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Spinal cord infarction: Vascular anatomy and etiologies

Michael T Mullen, MD
Michael L McGarvey, MD
Section Editor
Scott E Kasner, MD
Deputy Editor
Janet L Wilterdink, MD


Spinal cord infarction is a rare but often devastating disorder caused by a wide array of pathologic states. Patients typically present with acute paraparesis or quadriparesis, depending on the level of the spinal cord involved. The diagnosis is generally made clinically, with neuroimaging to confirm the diagnosis and exclude other conditions.

This topic discusses the vascular anatomy of the spinal cord as well as the epidemiology and causes of spinal cord infarction. The clinical features, diagnosis, prognosis, treatment and chronic complications of spinal cord infarction are discussed separately. Other causes of myelopathy are also discussed separately. (See "Spinal cord infarction: Clinical presentation and diagnosis" and "Spinal cord infarction: Prognosis and treatment" and "Chronic complications of spinal cord injury and disease" and "Disorders affecting the spinal cord" and "Anatomy and localization of spinal cord disorders".)


The incidence of spinal cord infarction has not been specifically reported. It has been estimated that spinal cord infarction accounts for approximately 1 percent of all strokes [1,2]. Extrapolating from estimates of total stroke incidence in the United States, which range from 540,000 to 780,000 per year, it is expected that 5000 to 8000 cases of spontaneous spinal cord infarction occur per year [3,4]. This may be an underestimate, as these figures likely do not include spinal cord infarction complicating major surgery, which is the most common cause of spinal cord infarction.

Spinal cord infarction typically occurs in adults; this is expected as it is usually a direct or indirect complication of atherosclerotic vascular disease; in one series, the mean age was 64 years [5]. However, children, even neonates, can develop spinal cord infarction in specific circumstances [6]. (See 'Etiologies' below.)


Three major vessels arising from the vertebral arteries in the neck supply the spinal cord (figure 1) [7]. There is one anterior spinal artery (ASA) and a pair of posterior spinal arteries (PSA). The ASA supplies the anterior two-thirds of the spinal cord. The ASA and PSAs anastomose distally at the conus medullaris [8].

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Literature review current through: Oct 2017. | This topic last updated: Mar 08, 2017.
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  1. Sandson TA, Friedman JH. Spinal cord infarction. Report of 8 cases and review of the literature. Medicine (Baltimore) 1989; 68:282.
  2. Geldmacher DS, Bowen BC. Vascular Disease of the Nervous System. In: Neurology in Clinical Practice, 4th, Bradley WG, Daroff RB, Fenichel GM, Jankovic J (Eds), Butterworth Heinemann, Philadelphia 2004. p.1313.
  3. Hirtz D, Thurman DJ, Gwinn-Hardy K, et al. How common are the "common" neurologic disorders? Neurology 2007; 68:326.
  4. Williams GR. Incidence and characteristics of total stroke in the United States. BMC Neurol 2001; 1:2.
  5. Robertson CE, Brown RD Jr, Wijdicks EF, Rabinstein AA. Recovery after spinal cord infarcts: long-term outcome in 115 patients. Neurology 2012; 78:114.
  6. Spencer SP, Brock TD, Matthews RR, Stevens WK. Three unique presentations of atraumatic spinal cord infarction in the pediatric emergency department. Pediatr Emerg Care 2014; 30:354.
  7. Prasad S, Price RS, Kranick SM, et al. Clinical reasoning: a 59-year-old woman with acute paraplegia. Neurology 2007; 69:E41.
  8. Hurst RW. Spinal vascular disorders. In: Resonance Imaging of the Brain and Spine, 2nd, Atlas SW (Ed), Lippincott, Philadelphia 2006. p.1387.
  9. Biglioli P, Roberto M, Cannata A, et al. Upper and lower spinal cord blood supply: the continuity of the anterior spinal artery and the relevance of the lumbar arteries. J Thorac Cardiovasc Surg 2004; 127:1188.
  10. Mohr JP, Benavente O, Barnett HJ. Spinal Cord Ischemia. In: Stroke Pathophysiology, Diagnosis, and Management, Barnett HJ, Mohr JP, Stein BM, Yatsu FM (Eds), Churchill Livingstone, Philadelphia 1998. p.423.
  11. Parent A. Blood Supply of the Central Nervous System. In: Carpenter's Human Neuroanatomy, 9th, Williams and Wilkins, 1996. p.93.
  12. Cheshire WP, Santos CC, Massey EW, Howard JF Jr. Spinal cord infarction: etiology and outcome. Neurology 1996; 47:321.
  13. Marcus ML, Heistad DD, Ehrhardt JC, Abboud FM. Regulation of total and regional spinal cord blood flow. Circ Res 1977; 41:128.
  14. Sandler AN, Tator CH. Effect of acute spinal cord compression injury on regional spinal cord blood flow in primates. J Neurosurg 1976; 45:660.
  15. Hickey R, Albin MS, Bunegin L, Gelineau J. Autoregulation of spinal cord blood flow: is the cord a microcosm of the brain? Stroke 1986; 17:1183.
  16. McGarvey ML, Cheung AT, Szeto W, Messe SR. Management of neurologic complications of thoracic aortic surgery. J Clin Neurophysiol 2007; 24:336.
  17. Weidauer S, Nichtweiss M, Lanfermann H, Zanella FE. Spinal cord infarction: MR imaging and clinical features in 16 cases. Neuroradiology 2002; 44:851.
  18. Iseli E, Cavigelli A, Dietz V, Curt A. Prognosis and recovery in ischaemic and traumatic spinal cord injury: clinical and electrophysiological evaluation. J Neurol Neurosurg Psychiatry 1999; 67:567.
  19. Messé SR, Bavaria JE, Mullen M, et al. Neurologic outcomes from high risk descending thoracic and thoracoabdominal aortic operations in the era of endovascular repair. Neurocrit Care 2008; 9:344.
  20. Xenos ES, Abedi NN, Davenport DL, et al. Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture. J Vasc Surg 2008; 48:1343.
  21. Cheung AT, Weiss SJ, McGarvey ML, et al. Interventions for reversing delayed-onset postoperative paraplegia after thoracic aortic reconstruction. Ann Thorac Surg 2002; 74:413.
  22. Maniar HS, Sundt TM 3rd, Prasad SM, et al. Delayed paraplegia after thoracic and thoracoabdominal aneurysm repair: a continuing risk. Ann Thorac Surg 2003; 75:113.
  23. Cambria RP, Clouse WD, Davison JK, et al. Thoracoabdominal aneurysm repair: results with 337 operations performed over a 15-year interval. Ann Surg 2002; 236:471.
  24. Estrera AL, Miller CC 3rd, Huynh TT, et al. Neurologic outcome after thoracic and thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 2001; 72:1225.
  25. Crawford ES, Mizrahi EM, Hess KR, et al. The impact of distal aortic perfusion and somatosensory evoked potential monitoring on prevention of paraplegia after aortic aneurysm operation. J Thorac Cardiovasc Surg 1988; 95:357.
  26. Cheung AT, Pochettino A, McGarvey ML, et al. Strategies to manage paraplegia risk after endovascular stent repair of descending thoracic aortic aneurysms. Ann Thorac Surg 2005; 80:1280.
  27. Sloan TB, Jameson LC. Electrophysiologic monitoring during surgery to repair the thoraco-abdominal aorta. J Clin Neurophysiol 2007; 24:316.
  28. Sandridge L, Kern JA. Acute descending aortic dissections: management of visceral, spinal cord, and extremity malperfusion. Semin Thorac Cardiovasc Surg 2005; 17:256.
  29. Gaul C, Dietrich W, Friedrich I, et al. Neurological symptoms in type A aortic dissections. Stroke 2007; 38:292.
  30. Joo JB, Cummings AJ. Acute thoracoabdominal aortic dissection presenting as painless, transient paralysis of the lower extremities: a case report. J Emerg Med 2000; 19:333.
  31. Donovan EM, Seidel GK, Cohen A. Painless aortic dissection presenting as high paraplegia: a case report. Arch Phys Med Rehabil 2000; 81:1436.
  32. Zull DN, Cydulka R. Acute paraplegia: a presenting manifestation of aortic dissection. Am J Med 1988; 84:765.
  33. Nandeesh BN, Mahadevan A, Santosh V, et al. Acute aortic dissection presenting as painful paraplegia. Clin Neurol Neurosurg 2007; 109:531.
  34. Inamasu J, Hori S, Yokoyama M, et al. Paraplegia caused by painless acute aortic dissection. Spinal Cord 2000; 38:702.
  35. Wityk RJ, Zanferrari C, Oppenheimer S. Neurovascular complications of marfan syndrome: a retrospective, hospital-based study. Stroke 2002; 33:680.
  36. Nedeltchev K, Loher TJ, Stepper F, et al. Long-term outcome of acute spinal cord ischemia syndrome. Stroke 2004; 35:560.
  37. Masson C, Pruvo JP, Meder JF, et al. Spinal cord infarction: clinical and magnetic resonance imaging findings and short term outcome. J Neurol Neurosurg Psychiatry 2004; 75:1431.
  38. Hussain MS, Shuaib A, Siddiqi ZA. Spinal cord transient ischemic attacks: a possible role for abciximab. Neurology 2005; 64:761.
  39. Servais LJ, Rivelli SK, Dachy BA, et al. Anterior spinal artery syndrome after aortic surgery in a child. Pediatr Neurol 2001; 24:310.
  40. Restrepo L, Guttin JF. Acute spinal cord ischemia during aortography treated with intravenous thrombolytic therapy. Tex Heart Inst J 2006; 33:74.
  41. Winter RB. Neurologic safety in spinal deformity surgery. Spine (Phila Pa 1976) 1997; 22:1527.
  42. Hobai IA, Bittner EA, Grecu L. Perioperative spinal cord infarction in nonaortic surgery: report of three cases and review of the literature. J Clin Anesth 2008; 20:307.
  43. Kalb S, Fakhran S, Dean B, et al. Cervical spinal cord infarction after cervical spine decompressive surgery. World Neurosurg 2014; 81:810.
  44. Kaya A, Yıldız Z, Nurkalem Z. Spinal cord infarction as a complication of percutaneous coronary intervention. Spinal Cord 2014; 52 Suppl 2:S5.
  45. Matsubara N, Miyachi S, Okamaoto T, et al. Spinal cord infarction is an unusual complication of intracranial neuroendovascular intervention. Interv Neuroradiol 2013; 19:500.
  46. Fujii L, Clain JE, Morris JM, Levy MJ. Anterior spinal cord infarction with permanent paralysis following endoscopic ultrasound celiac plexus neurolysis. Endoscopy 2012; 44 Suppl 2 UCTN:E265.
  47. Brown AC, Ray CE. Anterior Spinal Cord Infarction following Bronchial Artery Embolization. Semin Intervent Radiol 2012; 29:241.
  48. Park SJ, Kim CH, Kim JD, et al. Spinal cord injury after conducting transcatheter arterial chemoembolization for costal metastasis of hepatocellular carcinoma. Clin Mol Hepatol 2012; 18:316.
  49. Bansal S, Brown W, Dayal A, Carpenter JL. Posterior spinal cord infarction due to fibrocartilaginous embolization in a 16-year-old athlete. Pediatrics 2014; 134:e289.
  50. Reynolds JM, Belvadi YS, Kane AG, Poulopoulos M. Thoracic disc herniation leads to anterior spinal artery syndrome demonstrated by diffusion-weighted magnetic resonance imaging (DWI): a case report and literature review. Spine J 2014; 14:e17.
  51. Duprez TP, Danvoye L, Hernalsteen D, et al. Fibrocartilaginous embolization to the spinal cord: serial MR imaging monitoring and pathologic study. AJNR Am J Neuroradiol 2005; 26:496.
  52. Beer S, Kesselring J. Fibrocartilaginous embolisation of the spinal cord in a 7-year-old girl. J Neurol 2002; 249:936.
  53. Tosi L, Rigoli G, Beltramello A. Fibrocartilaginous embolism of the spinal cord: a clinical and pathogenetic reconsideration. J Neurol Neurosurg Psychiatry 1996; 60:55.
  54. Heckmann JG, Dütsch M, Struffert T, et al. Spinal cord infarction: a case of fibrocartilaginous embolism? Eur J Neurol 2007; 14:e23.
  55. Thöne J, Hohaus A, Bickel A, Erbguth F. Severe spinal cord ischemia subsequent to fibrocartilaginous embolism. J Neurol Sci 2007; 263:211.
  56. Raghavan A, Onikul E, Ryan MM, et al. Anterior spinal cord infarction owing to possible fibrocartilaginous embolism. Pediatr Radiol 2004; 34:503.
  57. Piao YS, Lu DH, Su YY, Yang XP. Anterior spinal cord infarction caused by fibrocartilaginous embolism. Neuropathology 2009; 29:172.
  58. Freyaldenhoven TE, Mrak RE, Rock L. Fibrocartilaginous embolization. Neurology 2001; 56:1354.
  59. Chang CW, Donovan DJ, Liem LK, et al. Surfers' myelopathy: a case series of 19 novice surfers with nontraumatic myelopathy. Neurology 2012; 79:2171.
  60. Duggal N, Lach B. Selective vulnerability of the lumbosacral spinal cord after cardiac arrest and hypotension. Stroke 2002; 33:116.
  61. Sladky JT, Rorke LB. Perinatal hypoxic/ischemic spinal cord injury. Pediatr Pathol 1986; 6:87.
  62. Lin CC, Chen SY, Lan C, et al. Spinal cord infarction caused by cardiac tamponade. Am J Phys Med Rehabil 2002; 81:68.
  63. Salamon E, Patsalides A, Gobin YP, et al. Dural arteriovenous fistula at the craniocervical junction mimicking acute brainstem and spinal cord infarction. JAMA Neurol 2013; 70:796.
  64. Novy J, Carruzzo A, Maeder P, Bogousslavsky J. Spinal cord ischemia: clinical and imaging patterns, pathogenesis, and outcomes in 27 patients. Arch Neurol 2006; 63:1113.
  65. Salvador de la Barrera S, Barca-Buyo A, Montoto-Marqués A, et al. Spinal cord infarction: prognosis and recovery in a series of 36 patients. Spinal Cord 2001; 39:520.
  66. Martinelli V, Comi G, Rovaris M, et al. Acute myelopathy of unknown aetiology: a clinical, neurophysiological and MRI study of short- and long-term prognostic factors. J Neurol 1995; 242:497.
  67. Cheng MY, Lyu RK, Chang YJ, et al. Spinal cord infarction in Chinese patients. Clinical features, risk factors, imaging and prognosis. Cerebrovasc Dis 2008; 26:502.
  68. Cheng MY, Lyu RK, Chang YJ, et al. Concomitant spinal cord and vertebral body infarction is highly associated with aortic pathology: a clinical and magnetic resonance imaging study. J Neurol 2009; 256:1418.
  69. Rathore MF, Gill ZA, Malik AA, Farooq F. Acute flaccid paraplegia: a rare complication of meningococcal meningitis. Spinal Cord 2008; 46:314.
  70. Mustafa KN, Hadidy A, Joudeh A, et al. Spinal cord infarction in giant cell arteritis associated with scalp necrosis. Rheumatol Int 2015; 35:377.
  71. Laufs H, Weidauer S, Heller C, et al. Hemi-spinal cord infarction due to vertebral artery dissection in congenital afibrinogenemia. Neurology 2004; 63:1522.
  72. Hsu CY, Cheng CY, Lee JD, et al. Clinical features and outcomes of spinal cord infarction following vertebral artery dissection: a systematic review of the literature. Neurol Res 2013; 35:676.
  73. Hakimi KN, Massagli TL. Anterior spinal artery syndrome in two children with genetic thrombotic disorders. J Spinal Cord Med 2005; 28:69.
  74. Young G, Krohn KA, Packer RJ. Prothrombin G20210A mutation in a child with spinal cord infarction. J Pediatr 1999; 134:777.
  75. Ramelli GP, Wyttenbach R, von der Weid N, Ozdoba C. Anterior spinal artery syndrome in an adolescent with protein S deficiency. J Child Neurol 2001; 16:134.
  76. Rothman SM, Nelson JS. Spinal cord infarction in a patient with sickle cell anemia. Neurology 1980; 30:1072.
  77. Márquez JC, Granados AM, Castillo M. MRI of cervical spinal cord infarction in a patient with sickle cell disease. Clin Imaging 2012; 36:595.
  78. Edwards A, Clay EL, Jewells V, et al. A 19-year-old man with sickle cell disease presenting with spinal infarction: a case report. J Med Case Rep 2013; 7:210.
  79. Ram S, Osman A, Cassar-Pullicino VN, et al. Spinal cord infarction secondary to intervertebral foraminal disease. Spinal Cord 2004; 42:481.
  80. Lemke RP, Idiong N, al-Saedi S, et al. Spinal cord infarct after arterial switch associated with an umbilical artery catheter. Ann Thorac Surg 1996; 62:1532.
  81. Brown MS, Phibbs RH. Spinal cord injury in newborns from use of umbilical artery catheters: report of two cases and a review of the literature. J Perinatol 1988; 8:105.
  82. Mori S, Sadoshima S, Tagawa K, et al. Massive spinal cord infarction with multiple paradoxical embolism: a case report. Angiology 1993; 44:251.
  83. Hirose G, Kosoegawa H, Takado M, et al. Spinal cord ischemia and left atrial myxoma. Arch Neurol 1979; 36:439.
  84. Petruzzellis M, Fraddosio A, Giorelli M, et al. Posterior spinal artery infarct due to patent foramen ovale: a case report. Spine (Phila Pa 1976) 2010; 35:E155.