Pediatric spinal cord stroke: clinical presentation, MRI features, and suspected mechanisms

Abstract

Background and Objectives: Spinal cord stroke (SCS) is an underrecognized cause of severe acute myelopathy in children that can be misdiagnosed as an infectious or inflammatory process. Limited characterization of clinical and neuroimaging features of pediatric SCS impede timely and accurate diagnoses. Our objectives were to (1) identify clinical and radiological features of SCS to prompt timely evaluation and accurate diagnosis and (2) gain insight into mechanisms of SCS. Methods: We conducted a retrospective case analysis of children (<18-years-old) diagnosed with SCS at a specialized referral institution between 2010 and 2025. Clinical records, imaging, and laboratory data were reviewed to identify key features of pediatric SCS. Results: Among the 56 included patients, 28 were male (50%), and the age distribution was bimodal, with peaks at one and 14 years. Pediatric SCS presented with hyperacute onset of motor, sensory, bladder/bowel, and pain symptoms. The lesions were predominantly anterocentral, longitudinally extensive, with the cervical spinal cord being most often affected. Over time from the onset of symptoms, MRI diffusion restriction decreased while gadolinium enhancement increased. CSF profile was non-inflammatory in 95% of cases. Suspected mechanisms were identified in 63% of cases, with vascular compression being the most commonly identified mechanism in 17 subjects (30%), while 38% were idiopathic. Chiari I malformations were identified as the main suspected cause of vascular compression, occurring in a subgroup of young patients with cervical SCS (n=8, 14%). Serum studies identified hypercoagulability in 38% of 40 subjects evaluated. Discussion: Recognition of specific clinical and neuroimaging profiles in pediatric patients with SCS may facilitate earlier identification and intervention. We propose a systematic evaluation of clinical history, with particular attention to the temporal course from symptom onset to nadir, early acquisition of spine MRIs with DWI sequences, serologic evaluations for hypercoagulability, and CSF studies to exclude inflammatory etiologies. This approach will provide a framework for continued efforts to better understand the mechanisms underlying pediatric SCS and develop prevention and treatment strategies.