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neuro.spinal-cord-infarct.v1

Spinal Cord Infarction (Anterior Spinal Artery Syndrome and other vascular cord lesions)

neurologyacutesubacuteadultgeriatricacuteinpatienttransition
Start encounter →Print handoutPRODUCTION

Lane F id+neuro-acute campaign wave-3 new-build (2026-05-26). Spinal cord infarct is the time-critical "stroke of the spinal cord" with the classical anterior-spinal-artery syndrome (bilateral motor + pain/temp loss with PRESERVED dorsal columns) and a diagnostic pivot vs acute transverse myelitis (Zalewski JAMA Neurol 2019 PMID 30264146). PubMed-MCP verification 2026-05-26 found the orchestrator-supplied "Robertson CCM 2012 ICU management" PMID candidate was not locatable on PubMed; substituted with the stronger Robertson Neurology 2011 long-term outcome anchor (PMID 22205760). The Cheshire 1996 venous infarction candidate was likewise not locatable and is dropped (flagged in design brief). Crawford classification anchor sourced from Coselli J Thorac Cardiovasc Surg 2016 3309-patient TAAA series (PMID 26898979). All 6 evidence PMIDs live-verified. RxCUI live-verification (RxNav curl 2026-05-26) — aspirin 1191 ✓, atorvastatin 83367 ✓, rosuvastatin 301542 ✓, enoxaparin 67108 ✓, heparin 5224 ✓, gabapentin 25480 ✓, pregabalin 187832 ✓, baclofen 1292 ✓. All 8 candidates verified clean. Registry-id resolution — used `protocol.stroke` (AHA/ASA 2026 arterial-stroke protocol) as the closest cross-reference for MAP-augmentation / antithrombotic / statin framework since no SCI-specific protocol exists in clinical-tools-registry.ts; `calc.ckd_epi_2021` + `calc.nihss` + `calc.caprini` resolve; panels `panel.cbc / panel.coag / panel.lipid / panel.cardiac / panel.inflammation` all resolve. Schema-blocked: no `workup.spinal_cord_infarct` / `workup.acute_myelopathy` / `workup.aortic_dissection_screen` / `workup.csf_drainage` / `protocol.spinal_cord_infarct` in clinical-tools-registry.ts at this build — workups array left empty; flagged for future depth-pass registry expansion. Settings shipped: ed / icu / inpatient / transition / outpatient (5). Severity triggers: 9 (high-cervical-respiratory / aortic-dissection-associated / periprocedural-aortic / complete-motor-paralysis-ASIA-A / evolving-deficit / FCE-young / sickle-cell / cardioembolic / transverse-myelitis-mimic). MAP ≥85 mmHg × 5-7 d target is extrapolated from TBI/SCI literature (Hawryluk paradigm) — not SCI-specific RCT. No proven acute thrombolysis evidence for cord infarct (cohort-level only); TPA explicitly NOT recommended in dossier (contrast with cerebral ischemia). Long-term prognosis ~50% regain ambulation (Robertson Neurology 2011 PMID 22205760); chronic neuropathic pain + bladder/bowel dysfunction common. §5.5.2 Bayesian depth-pass NOT performed at this build — D-dimer / NfL / NAR likelihood ratio derivations and ASIA-grade-to-mRS band-mapping flagged as NEEDS_SOURCE_REVIEW for future depth-pass-2.

Entry points (6)

  • symptom
    Sudden flaccid paraparesis / quadriparesis + dissociated sensory loss (motor + pain/temp loss with preserved proprioception) — classical anterior spinal artery syndrome (Zalewski JAMA Neurol 2019 PMID 30264146)
    sudden_paraparesis_dissociated_sensory
  • symptom
    Acute radicular / interscapular back pain followed within minutes by motor + sensory deficit at a discrete cord level (Zalewski JAMA Neurol 2019 PMID 30264146; Yadav J Stroke Cerebrovasc Dis 2018 PMID 30093205)
    acute_back_pain_with_radicular_motor_deficit
  • symptom
    Post-operative paraplegia / paraparesis after thoracoabdominal aortic aneurysm repair or aortic dissection surgery (Coselli J Thorac Cardiovasc Surg 2016 PMID 26898979)
    postop_paraplegia_after_aortic_surgery
  • symptom
    Elderly hyperextension injury with UE>LE weakness (central cord syndrome) — overlap with ischemic central cord pattern (Nasr/Rabinstein 2017 PMID 28688063)
    central_cord_hyperextension_elderly
  • imaging
    Whole-spine MRI T2 pencil-like hyperintensity / owl-eyes axial pattern ± DWI restriction in cord parenchyma (Zalewski PMID 30264146; Yadav PMID 30093205)
    cord_t2_pencil_owl_eyes_hyperintensity
  • imaging
    Acute DWI restriction in cord on MRI — emerging diagnostic feature in early SCI (Zalewski PMID 30264146)
    cord_dwi_restriction_acute

Required inputs (21)

  • agerequired
    demographic • used at CONTEXT
    Mayo cohort median age 60 (IQR 52-69); ASA dominant in older atherosclerotic; FCE typical in younger pregnant/Valsalva (Zalewski JAMA Neurol 2019 PMID 30264146; Robertson Neurology 2011 PMID 22205760)
  • sex
    demographic • used at CONTEXT
    Mayo SCI cohort 62.6% male (Robertson Neurology 2011 PMID 22205760)
  • sbprequired
    vital • used at TREATMENT
    Hemodynamic augmentation target MAP ≥85 mmHg × 5-7 d in acute SCI (Nasr/Rabinstein Curr Treat Options Neurol 2017 PMID 28688063 — TBI/SCI extrapolation)
  • maprequired
    vital • used at TREATMENT
    MAP target ≥85 mmHg drives vasopressor / fluid management decisions (Nasr/Rabinstein 2017 PMID 28688063)
  • respiratory_raterequired
    vital • used at RED_FLAGS
    High cervical SCI (C3-C5 phrenic) → respiratory failure → ICU + intubation (Robertson Neurology 2011 PMID 22205760)
  • femoral_vs_brachial_pulse_asymmetryrequired
    vital • used at RED_FLAGS
    Pulse asymmetry / BP-arm-differential is a key aortic-dissection clue when SCI is concurrent (Nasr/Rabinstein 2017 PMID 28688063)
  • mri_whole_spine_with_dwirequired
    imaging • used at INITIAL_WORKUP
    Whole-spine MRI with DWI is the diagnostic gold standard — T2 pencil-like + owl-eyes + DWI restriction in cord parenchyma (Zalewski JAMA Neurol 2019 PMID 30264146; Yadav PMID 30093205)
  • cta_aorta_dissection_screen
    imaging • used at INITIAL_WORKUP
    CTA aorta is indicated when chest/back pain + cord syndrome ± pulse asymmetry ± hypertensive surge — aortic dissection is 15% of SCI etiologies (Nasr/Rabinstein 2017 PMID 28688063)
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Baseline + screen for sickle cell (cord infarct in vaso-occlusive crisis), polycythemia, infection (Nasr/Rabinstein 2017 PMID 28688063)
  • coag_pt_inr_apttrequired
    lab • used at INITIAL_WORKUP
    Baseline before anticoag if cardioembolic etiology (Nasr/Rabinstein 2017 PMID 28688063)
  • creatininerequired
    lab • used at TREATMENT
    eGFR drives statin / antithrombotic / LMWH dosing decisions (Nasr/Rabinstein 2017 PMID 28688063)
  • lipid_panelrequired
    lab • used at INITIAL_WORKUP
    Atherosclerotic etiology accounts for ~50% of SCI; statin secondary prevention (Nasr/Rabinstein 2017 PMID 28688063)
  • troponin
    lab • used at INITIAL_WORKUP
    Concurrent ACS / cardioembolic source / Type-A aortic-dissection screen (Nasr/Rabinstein 2017 PMID 28688063)
  • csf_analysis
    lab • used at BRANCHING_WORKUP
    CSF analysis distinguishes SCI (acellular or mild pleocytosis 7/89 = 8% Zalewski PMID 30264146) from acute transverse myelitis (frank pleocytosis + oligoclonal bands)
  • serum_nfl_neurofilament
    lab • used at BRANCHING_WORKUP
    Elevated serum NfL relative to MRI T2-lesion area (NAR ≥0.35) discriminates SCI vs acute myelitis with AUC 0.93 (Sechi/Zalewski Stroke 2021 PMID 33423516) — Mayo research biomarker, emerging clinical adjunct
  • recent_aortic_surgery_or_endovascularrequired
    history • used at CONTEXT
    Periprocedural SCI is ~45% of cohort SCI etiologies; CSF drainage protocol applies (Robertson Neurology 2011 PMID 22205760; Coselli J Thorac Cardiovasc Surg 2016 PMID 26898979)
  • atherosclerosis_vascular_risk_factorsrequired
    history • used at CONTEXT
    Vascular risk factors (HTN, DM, smoking, dyslipidemia) present in 76% Mayo cohort (Zalewski PMID 30264146)
  • cardiac_embolic_source
    history • used at CONTEXT
    AF, valvular disease, recent MI, endocarditis → cardioembolic SCI → anticoag (Nasr/Rabinstein 2017 PMID 28688063)
  • sickle_cell_disease
    history • used at CONTEXT
    Sickle cell vaso-occlusive crisis causes SCI; treatment is exchange transfusion + hydration (Nasr/Rabinstein 2017 PMID 28688063)
  • vasculitis_systemic_inflammatory
    history • used at CONTEXT
    PAN, GCA, syphilis, SLE can cause SCI — vasculitis workup if young / unexplained / systemic features (Nasr/Rabinstein 2017 PMID 28688063)
  • recent_valsalva_or_minor_trauma_young
    history • used at CONTEXT
    Fibrocartilaginous embolism — young patient post-Valsalva / minor athletic trauma (Nasr/Rabinstein 2017 PMID 28688063)

12-phase flow (12)

  1. 1FRAME
    Acute or subacute SCI in adult — recognize the anterior spinal artery syndrome and rule out the must-not-miss mimics (aortic dissection, epidural compression, transverse myelitis) (Zalewski JAMA Neurol 2019 PMID 30264146)
    advance: SCI suspected on syndromic grounds
  2. 2ENTRY
    Sudden flaccid paraparesis / quadriparesis ± dissociated sensory loss ± radicular back pain → urgent whole-spine MRI with DWI (Zalewski PMID 30264146)
    inputs: age
    advance: SCI entry trigger captured + MRI ordered
  3. 3CONTEXT
    Atherosclerosis / recent aortic surgery / aortic dissection / cardiac embolic source / sickle cell / vasculitis / FCE substrate (Nasr/Rabinstein 2017 PMID 28688063; Zalewski PMID 30264146)
    inputs: atherosclerosis_vascular_risk_factors, recent_aortic_surgery_or_endovascular, cardiac_embolic_source, sickle_cell_disease, vasculitis_systemic_inflammatory, recent_valsalva_or_minor_trauma_young
    advance: Substrate / mechanism captured
  4. 4RED_FLAGS
    High cervical respiratory failure (C3-C5), aortic dissection signs (pulse asymmetry, BP arm-differential, chest/back pain + cord syndrome), hemodynamic instability, evolving deficit during admission (Nasr/Rabinstein 2017 PMID 28688063; Robertson Neurology 2011 PMID 22205760)
    inputs: respiratory_rate, femoral_vs_brachial_pulse_asymmetry
    advance: Airway / ICU triage complete
  5. 5INITIAL_WORKUP
    Urgent whole-spine MRI with DWI (T2 pencil-like + owl-eyes ± DWI restriction); CTA aorta if any dissection suspicion; CBC, coags, lipid, troponin, CMP (Zalewski JAMA Neurol 2019 PMID 30264146; Yadav PMID 30093205; Nasr/Rabinstein 2017 PMID 28688063)
    inputs: mri_whole_spine_with_dwi, cta_aorta_dissection_screen, cbc, coag_pt_inr_aptt, creatinine, lipid_panel, troponin
    actions: panel.cbc, panel.coag, panel.lipid, panel.cardiac, panel.inflammation
    advance: Cord lesion mapped + aortic dissection ruled out
  6. 6BRANCHING_WORKUP
    CSF if myelitis suspected (SCI acellular or mild pleocytosis 8% Zalewski cohort vs ATM frank pleocytosis); TTE/TEE if cardioembolic; hypercoag panel if young / unexplained; vasculitis workup if systemic features; serum NfL if available (Sechi Stroke 2021 PMID 33423516)
    inputs: csf_analysis, serum_nfl_neurofilament
    advance: Mechanism + mimics mapped
  7. 7DIFFERENTIAL
    SCI vs acute transverse myelitis (subacute, CSF pleocytic, gad-enhancement) vs epidural compression (separate dossier; surgical) vs epidural abscess/hematoma (separate; surgical) vs MS demyelination (multifocal CNS) vs NMOSD (AQP4-IgG) vs HSV/HTLV-1 myelitis (Zalewski PMID 30264146; Sechi Stroke 2021 PMID 33423516)
    advance: SCI confirmed; mimics excluded
  8. 8RISK_STRATIFICATION
    ASIA grade at nadir is the strongest predictor of long-term outcome (ASIA A/B = wheelchair / catheterization-dependent at follow-up; Robertson Neurology 2011 PMID 22205760)
    advance: ASIA grade documented
  9. 9TREATMENT
    Step 1 — Hemodynamic augmentation MAP ≥85 mmHg × 5-7 d (Nasr/Rabinstein 2017 PMID 28688063); Step 2 — aspirin 325 mg + statin if atherosclerotic (no SCI-specific RCT, extrapolated from arterial stroke secondary prevention); Step 3 — anticoag if cardioembolic / vertebral-dissection-extension; Step 4 — CSF drainage via lumbar catheter if periprocedural aortic-surgery SCI (Coselli 2016 PMID 26898979); Step 5 — neuropathic pain (gabapentin/pregabalin), spasticity (baclofen), bladder/bowel/skin/DVT-ppx (Nasr/Rabinstein 2017 PMID 28688063). NO routine thrombolysis — no SCI-specific evidence
    inputs: sbp, map, creatinine
    actions: protocol.stroke
    advance: Acute management decisions made + etiology-driven secondary prevention initiated
  10. 10DISPOSITION
    Neuro-ICU for respiratory failure, hemodynamic instability, evolving deficit, periprocedural CSF drainage; SCI rehab unit (IRF) when stable (Robertson Neurology 2011 PMID 22205760; Nasr/Rabinstein 2017 PMID 28688063)
    inputs: respiratory_rate
    advance: Bed allocated
  11. 11MONITORING
    Daily neuro + ASIA grading; bladder/bowel program; skin / pressure-injury surveillance; DVT prophylaxis (enoxaparin 40 mg SC daily); MAP monitoring × 5-7 d; statin adherence; aspirin tolerance (Nasr/Rabinstein 2017 PMID 28688063)
    advance: Monitoring plan documented
  12. 12FOLLOWUP
    SCI rehab (IRF / outpatient); neuropathic pain medication titration; spasticity management; mood / vocational; recurrent-event surveillance (etiology-driven) (Robertson Neurology 2011 PMID 22205760)
    advance: Long-term rehab + secondary-prevention plan documented