSF was never grossly bloody; in two patients with hemorrhagic infarction, the CSF was xanthochromic. The CSF pressure, protein values and leukocyte counts were less useful in differentiating intracerebral hemorrhage from cerebral infarction. Cases with hemorrhagic infarction could not be separated from those with ischemic infarction on the basis of CSF analysis. In clear CSF, the polymorphonuclear neutrophilic leukocyte (PNL) counts were never greater than 20 per cubic millimeter. In xanthochromic or cloudy CSF, leukocyte counts, especially PNLs, were frequently elevated, occasionally to the high levels.