key: cord-0738844-bvcr6gz8 authors: Bax, Francesco; Gigli, Gian Luigi; Iaiza, Francesca; Valente, Mariarosaria title: Spontaneous spinal cord ischemia during COVID-19 infection date: 2021-04-28 journal: J Neurol DOI: 10.1007/s00415-021-10574-x sha: 1fe01f926dd5553dbc34b6217a7480bec1c7b47c doc_id: 738844 cord_uid: bvcr6gz8 nan methylprednisolone were initiated, the latter due to initial concern of a possible autoimmune etiology. Coagulation panel showed mild elevation of D-dimer (582 ng/ml [reference values 0-500]), and reduced fibrinogen levels (161 mg/dL [reference values 180-380]). Factor II and V, C/S protein and anti-phospholipid antibodies were normal. Antinuclear, anti-extractable nuclear antigen, antineutrophil cytoplasmic and anti-double-strand-DNA antibodies, lupus anti-coagulant and cryoglobulin were negative. Complement fractions C3 and C4 were normal. CSF examination showed normal levels of protein, glucose, lactate and cells, with type I oligoclonal bands. Screening for Lyme disease and tick-borne encephalitis was negative. Somatosensory-evoked potentials showed no delay of central conduction latency. Motor-evoked potentials demonstrated slowing of central conduction time at upper limbs, while no motor response was obtained for lower limbs. A diagnosis of spontaneous ischemic myelopathy was made after exclusion of alternative diagnoses. On day 6, the patient developed fever (40 °C), oxygen desaturation, pleural effusion and bilateral lower lobes interstitial pneumonia. Dexamethasone and oxygen support were initiated. By day 12, fever had resolved and on day 21, oxygen therapy was weaned successfully. On day 43, the patient was transferred to Neurorehabilitation Unit, able to move upper limbs against little resistance and lower limbs on a flat surface, while bilateral brisk patellar reflexes (+ + +) and Babinski sign became evident. Follow-up spinal MRI scan is shown in Fig. 1 . At three months of follow-up, gait was possible only with the aid of a walker, mild somatosensory alterations were still evident, but starting at a lower level (T3) and AIS score was D. Spinal cord ischemia is a rare entity, accounting for only 1% of ischemic strokes [3, 4] . Common etiologies are aortic disease (usually procedure-related), mechanical compression of radicular arteries, dissection, atherosclerosis, embolism, vasculitis, or hypercoagulable states. Vascular risk factors and preceding physical maneuvers (i.e., Valsalva, load lifting, back hyperextension) are frequent among patients [3] [4] [5] . As often is the case [3] [4] [5] , no cause for spontaneous spinal cord ischemia was found in this patient. Moreover, the MRI alteration exceeded localization that is usually reported for such lesions [3, [5] [6] [7] . This element, along with the absence of a reported physical maneuver preceding the onset of symptoms, makes compression of radicular arteries unlikely as pathogenetic mechanism. On the other hand, the young age and the complete absence of risk factors for vascular disease point to an unusual pathogenetic mechanism. Although a causal relationship cannot be proved, the temporal relation of the patient's motor symptoms with the infection suggests that COVID-19, a possible trigger of neurovascular injury [8, 9] , may have played a role in causing the spinal cord ischemia. This case illustrates how vascular neurological complications may precede infection symptoms, in contrast with what has been reported for ischemic strokes that seem to present as a late complication of the infection, usually after two weeks from onset [10] . However, large vessels strokes have also been reported as the first disease manifestation in young individuals [11] , supporting the role of a precocious inflammatory and hypercoagulable state as a disease driver in this setting. We are aware of only one other report of spontaneous, possibly ischemic, myelopathy in a COVID-19 patient without concomitant vascular risk factors [12] . However, in this case, no CSF examination was performed, thus alternative diagnoses were not excluded. Updates of the international standards for neurologic classification of spinal cord injury Current and emerging treatment options for spinal cord ischemia Vascular myelopathies Characteristics of spontaneous spinal cord infarction and proposed diagnostic criteria Recovery after spinal cord infarcts: long-term outcome in 115 patients Spinal cord infarction: clinical and magnetic resonance imaging findings and short term outcome Stroke in patients with COVID-19: clinical and neuroimaging characteristics Neuropathogenesis and neurologic manifestations of the coronaviruses in the age of coronavirus disease 2019 Acute cerebrovascular disease following COVID-19: a single center, retrospective, observational study Large-vessel stroke as a presenting feature of Covid-19 in the young Case report: acute spinal cord myelopathy in patients With COVID-19. Front Neurol Acknowledgements None. The authors report no disclosure relevant to the manuscript.