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Clinical features in vertebral artery dissection are rarely associated with an ischaemic lesion of the spinal cord.1The few cases related and studied with MRI strictly involve the cervical cord.2-4 We add another patient with spontaneous bilateral vertebral artery dissection in whom the particularity was an isolated extensive ischaemia of the spinal cord from C4 to T5 vertebral levels.
A previously healthy 45 year old woman had paresthesiae of the right ankle lasting a few days. Ten days later, she had a right sided scapulothoracic pain and suddenly developed a predominantly right sided tetraparesia and urinary retention. There was no history of neck trauma. Cranial nerve examination was normal. There was a right sided hemiplegia and a moderate left sided hemiparesis. Deep tendon reflexes were normal, right plantar response was extensor. There were bilateral spinothalamic problems below T4 with loss of touch sense in the right leg. Thus the examination was consistent with atypical, right cervical Brown-Séquard’s syndrome.
Biological investigations were normal. CSF protein was 0.34 g/l, glucose 2.54 mmol/l (2.10–4.20 mmol/l). There were 7 white cells and 25 red cells/mm3.
There were no oligoclonal bands. The ECG was normal. There was no aortic dissection shown on CT or MRI. Visual evoked potentials were normal. Somatosensory evoked potentials were abnormal for the right lower limb at the cervical level. A sagittal T2 weighted MRI showed linear cord high signal from C4 to T5 vertebral levels consistent with an ischaemic lesion (figure). On corresponding axial cuts, this was shown to involve the region of the anterior horns at cervical level and to prevail on the right half of the spinal cord at dorsal level. MRI of the cerebellum and brain stem was normal. Cerebral angiography showed an irregular stenosis of the right and left cervical vertebral artery typical of a dissection. The patient was treated with oral anticoagulants. One year later, the sequelae were a spastic paraparesia with right sided central pain and mild urinary retention. MRI and MRA showed the resolution of the cord signal and normal right and left vertebral artery.
The cervical cord is mainly supplied by radicular arteries rising from the vertebral artery. Thus,vertebral artery dissection can lead to an ischaemia limited to the cervical cord. Extensive ischaemia to the dorsal cord (T5) is uncommon. Our results suggest that this area is sometimes supplied from the vertebral artery. Some authors state that this region could be a critical zone and its vascularisation could be provided from the arterial cervical cord region.5 The bilateral ischaemic lesions extending through several cervical and dorsal segments are in favour of watershed infarcts caused by hypoperfusion due to bilateral vertebral artery dissection.
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