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Chapter 17: Disorders of the Spinal Cord and Peripheral Nervous System in Critical Care

A 34-year-old woman presents with progressive weakness in all 4 limbs that reaches a nadir after 8 hours. She is taken to the emergency room, where her husband reports she had complained of neck and back pain earlier in the day. She has flaccid paralysis of all 4 limbs. She is areflexic. She is dysarthric, is pooling secretions, and is intubated for airway protection. Her MRI demonstrates T2 hyperintensity spanning the rostral medulla to the level of T4, which diffusion restricts. Upon directed questioning, her husband also mentions that she has a history of recent vision impairment, of unclear etiology. What is the most likely diagnosis?

A. Neuromyelitis optica

B. Anterior spinal artery infarct

C. Acute inflammatory demyelinating polyradiculoneuropathy

D. West Nile virus–associated flaccid paralysis

A. Neuromyelitis optica

Neuromyelitis optica is an immune-mediated inflammatory disorder of the central nervous system characterized by severe demyelination and axonal damage that predominantly targets the optic nerves and spinal cord. A common presentation of NMO is with transverse myelitis. The transverse myelitis of NMO is typically longitudinally extensive (extending across 3 or more contiguous vertebral segments). Neuromyelitis optica typically affects women, and the median age of onset is in the fourth decade of life. Acute spinal cord infarct (choice B) and transverse myelitis can present similarly. However, given the patient’s age and lack of identified vascular risk factors, acute spinal cord infarct is less likely. In addition, the explicit mention of recent visual deficits raises a concern for pathology encompassing more than just the spinal cord (ie, NMO).

Like cerebral infarcts, spinal cord infarcts and the resulting spinal shock have an abrupt onset, but less commonly can occur rapidly over minutes to a few hours. Transverse myelitis typically progresses over hours to days. Patients may complain of local back or neck pain in both infarct and TM., Although diffusion restriction is seen in strokes, it can also be seen in TM. Similar to cerebral infarcts, spinal cord infarcts tend to occur in older patients with cardiovascular risk factors. The temporal progression of the patient’s symptoms, as well as her age and medical history, make NMO the most likely diagnosis. The lack of prodromal viral illness makes AIDP and West Nile virus less likely (choices C and D).

A 34-year-old woman presents with progressive weakness in all 4 limbs that reaches a nadir after 8 hours. She is taken to the emergency room, where her husband reports she had complained of neck and back pain earlier in the day. She has flaccid paralysis of all 4 limbs. She is areflexic. She ...

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