Title : Thoracic sulcal artery infarct presenting as brown-sequard syndrome
Abstract:
Introduction: Thoracic spinal cord infarct is a rare but severe disorder that constitute 1-2% of neurological vascular emergencies. The severity, disease trajectory, progression and recovery rate remains a puzzle in view of its varies presentation and rarity.
Methods: We report a case of Thoracic sulcal artery infarct presenting as brown sequard syndrome
Report: A 70-year-old-man with hypertension and hyperlipidemia developed acute onset bilateral lower limb weakness, paresthesia and urinary incontinence over short days. He also reported back pain, but denied trauma, weight loss or fever. Examination revealed an upper motor neuron pattern of asymmetrical lower limb weakness, worse over the left leg, with a sensory level at T11. Acute myelopathy was suspected. There was dissociated sensory loss in keeping with an incomplete left Brown-Sequard Syndrome – reduced temperature and pinprick sense over the right leg, but reduced vibration sense over the left leg. Contrasted magnetic resonance imaging of the spine revealed an acute spinal cord infarct in the left T9-T10 hemicord. Sagittal images showed diffusion weighted imaging hyperintense lesions (Figure 1A) with corresponding apparent diffusion coefficient hypointensities (1B) in the thoracic cord at T9-T10, consistent with acute infarcts. Axial diffusion weighted imaging showed restricted diffusion in an “owl-eyes” pattern (1C) Extensive evaluation done ruling out aortic dissection, systemic vasculitis, thrombophilia and cardiogenic aetiology. However CT thoracic aortogram demonstrated extensive atherosclerotic plaque. He was treated with anti platelet therapy and intravenous hydration. He made partial improvement with physical rehabilitation but remains dependent on a walking frame and selfcatheterization
to date.
Conclusion: Unusual acute onset and progressive myelopathy impede recognition of spinal cord infarct and life threatening delay in treatment. Diffusion-weighted imaging is crucial for diagnosis of cord infarction.
Disclosure: Contrasted magnetic resonance imaging of the spine revealed an acute spinal cord infarct in the left T9-T10 hemicord. Sagittal images showed diffusion weighted imaging hyperintense lesions (Figure 1A) with corresponding apparent diffusion coefficient hypointensities (1B) in the thoracic cord at T9-T10, consistent with acute infarcts. Axial diffusion weighted imaging showed restricted diffusion in an “owl-eyes” pattern (1C) and repeat MRI done five days later showed development of corresponding axial T2 hyperintense lesions with the classic “owl-eyes” appearance. Computed tomography of the thoracic aorta found no arterial dissection but demonstrated extensive atherosclerotic plaques (Figure 1E)
