Stroke masquerading as transverse myelitis: Spinal cord ischemia and differential diagnosis in patients presenting with acute paraparesis – a series of nine cases

Introduction: Spinal cord ischemia accounts for about 1% of all strokes and is a rare stroke subtype whose diagnosis is often delayed. Because it presents with acute paraparesis, a sensory level, and sphincter dysfunction, it can be mistaken for transverse myelitis. Using nine patients evaluated with a preliminary diagnosis of transverse myelitis, this study aimed to emphasize the importance of spinal cord ischemia in the differential diagnosis of acute paraparesis.Methods: Nine patients evaluated for acute/subacute bilateral lower extremity weakness were reviewed retrospectively. Demographic and clinical characteristics, cranial and spinal MRI, diffusion MRI, CSF analysis, NMO-IgG, MOG-IgG, oligoclonal bands, EMG, and, where needed, CT/DSA angiography findings were evaluated, together with treatment responses.Results: Six of the patients were men and three were women, aged 34–84 years. All patients had bilateral lower extremity weakness, and most had a sensory level and sphincter dysfunction. Spinal cord ischemia was considered in three patients. In a 62-year-old patient, a thoracic lesion at the T2–T3 level showed diffusion restriction without contrast enhancement; in a 59-year-old patient, acute paraplegia developed after girdle-like pain, with an “owl’s eye” sign at T11–T12 and aortic dissection, aneurysm, and a paraaortic hematoma on CT/DSA. In a 77-year-old patient, sudden onset and lack of response to pulse steroids were interpreted as favoring ischemia. In the spinal ischemia cases, acute onset, diffusion restriction, absence of contrast enhancement, aortic pathology, and lack of response to immunotherapy were decisive in the differential diagnosis. The other cases were diagnosed as NMO-IgG–positive necrotizing myelitis, long-segment inflammatory myelitis/ADEM, recurrent transverse myelitis, a neoplastic process, and sensorimotor polyneuropathy.Discussion/Conclusion: Spinal cord ischemia is a rare but important cause of acute paraparesis and must always be considered in the differential diagnosis of transverse myelitis. Sudden onset, early diffusion restriction, the “owl’s eye” sign, absence of contrast enhancement, accompanying aortic pathology, and lack of response to immunotherapy are important clues favoring spinal ischemia. Early diagnosis can prevent unnecessary immunosuppressive treatment and allow etiology-directed management and secondary prevention to begin in a timely manner.Keywords: