Acute tetraplegia in a healthy patient: cryptogenic cervical ischaemic-venous myelopathy.

backgroundCervical spinal cord infarction is a rare condition, accounting for approximately 1-2% of all ischaemic events of the central nervous system (1,2). Diagnosis is often challenging due to clinical overlap with inflammatory, autoimmune, or compressive myelopathies (3). Early recognition is crucial to initiate appropriate treatment and avoid unnecessary or potentially harmful therapies. CASE PRESENTATION: We report the case of a 65-year-old previously healthy man who developed acute cervical pain and paraesthesia in the hands while exposed to sunlight, followed within one hour by complete tetraplegia and respiratory failure, with preserved sensation. Brain imaging was unremarkable, while cervical MRI revealed a T2 hyperintensity from C2 to C4, predominantly involving the anterior and paramedian columns ("H-sign") (4,5), without critical canal stenosis but with minimal disc indentations at C4-C6. CSF analysis was normal. Spinal angiography and transoesophageal echocardiography excluded arteriovenous fistulae, dissections, or embolic sources. A mild hyperhomocysteinaemia (15 µmol/L) was found, with positive anti-recoverin antibodies; anti-AQP4 was negative. The patient received corticosteroids and intravenous immunoglobulins, later discontinued when an ischaemic aetiology was suspected. Antiplatelet and prophylactic anticoagulation therapy were continued. The clinical course was complicated by ventilator-associated pneumonia due to Klebsiella aerogenes, successfully treated with cefepime. Partial motor recovery in the hands and feet was observed from day five onwards.

conclusionsThe clinical and radiological findings, combined with the negative work-up for inflammatory, embolic, or compressive causes, support a diagnosis of cryptogenic ischaemic cervical myelopathy, probably of acute ischaemic-venous origin favoured by minimal disc indentations. This case highlights the diagnostic complexity of acute non-traumatic myelopathies and the crucial role of early multidisciplinary evaluation to establish the aetiology and initiate timely functional rehabilitation (6-8).