Case Presentation: We share a case of a 64 year old male with no thrombophilia history who presented with bilateral ascending lower extremity weakness and numbness from feet to bilateral upper extremities, with associated shortness of breath. Physical exam was notable for areflexia along with and decreased strength and sensation in bilateral lower extremities, with decreased reflexes in upper extremities. Initial work up included stroke rule out with CT and MRI imaging, was negative. Differentials then included infectious processes and autoimmune demyelinating pathology. MRI of thoracic spine demonstrated an abnormal intramedullary lesion in the spinal cord from C6-T5, suspicious for infarct vs inflammation. He was immediately started on high dose IV steroids. Further work up included Lumbar puncture with CSF studies. While results were pending, due to high suspicion of Guillain Barre syndrome he received IVIG infusion. Repeat MRI demonstrated evolution and possible swelling due to mass lesion. Without improvement with IVIG therapy and LP results being negative, along with vasculitis and hypercoagulable workup being negative. There was high suspicion for anterior spinal artery occlusion. He underwent Spinal angiogram via IR, which revealed a non patent/visualization of spinal artery of Adamkiewicz . Patient was initiated on DOAC therapy with Eliquis. Shortly after this patient had significant improvement in his lower extremity weakness and paraesthesia.
Discussion: In a previously relatively healthy adult with new-onset rapidly progressive ascending weakness and paralysis, diagnoses including Guillain-Barre syndrome or multiple sclerosis are quickly moved to the top of our differential. Anterior spinal artery syndrome is a rare condition – in fact the incidence of this condition has not been yet reported, however it is suspected that spinal cord infarctions account for 1% of all strokes, leading to the suspected incidence of 5000 to 8000 cases a year. The most common causes of spinal infarcts are due to aortic surgery, aortic dissection, fibrocartilaginous embolism, systemic hypotension, vascular formations and other causes such as vasculitis and hypercoagulable states. In this case, the underlying cause of the occlusion of the artery of Adamkiewicz was never identified – our work-up for cardioembolic strokes was ruled out, in addition to CSF studies remaining negative for any infectious etiology. Due to this, we can suspect that this patient has a hypercoagulable state. He was initiated on Eliquis therapy, and has since been discharged to an acute rehab. In conclusion, we present a rare case of anterior spinal artery syndrome due to occlusion of the artery of Adamkiewicz with unknown etiology. The purpose of this presentation was to bring awareness to the condition and remind physicians to keep a high level of suspicion to do further work up such as spinal angiogram in this case.
Conclusions: The Artery of Adamkiewicz, also referred to as the arteria radicularis magna, is the dominant contributor of the anterior segmental medullary vessels from the aorta. Its anastomosis with the Anterior spinal artery at the T8 level allows for adequate blood supply to anterior spinal cord from T8 down to conus medullaris. Occlusion of this artery can lead to a wide constellation of non-specific symptoms that prove difficult to establish this diagnosis, however can have drastic effects on the function of the spinal cord.