Case Presentation: A 63 year-old man with diabetes mellitus, hypertension, and GERD presented from an outside hospital with bilateral upper extremity paralysis, paresthesias, and neck pain which started minutes after sneezing. Vital signs were stable and neurologic examination was remarkable for bilateral upper extremity strength of 0/5 with absent reflexes and reduced sensation to pinprick. Lower extremity neurologic function was preserved. Laboratory evaluation including ESR, CRP, CBC, CMP, ANA and ANCA were unrevealing. CT brain and MRI of cervical and thoracic spine without contrast were nondiagnostic. Ischemia, myelitis, central cord syndrome, infection, vasculitis, and compressive myelopathy were considered. He was treated with methylprednisolone and IVIG for possible transverse myelitis. Acyclovir was added after lumbar puncture showed elevated protein, then was discontinued when CSF HSV returned negative. Repeat MRI of the brain and spine with contrast showed acute spinal cord infarction from C2 to T1. CTA showed bilateral non-occlusive narrowing of carotid arteries, a patent anterior spinal artery, and a patent but diminutive right vertebral artery suggestive of prior dissection. Additional work-up was negative for arrhythmia and echocardiogram was normal. No intervention was recommended by neuroendovascular surgery. The patient’s reflexes returned along with some movement in his fingers, and he was discharged on aspirin and clopidogrel with outpatient therapy.

Discussion: Spinal cord infarctions account for only 0.3 to 1% of all strokes. Symptoms of anterior spinal artery infarction include neck or back pain and bilateral limb weakness. Acute loss of deep tendon reflexes and pain and temperature sensation, usually with preservation of proprioception, correlate with the involved cord territory. Autonomic dysfunction with potentially life-threatening side effects including hypotension and bradycardia can occur, as well as bowel, bladder, and/or sexual dysfunction. Involvement of the rostral cord can lead to respiratory decompensation. Etiologies include vascular malformations, trauma, vertebral artery dissection, aortic disease and surgery, infections, spinal disease, vasculitis, arteriosclerosis, embolic events, prothrombotic states, hypotension and cocaine abuse. More than half of cases may be idiopathic. Workup includes MRI of the spine and vascular assessment, with further testing driven by cause. It is important to note, as in our case, that early or non-contrast MRI may be negative. Immediate treatment may include intensive care unit admission and preservation of blood pressure. Further treatment will depend upon etiology, with thrombolysis considered to be investigational. Survival rate is 80-90%, but the majority of patients are left with deficits. In this patient, the violent sneeze likely caused vertebral artery dissection, which led to the infarction.

Conclusions: This was an unfortunate case of anterior spinal artery infarction. Although rare, this condition should be suspected with presentations of acute neck pain, paralysis and sensory disturbance of the upper extremities. A violent sneeze may be the inciting event.