Thrombolysis in spinal cord infarction: Case report and systematic review

Clinical Snapshot

Key Findings

• Effect Size: 56% of patients achieved favorable outcomes (14/25)

• Primary Outcome: Functional independence at follow-up (mRS 0-2)

• Nnt Or Sensitivity: Number needed to treat cannot be calculated without control group

• Confidence Interval: Not applicable for case series data

Clinical Application

Limited to centers with stroke expertise and rapid MRI capability for SCI diagnosis Would require TGA approval for off-label alteplase use; consideration within comprehensive stroke center protocols; alignment with National Stroke Foundation guidelines needed Carefully selected patients with acute spinal cord infarction presenting within thrombolysis time windows

Abstract

INTRODUCTION: Spinal cord infarction (SCI) is a rare but severe cause of acute myelopathy, and evidence supporting reperfusion therapies remains limited. METHODS: We report a 73-year-old man with spontaneous cervical SCI treated with intravenous alteplase and perform a systematic review (database search from inception to 13 November 2025) of case reports/series describing intravenous (IV) or intra-arterial (IA) thrombolysis for SCI, extracting data about clinical presentation, diagnostic and therapeutic work-up and functional outcomes. RESULTS: Our patient improved after thrombolysis and achieved functional independence at 3 months (modified Rankin Scale [mRS] 2). The review identified 21 studies (19 case reports, 2 case series) totaling 25 patients; including our case, 26 patients were analyzed. Mean age was 57.4 years (range 14-83), and anterior spinal artery (ASA) syndrome was the most common presentation. Most patients received IV thrombolysis; 4 underwent IA therapy (alone or combined). Considering the last available assessment, 14/25 patients (56.0%) had a favorable outcome (mRS 0-2), 8/25 (32.0%) had mRS 3, and 3/25 (12.0%) had mRS 4-5. No symptomatic treatment-related hemorrhagic complications were reported. DISCUSSION AND CONCLUSION: Published experience suggests that thrombolysis in carefully selected patients with suspected SCI may represent a reasonably safe therapeutic option, but evidence is limited and subject to major bias. Prospective registries and multicenter studies are needed to clarify safety, efficacy, and selection criteria.

References

1. 1.Di Pietro, A., Spina, E., Maurea, C., De Mase, A., Servillo, G., Barbato, S., Giordano, F., Muto, M., Miniello, S., Candelaresi, P., & Andreone, V. (2026). Thrombolysis in spinal cord infarction: Case report and systematic review. Neurological Sciences. https://doi.org/10.1161/STROKEAHA.119.027478