Treatment of Vascular Myelopathies

Purpose of review: This article reviews the treatment of vascular myelopathies of various causes, with an emphasis on the treatment and prevention of the most common non-traumatic etiologies: ischemia secondary to open and endovascular interventions for treatment of thoracoabdominal aortic aneurysms and spontaneous (non-periprocedural) spinal cord ischemia and infarction. Recent findings: Acute vascular myelopathies can present as sudden or rapid onset of paraplegia or quadriplegia. In such cases, spine MRI allows rapid and reliable exclusion of compressive or hemorrhagic lesions and may identify acute spinal cord ischemia; thus, it should be the preferred radiological technique for the evaluation of patients with suspected acute vascular myelopathy. Pressure-based protocols have improved the safety of intra- and post-procedural prophylactic and therapeutic cerebrospinal fluid drainage during thoracic aortic procedures, including open and endovascular treatment of thoracic aortic aneurysms and aortic valve replacements. Increasingly sophisticated and staged endovascular approaches to treat aortic aneurysms have greatly reduced the risk of spinal cord infarction and may not require prophylactic drainage in some cases. Spontaneous spinal cord infarction is less common, and acute treatment remains experimental. Summary: Acute myelopathies may be caused by various forms of vascular disease, and some of those causes can be treatable. Emergency MRI is often necessary to guide therapeutic interventions.