819 - Idiopathic Anterior Spinal Cord Infarct in a Pediatric Patient: A Case Report

11-year-old presented with sudden back pain and lower extremity weakness found to have an anterior cord infarct from T9 to the tip of the conus.


Case Description:

A previously healthy 11-year-old female presented with sudden atraumatic lower extremity weakness and mid-thoracic pain. Examination was significant for absent sensation to temperature and light touch below T10 dermatome bilaterally; absent patellar and ankle reflexes; and flaccid rectal tone. 

Initial MRI identified T7-T9 hydrosyringomyelia, suspected to be noncontributory. MRI brain with and without contrast and CSF studies were unremarkable, making intracranial, infectious, autoimmune, and demyelinating etiologies unlikely. 

Patient was placed on empiric intravenous steroids for several days with no functional improvement. Repeat MRI thoracic spine two days later identified anterior cord signal abnormality with diffusion restriction from T9 to the tip of the conus, indicating anterior cord infarction. Thrombophilia panel was unremarkable. 


Discussions: Anterior cord syndrome (ACS) is characterized by lower extremity paralysis, loss of pain and temperature sensation, occasional autonomic instability, and frequently neurogenic bowel and bladder dysfunction. In this case, a comprehensive hematologic, infectious, and autoimmune workup yielded negative results. The presentation is consistent with idiopathic ACS, an exceedingly rare diagnosis, particularly in the pediatric population. The course of ACS is typically marked by rapid progression, with peak neurological deficits occurring within 24 hours. In idiopathic presentations, the lesions most commonly localize to the thoracolumbar spinal cord. Initial MRI may not demonstrate definitive evidence of infarction and may appear unremarkable. Therefore, repeat MRI is recommended if clinical suspicion of spinal cord pathology persists.

Conclusions: Idiopathic ACS represents an exceptionally rare and diagnostically challenging condition in the pediatric population. Given its acute presentation and potential for severe neurological deficits, early recognition is critical. Clinicians should remain aware that initial imaging may appear normal, emphasizing the importance of repeat imaging when clinical suspicion remains high.