Vascular myelopathies

Vascular myelopathies include several diagnoses that are often misdiagnosed or undertreated. Some represent neurologic emergencies, such as spinal cord infarction, and others can be disabling if they remain unrecognized, such as spinal dural arteriovenous fistulas. This review describes the clinical characteristics and current therapeutic strategies for the most common vascular myelopathies and emphasizes practical concepts for the clinician.

Although none of the vascular myelopathies have been studied in large prospective studies and their treatments have not been tested in randomized controlled trials, recent years have brought advances in diagnostic imaging and treatment alternatives as well as useful information regarding prognosis. Refinement in MRI technique now allows precise, noninvasive diagnoses of most vascular myelopathies and is crucial for the exclusion of differential diagnoses. Surgical and endovascular therapies are highly effective in treating spinal vascular malformations. Longitudinal studies have shown that the prognosis of spinal cord infarction is more favorable than previously conceived, and even patients with severe deficits can achieve meaningful recovery.

Clinicians should be keenly aware of the clinical and radiologic features of the various vascular causes for acute or progressive myelopathy. Optimal management of patients with vascular myelopathies requires close collaboration with neuroradiologists, neurointerventionalists, and vascular neurosurgeons. Prognosis should be estimated with caution because functional outcomes over time may be better than initially expected. Vascular myelopathies are infrequent, but their consequences to the patient's functional capacity can be devastating. Because of their relative rarity, these disorders are often initially misdiagnosed, and, in some cases, this delay in arriving at the correct diagnosis can prove very detrimental. This article reviews the essential concepts of diagnosis and management of vascular diseases of the spinal cord, both ischemic and hemorrhagic, beginning with a basic summary of the vascular anatomy of the cord, as this knowledge is crucial for an understanding of the pathologies.