Spinal cord veinous thromboses

Spinal venous thromboses (a form of spinal vascular accident) are rare. They may or may not lead to an infarct, which could be secondary to hemorrhage, and generally do not correspond to arterial territories (high individual variability of venous networks, rapid development of collaterals, and frequent multiplicity of thrombotic sites).

Although they are not well-known and their management is poorly codified, they constitute medical emergencies. The functional prognosis is considered to be worse than for cerebral venous thromboses.

Etiologies

• Idiopathic
• Spinal and dural arteriovenous malformations
• Congenital and acquired thrombophilias
• Compression by extramedullary tumors
• Decompression accidents (nitrogen microbubbles)
• Iatrogenic: sclerosis or endoscopic ligation of esophageal varices

Clinical Presentation

• Rapid onset of:
  • Most often begins with back and/or abdominal pain, possibly radiating to the lower limbs.
  • Followed after a few hours by a sensory-motor deficit in the lower limbs and sphincter disturbances, rapidly evolving into severe disability.

Complementary Examinations

• Spinal MRI: non-specific enlargement of the spinal canal (may mimic a tumor or myelitis). Visualization of thrombosis on venous sequences is random. Infarction generally appears after the 6th hour (earlier on diffusion sequences), and its topography may suggest a venous origin.
• Variable examinations for etiological purposes depending on the presentation (cf. cerebral venous thromboses).

Therapeutic Management - Treatments

Evidence-based medicine in this area is very limited (expert consensus) and mirrors the management of cerebral venous thromboses (which has been shown to be very effective).

In emergency situations: hospitalization + therapeutic dose anticoagulation with heparin + general measures (prophylactic PPIs, etc.).

Etiological treatment if applicable.

Bibliography

EMC, traité de Neurologie, 2018

Osborn AG et al, Brain, Elsevier, 2018