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neuro.spinal-cord-infarct.v1PRODUCTION
neuro.spinal-cord-infarct.v1

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

neurologyacutesubacuteadultgeriatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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)

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SCI suspected on syndromic grounds

Patient inputs (21)

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)

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)

Vascular risk factors (HTN, DM, smoking, dyslipidemia) present in 76% Mayo cohort (Zalewski PMID 30264146)

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)

Baseline + screen for sickle cell (cord infarct in vaso-occlusive crisis), polycythemia, infection (Nasr/Rabinstein 2017 PMID 28688063)

Baseline before anticoag if cardioembolic etiology (Nasr/Rabinstein 2017 PMID 28688063)

Atherosclerotic etiology accounts for ~50% of SCI; statin secondary prevention (Nasr/Rabinstein 2017 PMID 28688063)

High cervical SCI (C3-C5 phrenic) → respiratory failure → ICU + intubation (Robertson Neurology 2011 PMID 22205760)

Pulse asymmetry / BP-arm-differential is a key aortic-dissection clue when SCI is concurrent (Nasr/Rabinstein 2017 PMID 28688063)

Hemodynamic augmentation target MAP ≥85 mmHg × 5-7 d in acute SCI (Nasr/Rabinstein Curr Treat Options Neurol 2017 PMID 28688063 — TBI/SCI extrapolation)

MAP target ≥85 mmHg drives vasopressor / fluid management decisions (Nasr/Rabinstein 2017 PMID 28688063)

eGFR drives statin / antithrombotic / LMWH dosing decisions (Nasr/Rabinstein 2017 PMID 28688063)

CSF analysis distinguishes SCI (acellular or mild pleocytosis 7/89 = 8% Zalewski PMID 30264146) from acute transverse myelitis (frank pleocytosis + oligoclonal bands)

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

Mayo SCI cohort 62.6% male (Robertson Neurology 2011 PMID 22205760)

AF, valvular disease, recent MI, endocarditis → cardioembolic SCI → anticoag (Nasr/Rabinstein 2017 PMID 28688063)

Sickle cell vaso-occlusive crisis causes SCI; treatment is exchange transfusion + hydration (Nasr/Rabinstein 2017 PMID 28688063)

PAN, GCA, syphilis, SLE can cause SCI — vasculitis workup if young / unexplained / systemic features (Nasr/Rabinstein 2017 PMID 28688063)

Fibrocartilaginous embolism — young patient post-Valsalva / minor athletic trauma (Nasr/Rabinstein 2017 PMID 28688063)

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)

Concurrent ACS / cardioembolic source / Type-A aortic-dissection screen (Nasr/Rabinstein 2017 PMID 28688063)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationallife_threateninghigh_cervical_respiratory_failure
    High cervical SCI (C3-C5 phrenic) with FVC<15 mL/kg, NIF<−20, RR>30 or SpO2<92% (Nasr/Rabinstein 2017 PMID 28688063)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningaortic_dissection_associated_sci
    CT angiogram aorta shows acute Type A or Type B dissection with cord syndrome (Nasr/Rabinstein 2017 PMID 28688063)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningperiprocedural_aortic_surgery_sci
    SCI within 24-72 h of TAAA / open thoracic-aortic / TEVAR repair (Coselli J Thorac Cardiovasc Surg 2016 PMID 26898979)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecomplete_motor_paralysis_asia_a
    ASIA A (complete motor and sensory loss below level) at nadir (Robertson Neurology 2011 PMID 22205760)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereevolving_deficit_during_admission
    Worsening ASIA grade / new deficit during admission despite MAP augmentation (Nasr/Rabinstein 2017 PMID 28688063)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefibrocartilaginous_embolism_young_pregnant
    Young (often pregnant or post-partum) patient with SCI after Valsalva / minor athletic trauma — fibrocartilaginous embolism suspicion (Nasr/Rabinstein 2017 PMID 28688063)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresickle_cell_vaso_occlusive_cord_infarct
    SCI in sickle cell disease vaso-occlusive crisis (Nasr/Rabinstein 2017 PMID 28688063)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecardioembolic_source_identified
    TTE/TEE shows AF / valvular vegetation / LV thrombus / PFO with cryptogenic SCI (Nasr/Rabinstein 2017 PMID 28688063)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatetransverse_myelitis_alternative_diagnosis
    MRI subacute (hours-days) progression + CSF pleocytosis + gad-enhancement → acute transverse myelitis pivot to separate engine (Zalewski PMID 30264146; Sechi Stroke 2021 PMID 33423516)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

SCI hemodynamic augmentation + etiology-driven antithrombotic / statin + CSF drainage + neuropathic-pain ladder (Nasr/Rabinstein Curr Treat Options Neurol 2017 PMID 28688063; Coselli J Thorac Cardiovasc Surg 2016 PMID 26898979; Robertson Neurology 2011 PMID 22205760)
axis: sci_acute_secondary_prevention_bundlestep 1 - Step 1 — Hemodynamic augmentation MAP ≥85 mmHg × 5-7 d (Nasr/Rabinstein 2017 PMID 28688063 — TBI/SCI extrapolation)
Selected step "Step 1 — Hemodynamic augmentation MAP ≥85 mmHg × 5-7 d (Nasr/Rabinstein 2017 PMID 28688063 — TBI/SCI extrapolation)" — SCI confirmed on whole-spine MRI; hemodynamically stable enough to tolerate vasopressor support
  • maintain_MAP_>=85_mmHg_x_5-7d
    first line
    hemodynamic_augmentation
    triggers: SCI_confirmed, hemodynamically_stable_for_pressor_support
    Hemodynamic augmentation target MAP ≥85 mmHg × 5-7 d in acute SCI (Nasr/Rabinstein 2017 PMID 28688063 — TBI/SCI extrapolation; no SCI-specific RCT)

outpatient playbook — drug actions (3)

  1. 1. aspirin OR oral anticoag + atorvastatin
    rxcui 1191
    Aspirin 81 mg PO daily OR DOAC per AF / cardioembolic; atorvastatin 80 mg PO daily • PO • daily
    trigger: SCI maintenance
    Composite secondary prevention (Nasr/Rabinstein 2017 PMID 28688063)
  2. 2. gabapentin OR pregabalin
    rxcui 25480
    Gabapentin 1200-1800 mg/d divided TID OR pregabalin 150-300 mg/d divided BID • PO • TID / BID
    trigger: Neuropathic pain persistent
    First-line neuropathic pain in SCI (Nasr/Rabinstein 2017 PMID 28688063)
  3. 3. baclofen
    rxcui 1292
    20-80 mg/d divided TID • PO • TID
    trigger: Spasticity persistent
    First-line oral antispasticity (Nasr/Rabinstein 2017 PMID 28688063)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: 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); 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); Post-operative paraplegia / paraparesis after thoracoabdominal aortic aneurysm repair or aortic dissection surgery (Coselli J Thorac Cardiovasc Surg 2016 PMID 26898979).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Spinal Cord Infarction (Anterior Spinal Artery Syndrome and other vascular cord lesions)** (neuro.spinal-cord-infarct.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **SCI hemodynamic augmentation + etiology-driven antithrombotic / statin + CSF drainage + neuropathic-pain ladder (Nasr/Rabinstein Curr Treat Options Neurol 2017 PMID 28688063; Coselli J Thorac Cardiovasc Surg 2016 PMID 26898979; Robertson Neurology 2011 PMID 22205760)** — step "Step 1 — Hemodynamic augmentation MAP ≥85 mmHg × 5-7 d (Nasr/Rabinstein 2017 PMID 28688063 — TBI/SCI extrapolation)".
1. maintain_MAP_>=85_mmHg_x_5-7d (hemodynamic_augmentation, first line) — Hemodynamic augmentation target MAP ≥85 mmHg × 5-7 d in acute SCI (Nasr/Rabinstein 2017 PMID 28688063 — TBI/SCI extrapolation; no SCI-specific RCT)

Setting playbook (outpatient) — SCI clinic + stroke clinic 4-6 wk + 3 mo + 12 mo: ASIA grade reassessment, secondary-prevention adherence (aspirin/anticoag + statin), neuropathic pain optimization, spasticity management, bladder/bowel optimization, mood / vocational, recurrent-event surveillance (Robertson Neurology 2011 PMID 22205760; Nasr/Rabinstein 2017 PMID 28688063)
2. aspirin OR oral anticoag + atorvastatin Aspirin 81 mg PO daily OR DOAC per AF / cardioembolic; atorvastatin 80 mg PO daily PO daily — SCI maintenance (Composite secondary prevention (Nasr/Rabinstein 2017 PMID 28688063))
3. gabapentin OR pregabalin Gabapentin 1200-1800 mg/d divided TID OR pregabalin 150-300 mg/d divided BID PO TID / BID — Neuropathic pain persistent (First-line neuropathic pain in SCI (Nasr/Rabinstein 2017 PMID 28688063))
4. baclofen 20-80 mg/d divided TID PO TID — Spasticity persistent (First-line oral antispasticity (Nasr/Rabinstein 2017 PMID 28688063))

Non-pharmacologic actions:
- Continued PT / OT / rehab medicine for ASIA improvement (Robertson Neurology 2011 PMID 22205760)
- Smoking + alcohol cessation reinforcement
- Recurrent-stroke / SCI symptom education
- Vocational rehab / driving evaluation
- Pressure-injury surveillance + caregiver training

AVOID / contraindication checks:
- No_routine_systemic_thrombolysis_in_SCI_no_evidence (Nasr/Rabinstein 2017 PMID 28688063)
- No_aggressive_BP_lowering_in_acute_SCI_perfusion_dependent (Nasr/Rabinstein 2017 PMID 28688063)
- No_dual_antiplatelet_unless_specific_indication_eg_intracranial_stenting
- No_LMWH_if_HIT_history (use argatroban / bivalirudin / fondaparinux)
- Gabapentin_pregabalin_renal_dose_adjust_CrCl<60
- Atorvastatin_drug_interactions_with_strong_CYP3A4_inhibitors

Monitoring

Regimen monitoring:
- MAP q1h during acute phase target >=85 mmHg x 5-7d (Nasr/Rabinstein 2017 PMID 28688063)
- daily ASIA grading first week (Robertson Neurology 2011 PMID 22205760)
- CK at baseline then clinical if statin intolerance symptoms
- platelet count q3d if heparin (HIT screen)
- CSF pressure continuous if lumbar drain target <10mmHg (Coselli PMID 26898979)
- DVT surveillance weekly in immobile SCI
- pressure injury assessment daily
- lipid panel at 4-6 wk after statin initiation

Setting (outpatient) monitoring:
- Clinic visit at 7-14 d post-discharge for medication reconciliation (Nasr/Rabinstein 2017 PMID 28688063)
- SCI / stroke clinic at 4-6 wk, 3 mo, 12 mo, then annually (Robertson Neurology 2011 PMID 22205760)
- Lipid panel at 4-6 wk then annually
- PHQ-9 at each follow-up
- Renal function if chronic anticoag/LMWH

Follow-up plan: SCI rehab (IRF / outpatient); neuropathic pain medication titration; spasticity management; mood / vocational; recurrent-event surveillance (etiology-driven) (Robertson Neurology 2011 PMID 22205760)
- Close-out criterion: Long-term rehab + secondary-prevention plan documented

Monitoring phase: 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)

Disposition

Current setting: outpatient — SCI clinic + stroke clinic 4-6 wk + 3 mo + 12 mo: ASIA grade reassessment, secondary-prevention adherence (aspirin/anticoag + statin), neuropathic pain optimization, spasticity management, bladder/bowel optimization, mood / vocational, recurrent-event surveillance (Robertson Neurology 2011 PMID 22205760; Nasr/Rabinstein 2017 PMID 28688063)

Disposition criteria:
- Lifelong secondary prevention (aspirin + statin if atherosclerotic; anticoag if cardioembolic) (Nasr/Rabinstein 2017 PMID 28688063)
- Annual clinic follow-up indefinite

Escalation triggers (move to higher acuity):
- New focal deficit / TIA-spectrum → ED (Nasr/Rabinstein 2017 PMID 28688063)
- New severe back / chest pain → ED (rule out recurrent SCI or new aortic event)
- PHQ-9 ≥15 OR suicidal ideation → urgent psych referral
- Refractory neuropathic pain or spasticity → pain / rehab specialist
- New pressure injury → wound care specialist

Patient Action Plan

**Spinal cord infarct secondary prevention + recovery action plan**
Personalised values: etiology_class, asia_grade, antithrombotic_choice, bladder_management, neuropathic_pain_severity.

**Doing well — on stable regimen + rehab** (green):
Triggers:
- no_new_weakness_or_numbness
- no_new_back_pain
- medications_taken_as_prescribed
- rehab_attendance_consistent
- bladder_bowel_routine_intact
Actions:
- Continue secondary-prevention regimen (aspirin/anticoag + statin) as prescribed
- Continue gabapentin/pregabalin + baclofen as titrated
- Continue rehab + bladder/bowel/skin routine
- Attend scheduled SCI / stroke clinic visits

**Caution — call SCI / stroke clinic same day** (yellow):
Triggers:
- new_persistent_back_pain_x_>24h
- worsening_neuropathic_pain
- medication_side_effect
- difficulty_with_catheterization
- new_pressure_area
Actions:
- Call the SCI / stroke clinic / rehab clinic same day
- Do NOT stop secondary-prevention medication without instruction
- Bring medication list to clinic call

**Emergency — call 911 / go to ED** (red):
Triggers:
- new_weakness_or_paralysis_in_any_limb
- new_severe_back_or_chest_pain
- new_difficulty_breathing
- loss_of_bladder_or_bowel_control_acute
- major_bleed
- autonomic_dysreflexia_severe_BP_or_headache
Actions:
- Call 911 / go to nearest ED
- Bring medication list and SCI summary
- Tell ED you have a history of spinal cord infarct on antithrombotic therapy
Contact provider when:
- Any red-zone trigger
- After any ED visit so SCI team is updated

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] High cervical SCI (C3-C5 phrenic) with FVC<15 mL/kg, NIF<−20, RR>30 or SpO2<92% (Nasr/Rabinstein 2017 PMID 28688063)
- [LIFE_THREATENING] CT angiogram aorta shows acute Type A or Type B dissection with cord syndrome (Nasr/Rabinstein 2017 PMID 28688063)
- [LIFE_THREATENING] SCI within 24-72 h of TAAA / open thoracic-aortic / TEVAR repair (Coselli J Thorac Cardiovasc Surg 2016 PMID 26898979)

Citations

- Mayo Clinic 133-patient spontaneous SCI cohort + proposed diagnostic criteria (Zalewski JAMA Neurol 2019 PMID 30264146) + Mayo 115-patient long-term outcome (Robertson Neurology 2011 PMID 22205760) + Nasr/Rabinstein expert framework (Curr Treat Options Neurol 2017 PMID 28688063) [PMID:30264146](https://pubmed.ncbi.nlm.nih.gov/30264146/)
- Cited evidence (PMID 22205760) [PMID:22205760](https://pubmed.ncbi.nlm.nih.gov/22205760/)
- Cited evidence (PMID 33423516) [PMID:33423516](https://pubmed.ncbi.nlm.nih.gov/33423516/)
- Cited evidence (PMID 30093205) [PMID:30093205](https://pubmed.ncbi.nlm.nih.gov/30093205/)
- Cited evidence (PMID 28688063) [PMID:28688063](https://pubmed.ncbi.nlm.nih.gov/28688063/)

Last reconciled with current guidelines: 2026-05-26.
References
  • Mayo Clinic 133-patient spontaneous SCI cohort + proposed diagnostic criteria (Zalewski JAMA Neurol 2019 PMID 30264146) + Mayo 115-patient long-term outcome (Robertson Neurology 2011 PMID 22205760) + Nasr/Rabinstein expert framework (Curr Treat Options Neurol 2017 PMID 28688063) — PMID:30264146
  • Cited evidence (PMID 22205760) — PMID:22205760
  • Cited evidence (PMID 33423516) — PMID:33423516
  • Cited evidence (PMID 30093205) — PMID:30093205
  • Cited evidence (PMID 28688063) — PMID:28688063