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Neurology · Topical Diagnosis in Neurology

Vascular diseases of the spinal cord

Infarctus medullae spinalis

Vascular pathologies of the spinal cord are significantly less common than cerebral strokes, but they often lead to severe, disabling deficits. They are based on impaired arterial inflow, obstructed venous outflow, or spontaneous hemorrhages into the spinal canal structures.

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Rarity of ischemiaA robust anastomotic network reliably protects the spinal cord from extensive infarctions.
Key markerVertebral body ischemia on MRI is a crucial sign of infarction in the adjacent spinal cord area.
Emergency careSpinal epidural hematoma requires immediate surgical evacuation.
Venous congestionArteriovenous fistulas cause congestive myelopathy due to elevated venous pressure.
4 min readFor medical studentsUpdated Sep 25, 2026
Material prepared by WhiteCoat Pro editorial team based on platform study guidesReviewed by medical editor: Aulov A. A., general practitioner · 09/24/2026

Ischemic lesions (infarctions)

Infarctions of the spinal cord parenchyma are rare. Two factors contribute to this: the presence of a rich compensatory network of vascular anastomoses and the physical impossibility for large emboli to penetrate small spinal arteries. Aortopathies or aortic occlusions also rarely lead to such complications. The clinical presentation strictly depends on the affected vascular territory:

  • Anterior spinal artery territory. The deficit develops acutely and is accompanied by pain. For example, a lesion in the upper cervical region causes flaccid arm paresis (destruction of anterior horns), spastic leg paraparesis (damage to corticospinal tracts), and loss of pain and temperature sensitivity. The primary diagnostic sign is the complete preservation of proprioception and epicritic sensation, as the posterior columns are supplied by a different blood source.
  • Posterior spinal artery territory. Ischemia affects the posterior horns, roots, and columns. It is characterized by the loss of epicritic and proprioceptive sensitivity below the level of the lesion, local segmental disorders, and potential spastic paraparesis.

Venous outflow disorders

Elevated pressure in spinal veins is most commonly associated with an arteriovenous fistula (shunt), which drains arterial blood directly into intradural veins. When the shunted blood volume exceeds the drainage capacity of the vessels, congestive myelopathy (Foix-Alajouanine disease) develops.

The disease typically affects elderly men. Its onset is marked by gait ataxia, spastic paraparesis, and radicular pain. As it progresses, pelvic organ function becomes impaired, and protopathic followed by epicritic sensation is lost. In late stages, necrosis of the anterior horns occurs, causing spastic paraparesis to transform into flaccid paralysis. The condition is curable with timely surgical obliteration of the fistula.

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Spinal hemorrhages

Unlike ischemia, hemorrhagic lesions of the spinal cord frequently require emergency neurosurgical intervention.

  1. Hematomyelia is hemorrhage directly into the spinal cord parenchyma. It is more commonly traumatic in origin, and less frequently caused by the rupture of a vascular malformation. Blood spreads vertically along the gray matter, making the resulting neurological deficit closely mimic the clinical picture of syringomyelia.
  2. Spinal epidural hematoma. As a rule, it localizes in the thoracic region. It begins with acute radicular pain at the level of the hemorrhage, after which symptoms (paresthesias, weakness) rapidly ascend from the distal lower extremities. Without immediate evacuation of the hematoma, irreversible paraplegia develops.

Diagnostic challenges

Imaging of vascular spinal pathologies is fraught with several challenges. Standard MRI in infarctions has insufficient specificity, and diffusion-weighted imaging (DWI), which works exceptionally well for cerebral strokes, is of limited diagnostic value here due to low spatial resolution. A crucial clue is the detection of ischemic changes in the vertebral body, which is supplied by the same radicular artery as the affected spinal segment. Contrast enhancement in the infarction zone is absent during the first few days because the blood-brain barrier is not disrupted immediately. A lumbar puncture is mandatory to rule out an infectious process.

Detecting arteriovenous fistulas is also difficult: MRI only reveals edema and dilated perimedullary veins. Precise localization of the fistula requires technically complex angiography.

Briefly: answers to topical questions

Which specific spinal cord pathways are damaged in anterior spinal artery syndrome?

In anterior spinal artery syndrome, the spinothalamic and corticospinal (pyramidal) tracts are affected. The blood supply territory of this basin includes the following pathways:

  • Lateral spinothalamic tract — its ischemia causes analgesia and thermoanesthesia.
  • Anterior spinothalamic tract — is also supplied by this artery.
  • Pyramidal tract (including the lateral corticospinal tract) — its damage leads to the development of spastic paraparesis.

The posterior columns, responsible for proprioceptive and epicritic sensitivity, remain unaffected because they are supplied by posterolateral vessels.

What etiological factors most commonly lead to the formation of spinal epidural hematoma?

Spinal epidural hematoma may be associated with neuraxial anesthesia in patients receiving anticoagulant therapy. Spinal hematoma should also be suspected in patients taking anticoagulants who have recently undergone spinal puncture or back trauma. Performing neuraxial anesthesia against the background of anticoagulant therapy increases the risk of hemorrhagic complications, the most dangerous of which is spinal epidural hematoma.

From which major vessels does the artery of Adamkiewicz arise, and what section of the spinal cord does it supply?

The artery of Adamkiewicz (a. radicularis magna) branches off from the aorta and serves as the primary blood supply source for the lower thoracic, lumbar, and sacral segments of the spinal cord.

This largest vessel, also known as the arteria radicularis magna or lumbar enlargement artery, typically originates at the T9 to L2 level (most frequently on the left side). It subsequently joins the anterior spinal artery at an acute angle, supplying the corresponding regions.

How to memorize

For the differential diagnosis of anterior spinal artery syndrome, use the "Three P's" rule: Paresis, Pain/temperature loss, but Proprioception preserved.

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What else to study on this topic

  • Surgical anatomy of radicular arteries and the artery of Adamkiewicz
  • Differential diagnosis of congestive myelopathy and intramedullary tumors
  • Technique of angiographic search for spinal arteriovenous fistulas
  • Features of lumbar puncture in suspected spinal infarction

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Other topics in the section "DeMyer's The Neurologic Examination" / "Duus' Topical Diagnosis in Neurology"

Blood supply to the spinal cordClassification of vascular diseases of the nervous systemChronic cerebral ischemiaTransient cerebrovascular disordersCerebral artery lesion syndromesDiagnostics of nervous system diseases
Entire section "Topical Diagnosis in Neurology"

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