Attending Physician Hartford HealthCare Hartford, Connecticut, United States
Case Diagnosis: Spinal Cord Ischemia
Case Description: A 33-year-old male with no significant past medical history has an acute onset of bilateral lower extremity weakness (left greater than right) with pain one day after a flight. Upon arrival to the emergency department, patient was unable to ambulate. Initial CT head and spine were negative for acute pathology. With concern for possible bilateral anterior cerebral artery occlusion or spinal cord infarct, neurology administered tenecteplase. Initial brain and spine MRI were negative for acute infarct and noted T7-T8 disc bulges without cord compression. Though pain resolved, patient had urinary retention and leg weakness that did not initially improve. Neurosurgery recommended decompression and fusion of T7-T8. PM&R was consulted and suggested delay in surgery with repeat spine MRI in 48 hours given physical exam findings and additional work up as directed by neurology. Repeat spine MRI noted T11-T12 spinal cord ischemia with bilateral T2 weighted signals in the anterior horns.
Discussions: Transesophageal echocardiogram was positive for patent foramen ovale with predominant right to left shunting and atrial septal aneurysm. Bilateral upper and lower extremity dopplers were negative for thrombi. MRV pelvis was negative for thrombi and positive for May-Thurner Syndrome. Hypercoagulability studies were negative. Functional status significantly improved from moderate/maximum assistance to modified independence by discharge. He was transitioned home with outpatient therapies and continued follow up with a physiatrist. Spinal cord ischemia is rare with few case reports detailing the use of tenecteplase within a 4.5 hour window. The case presented demonstrates an atypical presentation of spinal cord ischemia with tenecteplase administered beyond this timeframe with outstanding affect.
Conclusions: PM&R consultation services provide significant diagnostic value and collaboration in atypical presentations of acute neurological and musculoskeletal pathologies. Additionally, more research is needed on the time frame of therapeutic benefit for tenecteplase in suspected spinal cord ischemia.
