Case Presentation:
A 53‐year‐old male with fibrosing mediastinilis presents with a 1‐day history of cough and hemoptysis. His past medical history was significant for hypertension and fibrosing mediastinitis diagnosed in 2005. On exam, the patient was tachypneic and hypoxic, with an oxygen saturation of 88% on room air. Other vital signs were normal. Lung exam revealed decreased breath sounds in the right upper lobe and bilateral expiratory wheezing. Clubbing of extremities was noted. No focal deficits were found on gross neurologic exam. Laboratories showed anemia with hemoglobin of 8.8 g/dL and normal platelets and clotting factors. Given his hemoptysis and anemia, he underwent emergent bronchial artery embolization in interventional radiology. The first right intercostal bronchial trunk was embolized to stasis. During the procedure, the patient complained of severe persistent back pain and became agitated and uncooperative. The procedure was terminated early, and he was sent to the floor. The following morning, the patient reported he was unable to move his legs. Neurologic exam revealed decreased sensation to pinprick below T8 and diminished strength (2/5) in bilateral lower extremities. Rectal tone was normal. Thoracic and lumbar spine MRI showed abnormal signal in The anterior spinal cord at T9 through T12, consistent with acule spinal cord infarction.
Discussion:
Spinal cord infarction is a rare complicalion of bronchial artery embolization, with an estimated prevalence of 1.4%‐6.5%. It often occurs in the anterior spinal artery distribution via the artery of Adamkiewiez. which rises between T9 and T12. This vessel has a characteristic hairpin configuration and supplies the lower two thirds of the spinal cord. Patients with anterior spinal artery infarction can present with abrupt onset of back pain followed by flaccid bilaleral paralysis, loss of bowel or bladder control, and decreased temperature and pinprick sensation. Proprioception and vibratory sense are usually preserved. Initial diagnosis is clinical and may be confirmed by MRI. Management is supportive, including early aggressive physical therapy, and urinary catheterization to prevent retention. Permissive hypertension is allowed to maintain spinal cord perfusion. Systemic corticosteroids have not been studied in spinal cord ischemia and are not currently recommended.
Conclusions:
This case illustrates anterior spinal artery infarction, an uncommon but serious complication following bronchial artery embolization. Patients complaining of back pain or weakness following this procedure should have a comprehensive neurologic exam for early diagnosis and management. Giver the frequency of use, physicians should understand the complications of minimally invasive procedures.
Author Disclosure:
C. Delille, none; R. Klein, none; M. Fleischman, none.