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= Spinal Cord Stroke = Its preventive measures include decreasing the risk factors and maintaining enough spinal cord perfusion pressure during and after the operation. Radiologists always apply different MRI protocols for the diagnosis of both ischemic and hemorrhagic spinal stroke. Treatment for spinal cord stroke is mainly determined by the symptoms and the causes of the disease. For ischemic spinal stroke patients, antiplatelet and corticosteroids might be used to reduce the risk of blood clot. For hemorrhagic spinal stroke patients, rapid surgical decompression is applied to minimize the neurological injuries. Patients may spend years for the significant recovery after the spinal cord stroke.

Risk factors
Modifiable risk factors that contribute to the common strokes such as hypertension and heart disease, are found less common in the formation of spinal cord stroke. On the other hand, diabetes mellitus, peripheral artery disease, smoking and cholesterol are associated more with such disease. Prevention and treatment of these modifiable risk factors could reduce the likelihood of spinal cord stroke.

Intraoperative strategy
As the high difficulty for the detection during operation, somatosensory evoked potential monitoring or motor evoked potential monitoring is necessary to early detect the spinal cord ischemia in anesthetized patient for quick intervention. Cerebrospinal fluid drainage is always used to decrease intraspinal pressure and increase blood flow to the spinal cord to avoid hypotension, thus reducing the risk of spinal cord ischemia.

Postoperative strategy
The aims of postoperative management are to maintain enough spinal cord perfusion pressure, and make serial neurologic assessments to detect the disease. Similar as in the intraoperative strategy, increasing the spinal cord perfusion as an immediate intervention may increase the chance for a successful treatment. Neurological examination should be conducted after anesthesia to test the motor function of the low extremity of patients. By using this method to detect whether patients have spinal cord ischemia, doctors could decide whether rapid treatment should be provided.

Diagnosis
Spinal stroke could be easily misdiagnosed because of its rarity. The doctor will first assess the clinical symptoms of the patient, such as paralysis, sensory loss and urinary and bowel dysfunction, to determine whether it is possible for the spinal stroke. After that, different MRI imaging protocols will be used, including axial and sagittal T1 and T2-weighted sequences and diffusion-weighted imaging (DWI).

Ischemic spinal cord stroke
As the non-contrast CT and spine CT angiography are ineffective in imaging modalities, doctors use MRI to confirm the diagnosis. MRI findings, including pencillike hyperintensities on T2-weighted sagittal images and “owl’s eyes” or “snake eyes” sign on T2 axial images, indicating the infarction is predominately in the watershed area of the gray matter of ventral horn (ASA infarct). Also, posterior paramedian triangular hyperintensity in T2 hyperintensity indicates PSA infarct. On a T1 sequence, we may also observe a cord expansion and a decreased signal. However, traditional MRI may show no abnormality especially for those patients in the acute phase. DWI is very sensitive for early detection of spinal cord infarction and shows a typical high signal intensity.

Hemorrhagic spinal cord stroke
To identify the hematoma in the spinal cord, MRI with and without gadolinium enhancement is the preferred choice. CT is also used to identify the hemorrhage and provide evidence for pathological analysis. Complete spinal MRI with MR angiography is used when patients with subarachnoid hemorrhage without the intracranial etiology. As the evaluation of the need for intradural interrogation is important, it is necessary to differentiate between subdural and epidural hematomas. Based on the location of the hematoma, use both axial and sagittal images of MRI to identify the boundary between hematoma and fat. An inverted Mercedes-Benz sign shows the spinal subdural hematoma on the axial image.

Treatment
Given the rarity and heterogeneity of the spinal cord stroke, symptomatic treatment of associated complications is applied, which is based on patients' own circumstances.

Ischemic spinal cord stroke
Although some literature suggest that thrombolysis could be the treatment for ischemic spinal stroke, the associated risks are unknown due to the scarce data. If the cause is global hypoperfusion, maintaining enough blood pressure to maintain adequate spinal perfusion is needed. Also, anticoagulation and antiplatelet agents have been prescribed to prevent vascular occlusion or embolism. Corticosteroids are prescribed in situations of vasculitis or aortitis.

Surgical decompression
The goal of treatment in an acute situation is to relieve pressure on the spinal cord. To limit neurological injury, surgical decompression should be undertaken as soon as possible. Several case studies show a substantial link between the time from bleeding to surgical decompression and neurological outcome, with the greatest results coming from individuals who had surgery within 12 hours after symptom onset.

Administration of large dose corticosteroids
While waiting for surgery, high-dose corticosteroids were administered in the acute phase. It could reduce edema and secondary cord compression.

Reversal of anticoagulation
As anticoagulation treatment with warfarin or heparin has been linked to spontaneous hematomyelia, reversal anticoagulation is used to reduce the risk of bleeding by using suitable antidotes. Protamine is used to reverse heparin and low molecular-weight heparin. Vitamin K is a reversal agent for warfarin.

Prognosis
It is possible that spinal cord ischemia patients have a full recovery. Although the mortality rate after spinal cord ischemia is relatively high (23%), 58% of the survivors were ambulating with or without gait assistance at their final follow-up appointment. Patients with total paraplegia and sensory loss at nadir can, however, progress significantly over months to years.