Dokkyo Journal of Medical Sciences
36（2）：89 〜 93，200989

Case Report

Anterior Spinal Artery Syndrome in 13-year Old boy：A Case Report
122George Imataka , Reina Yamazaki , Shigeko Kuwashima ,Hideo Yamanouchi 1 and Osamu Arisaka 1
Department of Pediatrics 1 and Radiology 2 , Dokkyo Medical University School of Medicine

SUMMARY
We herein report a rare case of a child patient with anterior spinal artery syndrome. The patient presented with mobility impairment in the lower limbs after suffering from a common cold. Temperature perception and pain perception were lost in both sides below the level of the fourth thoracic spine. In a thoracic
spine MRI, abnormal signals were detected in the ventral side of the spinal cord below the Th3 level, thus
leading to our diagnosis of anterior spinal artery syndrome. Gamma globulin therapy and steroid pulse therapy were applied concomitantly but no obvious effects were obtained. Continuing treatment with rehabilitation started for one month. Four months later, he was able to maintain a standing position and walk using awalking stick. The loss of temperature perception and pain perception in both sides below the Th4 remained.
In the present case, movements in daily life became possible through the effects of rehabilitation. However, an impairment in the patient’s temperature and pain perception remained, and thus close attention is required for various disorders and in daily life.
Key Words： anterior spinal artery syndrome, child, magnetic resonance imaging, steroid pulse, gamma
globulin therapy

INTRODUCTION
Anterior spinal artery syndrome（ASAS）is a syndrome that develops as（1）rapid paraplegia below theaffected area,（2）a dissociable sensomobile disorderrare. We experienced the case of a 13-year-old boy
with this syndrome and herein report his clinicalcourse.

CASE REPORT

below the affected area, and（3）a vesicorectal disor-

The patient was a 13-year-old boy whose bodyder due to a disorder in blood circulation and occlusion

height was 165 cm and body weight was 75 kg. His de-of the anterior spinal artery, which dominates 2/3 ofvelopment was normal, his family history included al-

the ventral side of the spinal cord 1）. There are occa-lergies, and he had a history of treatment for asthma.

sional reports of adult patients2）

but child patients areThe season was spring. In the morning of the third
day of his cold symptoms, he experienced discomfort

Received March 10, 2008；accepted April 10, 2009
Reprint requests to：George Imataka M.D.
Department of Pediatrics, Dokkyo Medical
University School of Medicine, Mibu, Tochigi,
321-0293 Japan.

in his knees. He walked to the bathroom by himself,
but after urinating, he suddenly lost all strength in his
lower limbs and could not walk. He was referred toour hospital for a complete examination by a nearby
orthopedics department.

90

George ImatakaADJMS

B
Figure 1 Spinal Magnetic Resonance Imaging
A lesion in T2 weighted image（A）passing symmetrically, continuously, and longitudinally through theintraventral spinal cord at the Th2/3-Th11 level was observed. Horizontal cross-section through thespinal cord at the Th5 level（B）.An abnormally signal was observed in the area indicated by the arrow.

His consciousness was clear during consultation. He

ultrasonography also showed normal results.

had a cough and mild reddening in his pharynx. The

The results of the brain MRI and MRA were normal.

movements and senses of his face, eyeballs, neck, andIn the thoracic spinal MRI（Fig. 1A, 1B）, abnormal

upper limbs were normal, but his temperature percep-

signals were detected in the Th2/3-Th11 level of thetion and pain perception were lost below his third tho-

intraventral spinal cord and he was thus diagnosed toracic spine, though the position perception and vibra-

have ASAS.

tion perception of the affected area were maintained.

We conducted 5-day 400-mg/Kg gamma globulin

In terms of muscle movements below the affected

therapy and 2-day 30-mg/kg steroid pulse therapy

area, he was unable to move either side of his abdomi-

but no obvious clinical improvements were observed.

nal area or his lower limbs, and a manual muscle test

An elastic hose was used to prevent venous thrombus.

showed only the extensor digitorum longus muscle of

He had no urge to defecate and was thus given an en-

his right lower limb was Level 1（trace）while the oth-ema. Urethral catheterization was used for urination.

er muscles were Level 0. He was unable to urinate orRehabilitation began which was conducted mornings.

defecate by himself. Abdominal reflexes, patella tendon

After one month, the deep tendon reflexes of thereflexes, and Achilles tendon reflexes in both sides

lower limbs increased to 3＋ in both his right and left

were negative, though the Babinski’s reflex in bothlimbs. The Babinski’s reflex and Chaddock’s reflex

sides was positive.

were positive in both sides. Muscle strength improved

The results of a general blood test were normal. Heto 2＋ in the illisopsoas, 2＋ in both quadriceps femoris

tested negative for mycoplasma, Epstein-Barr virus,

muscles and the hamstrings, and 3＋ in the anteriorand cytomegalovirus antibody levels. He was also neg-tibial muscles, but he was unable to urinate by himself.

ative for anticardiolipin antibodies. His IgE was 480.

Two months later, he moved to a community reha-

The results of the general spinal fluid test were nor-bilitation center to undergo more intensive rehabilita-mal. No oligoclonal band was detected. Myelin basic

tion and was consequently able to maintain a standing

protein levels were normal. His IgG index was 0.352.

position and walk using a walking stick after four

No virus was separated from his spinal fluid. Cardiacmonths.

36（2）（2009）

Anterior Spinal Artery Syndrome
Table 1Case references

91

Report of anterior spinal artery syndrome of childhood in Japan from 1994 to 2008.
abnormalagesex

initial symptom

intensity areaof MRI

treatment

prognosis（walking capability）

etiology

No.

No.

116）

7yF

pain in large thigh on
both sides

Th7 〜 Th12

steroid pules,
aspirin hybaroxia,
edaravone217）

15yF

backache → bothparalyses of the lower
extremities

Th3 〜 Th8

steroid pules,
glyceol

The disorder of the sensation for
pain and temperature remains.
（walking with brace）

type Ⅱ
diabetes318）

25daysFBoth hands are not
moved

C5 〜 Th1

artificial
ventilation

severe psychomotor retardation（It is not possible to walk.）

fetalhydrops

C4 〜 C6

artificial
ventilation steroid
pulse, glyceol

complete paralysis of both arms
（walking with brace）

uncertain

Movement disorder of both lower
limbs Th7 or less.
uncertain（It is not possible to walk）.

419）,20）

11y

F

Breathing difficulties
occurred on the fifth
cold day.

520）

8y

F

Quadriplegia ＋
breathing difficulties
after two hours falls

C4 〜 C8details are
uncertain

spastic paralysis of left arm andflaccid paralysis of right arm（walking without brace）

uncertain

ourcase─

15y

M

Walking difficulties
occurred on the third
cold day morning.

Th2/3 〜
Th11IVIg, steroid pulse
vitamin B

The disorder of the sensation for
pain and temperature remains.
（walking without brace）

uncertain

One year later, he was able to walk long distances

adult cases of ASAS, it normally develops in the elder-and urinate by himself. However, the loss of tempera-

ly after surgery for aortic aneurysm due to, for exam-

ture perception and pain perception in both sides be-ple, thrombus or embolus caused by arterial sclerosis,

low Th4 remained. He remained unaware of bruises

or compression caused by an extramedullary lesion.

caused by falling down during his daily activities, andHowever, this case was that of a rare child patient.

thus close attention was required.

The cause of many pediatric cases of ASAS is un-

Two years after the initial onset, he visited the out-known. The cause of ASAS in our case, who was apatient department complaining of a fever and acute

13-year-old patient, was also unknown. To the extent

diarrheal symptoms although he had no subjectiveof our search, there were 5 cases in Japan during thesymptoms of abdominal pain due to his impaired pain

past 15 years from 1994 to 2008. These 6 cases, includ-perception. We observed an increase in inflammatory

ing this case, are shown in the order of publication

reaction and inpatient hospital care was required due（Table 1）16 〜 20）. The cause could not be clearly identi-to acute bacterial gastroenteritis.

fied in any of these 6 cases as shown in the table. The

At present, he is still continuing rehabilitation while
attending high school.

DISCUSSION

underlying disease that may have been involved in theonset of ASAS was found in 2 cases, wherein Case 2
was type II diabetes and Case 3 was a newborn casethat was under artificial ventilation due to fetal edema.

The spinal cord consists of three arteries：two pos-

ASAS is diagnosed through abnormal signals in spi-terior spinal arteries and one anterior spinal artery.

nal MRI. Normally, in anterior spinal artery syndrome,

Therefore, a disorder in the blood circulation of the an-high-intensity areas of an enlarged spinal cord that

terior spinal artery creates a situation with no substi-

are well defined from the back side are detected intute path for blood circulation and it often results inseveral segments of the vertebral bodies in MRI and incritical long-term symptoms of spinal cord infarction,the abdominal sides of the affected area in a T2

thus creating the problem of severe aftereffects. Inweighted image. In this patient, abnormal signals were92

George Imataka

observed in at least nine vertebral bodies, and the affected area was broad.

DJMS
Sci 13：86-88, 2008.

7）Arai S, Utsunomiya H, Wakugawa Y, Uwadoko T：A

The only treatment methods for ASAS are systemic
therapies, but there are reports of thrombolytic thera-case of spinal infarction caused by disc herniation.
Brain Nerve 59：997-1000, 2007.（Japanese）

py with urokinase at an early stage being effective in8）Pantet O, Frischknecht R, Croquelois A：Sudden

some adult patients. However, there is no effective

paraplegia due to an anterior spinal artery syndrome

treatment method for ASAS in children. We performed

during the cause of Staphylococcus aureus septicemia.

gamma globulin therapy and steroid pulse therapy for

Cerebrovasc Dis 24：307-309, 2007.

their immunological mechanisms and anti-inflammato-9）Aylwin C, Tai N, Walsh M：Anterior spinal arteryry effects but obtained no obvious effect. However, insyndrome after abdominal stabbing and resuscitative

the daily life of this patient, the loss of temperature

thoracotomy. J Trauma 62：526-528, 2007.

perception and pain perception below his thoracic10）Tuncel G, Ozalp G, Canoler O, Cakmak H, Ergeneci A,

spine has remained. It is necessary to provide lifestyle

Kadiogullari N：Anterior spinal artery syndrome af-guidance to compensate for his permanent insensitivity

ter thoracic surgery. J Coll Physicians Surg Pak 25：

to pain and prevent, for example, injuries in his lower819-820, 2005.

limbs without the patient himself realizing and deterio-11）Yoshida S, Nitta Y, Oda K：Anterior spinal artery

rations of gastroenteritis symptoms resulting in thesyndrome after minimally invasive direct coronary ar-need for inpatient hospital care.

tery bypass grafting under general combined epiduralanesthesia. Jpn J Thorac Cardiovasc Surg 53：230-

Acknowledgement.

This study was partially sup-233, 2005.

ported by the Ministry of Education, Culture, Sports,

12）Dinca-Avarvarei L, Valdes-Cruces JC, Quesada-Gar-Science and Technology （MEXT） KAKENHI No.

cia M, Izquierdo G：The value of diffusion magnetic

18790733 Grant-in- Aid for Young Scientists（B）andresonance imaging in diagnosing infarction of the an-the Dokkyo Medical University, Investigator-Initiatedterior spinal artery. Rev Neurol 40：282-285, 2005.

Research Grant（No. 2010-01-6）.

（Spanish）

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