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A 59 year old man with history of smoking, hypertension, diabetes mellitus, and hypercholesterolemia presented suddenly with numbness and weakness of both upper limbs. A few minutes after that he felt an intense and oppressive chest pain accompanied by profuse diaphoresis, severe hypotension, bradycardia, and low level of consciousness. No elevated damage cardiac markers or electrocardiographic changes were registered. Aortography ruled out an aortic dissection whereas coronary angiography showed a moderate stenosis in the left coronary trunk, which was stented.
An adequate neurological examination could be performed only after 48 hours, when the patient was extubated. He had a bilateral, predominantly proximal (MRC grade 2/5 versus 4/5 for the distal muscles), flaccid arm paresis, with absent reflexes. Muscular balance and deep tendon reflexes in both lower limbs were normal. All sensory modalities were preserved and there were neither autonomic abnormality nor Babinski sign.
Cranial MRI ruled out bilateral brain infarctions in the border zone between middle and anterior cerebral artery territories—the most frequent aetiology of acute man-in-the-barrel syndrome. Surprisingly, cervical MR demonstrated a spinal anterior artery territory infarction between C2 and C7 levels involving exclusively both anterior horns of the spinal cord (panels A and B), whose cells are known to have a special vulnerability to ischaemia.1–3 Magnetic angioresonance made evident a severe atheromatosis within the right vertebral artery (panel C).
Prominent vegetative symptoms and chest pain at the onset provoked an initial misdiagnosis of acute myocardial infarction despite the absence of compatible biochemical and electrocardiographic changes, but they can be plausibly explained by a transient ischaemia of intermediate-lateral horns and of spinothalamic tracts at the lower segments of cervical cord, respectively.4,5
Cervical cord infarction should be considered as a cause of acute bilateral arm paresis and included in the differential diagnosis of chest pain with accompanying neurological symptoms together with myocardial infarction and aortic dissection.
Competing interests: none declared
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