Abdel-Mannan and Mahmud Journal of Medical Case Reports 2011, 5:31 http://www.jmedicalcasereports.com/content/5/1/31 Page 2 of 4 and sensory loss occur at the spinal cord segmental levels of infarct. Predictably, the syndrome of symptoms varies with the level of the spinal cord in which the lesion occurs. The causes of ASCIS include arteritis of intrinsic cord vessels and emboli and/or atheromata. Compression by intervertebral discs or embolization of disc fragments can also cause ischemia (often without a history of trauma). Aortic clamping (during aortic surgery) and dissecting aortic aneurysms are also recognized causes. On admission, it is essential to evaluate any neurologi- cal signs and to carefully document the extent of any neurological deficit. Patients should also be monitored for hemodynamic stability, including blood pressure. Routine investigations should include the following: 1. Full blood count, erythrocyte sedimentation rate (ESR), lipid and/or cholesterol levels, a serological test for syphilis and electrolyte analysis; 2. Leukocytosis, which may suggest an infectious cause such as myelitis; 3. Vascular risk factors should be assessed in all patients, including fasting blood glucose, lipids and/or cholesterol, anti-cardiolipin and/or anti-phospholipid syndromes and other coagulation disorders (including thrombocytosis); 4. A vasculitis and/or arteritis screen, including ESR, antinuclear antibodies and complement levels; and 5. Diabetes mellitus, which is present in about half of patients with an epidural abscess, as well as being a risk factor for vascular pathology. Imaging studies are performed not only to diagnose ischemic regions of the spinal cord that explain the symp- toms, but also to exclude any mass or space-occupying lesions that may be compressing the spinal cord or its vas- cular supply, either intra- or extra-axial. Magnetic reso- nance imaging (MRI) is the safest and surest way to identify such a lesion, as well as providing important infor- mation regarding the integrity of the spinal cord. On T2- weighted (T2W) MRI scans, high signal intensity in the region of the infarct as well as cord enlargement (on T1- weighted images) are common findings [5]. However, it was reported in one recent study that a mere 45% of patients with acute spinal cord ischemia or infarction demonstrate signal intensity changes on T2-weighted MRI scans [6]. It is important to note that MRI scans can show normal spinal cord signals in the first few hours of clinical evolution, and pathological changes appear only in later studies. The use of diffusion weighted imaging (DWI) is well established in the brain, but much less so in the spinal cord because of technical difficulties while acquiring images. Recent reports, however, suggest that DWI offers greater sensitivity than T2W images in the diag- nosis of acute spinal ischemia [7,8] and that changes may be detectable at earlier stages on DWI scans than on T2W images, presenting DWI MRI as the standard for non-invasive diagnostic imaging in the setting of acute spinal infarction. Case Presentation Our patient, a 67-year-old Caucasian man, presented in the morning to the emergency department complaining of a sudden onset of excruciating right-sided arm and neck pain radiating to his head, followed by two epi- sodes of vomiting. Both arms had reduced power from the shoulder distally. He complained of weakness in his legs, but denied any recent trauma, falls or loss of con- sciousness. On initial examination, shoulder abduction and adduction were absent, and flexion and extension of the elbow joint 2/5 on the Medical Research Council (MRC) power scale. Power in the lower limbs was nor- mal. All modalities of sensation were intact bilaterally in the upper and lower limbs. No cranial nerve abnormal- ities were detected. The patient had recently been diagnosed with hyper- tension and type 2 diabetes. His blood results on admis- sion showed no abnormalities apart from a high glucose level consistent with untreated diabetes. A computed tomography angiogram showed no signs of thrombosis or dissection of the aorta. A spinal MRI scan showed a high-intensity lesion in the anterior two-thirds of the gray matter extending from C3 to C5 (Figures 1 and 2). He was diagnosed with anterior spinal artery ischemia Figure 1 Axial T2-weighted magnetic resonance imaging (MRI) scan shows abnormally high signal intensity throughout the spinal cord at levels C3-C5. This is a common finding for regions of infarct.