1231 - Embolic Spinal Cord Infarctions Presenting as Ipsilateral Hemiparesis in Setting of Atrial Fibrillation

Case Diagnosis: A case of acute ipsilateral hemiparesis following embolic spinal cord infarctions secondary to atrial fibrillation with rapid ventricular rate.

Case Description: A 72-year-old male with multiple medical comorbidities presented to the hospital for an elective double lung transplant. His postoperative course was complicated by new-onset atrial fibrillation with a rapid ventricular rate, followed by the development of right-sided hemiparesis with clonus and hyperreflexia. Initial magnetic resonance imaging (MRI) of the brain showed no acute infarction, lumbar puncture ruled out infection and transverse myelitis, and an electroencephalogram revealed no epileptiform activity. Subsequent MRI of the cervical and thoracic spine demonstrated embolic infarctions localized to the right hemicord at C2-C3, C4-C5, T5-T6, and T8-T9 levels. With anticoagulation therapy and one month of acute inpatient rehabilitation, he achieved progress to supervision/modified independence in activities of daily living and mobility.

Discussions: This rare case highlights nontraumatic spinal cord injury with ipsilateral hemiparesis from embolic events associated with atrial fibrillation. While atrial fibrillation is a recognized risk factor for cerebral infarction, its role in spinal cord infarction remains less established. Spinal cord infarctions comprise only 0.3-1% of all strokes, with the incidence of infarction from cardioembolism largely unknown. Typically, spinal cord infarction presents as a syndrome with a constellation of deficits, making isolated ipsilateral weakness unusual and prone to misdiagnosis as a cerebral stroke.

Conclusions: In cases of acute, isolated ipsilateral weakness post-arrhythmic event, clinicians should consider spinal cord infarction as part of the differential diagnoses. Despite typically poor prognosis, anticoagulation and intensive rehabilitation may aid these patients in regaining functional independence.