Differentiating Weakness-an Atypical Presentation of Acute Neuromuscular Paralysis: A Case Report

Spinal cord infarction is a rare but critical cause of acute neuromuscular paralysis, accounting for approximately 1.2% of all strokes. Timely diagnosis is essential but challenging due to its clinical overlap with more common etiologies. Failure to promptly identify spinal cord infarction can result in irreversible neurological deficits and missed opportunities for secondary prevention.

A 66-year-old female presented to the emergency department with progressive bilateral limb weakness, numbness, and urinary incontinence. The examination revealed symmetric weakness, impaired coordination, and diffuse sensory loss. She was admitted and empirically treated with intravenous immunoglobulin for suspected atypical acute inflammatory demyelinating polyneuropathy. Despite mild improvement, worsening hyperreflexia and spasticity raised concern for a central process. Cervical magnetic resonance imaging revealed extensive cord edema, and further workup identified a cerebellar infarct and a patent foramen ovale, suggesting an embolic source. Evolving myelomalacia on follow-up imaging confirmed a diagnosis of anterior spinal artery infarction. The patient was started on secondary stroke prevention and discharged to rehabilitation with persistent motor and autonomic deficits.

Spinal cord infarction may initially resemble peripheral neuropathy, leading to misdiagnosis and delayed treatment. This case highlights the importance of repeat imaging and reconsideration of central causes in atypical or evolving presentations. Emergency physicians should maintain a high index of suspicion for spinal cord infarction in cases of rapidly progressive paralysis. Early imaging and multidisciplinary evaluation are critical to minimize long-term morbidity.