Evaluation of a patient with spinal cord infarction after a hypotensive episode.

Case Description A 72-year-old man with past medical history significant for peripheral vascular disease, bilateral carotid stenosis, hypertension, dyslipidemia, and heavy tobacco use developed sudden severe chest pain and received sublingual nitroglycerin with pain resolution. The patient was able to walk to the ambulance, but on arrival in the emergency room had a systolic blood pressure of 60 mm Hg, which was thought to be secondary to nitroglycerin. He was given intravenous fluids. A few hours later, he complained of being unable to move his legs and was found to be paraplegic with urinary retention and a T4 sensory level to pain and temperature with preserved light touch, vibration, and joint position sense. Additional intravenous fluids resulted in minimal improvement. Emergent MRI of the spine was nondiagnostic, but a follow-up MRI the next day showed abnormal signal intensity within the anterior gray matter on T2-weighted images from the T2 through T5 level, with corresponding signal on diffusion weighted imaging. A computed tomography of the chest showed no aortic dissection. Cardiac telemetry and echocardiogram were unremarkable. A fasting low density lipoprotein was 120. He was treated with intravenous fluids, aspirin 81 daily, an increased statin dose, and eventually discharged to an acute rehabilitation facility. Six month later, his lower extremity strength had improved. He was able to walk 45 feet with a wheeled walker and required intermittent urinary catheterization.