Nonhemorrhagic Spinal Cord Venous Infarction Without Evidence of Arteriovenous Shunt: Medical Treatment with Anticoagulation and Dual Antiplatelet Therapy Resulting in Partial Neurological and Radiological Recovery

We describe the case of a 43-year-old woman who suddenly presented with painless neurological deficit of her lower extremities characterized by flaccid paraparesis, bilateral sensory disturbances, and neurogenic bladder. An emergency whole-spine MRI revealed diffusion restriction at the level of the conus medullaris. Additionally, a centromedullary hyperintense T2-weighted imaging (T2WI) lesion extending cranially to T9 and what appeared to be engorged perimedullary vessels in the dorsal surface of the spinal cord were observed. These findings were compatible with spinal cord infarction (SCI) of the conus medullaris in the presence of venous congestion. A comprehensive angiographic examination of the spine excluded arteriovenous shunts or the presence of arterial occlusions, while abdominal imaging ruled out arterial dissections. The remainder of the diagnostic workup, including serum, cerebrospinal fluid, immunologic, and coagulation profiles, were within normal limits. Spontaneous SCI of venous origin was diagnosed, with suspicion of radiculomedullary venous thrombosis as the cause of the observed vasogenic edema. Empiric treatment with anticoagulation and dual antiplatelet therapy was started on day 2, and then intensive rehabilitation began. At 6-month follow-up, the patient exhibited significant neurological improvement. This coincided with an overall radiologically favorable evolution, including the disappearance of previously identified engorged perimedullary veins, suggesting that venous congestion was the primary cause of the patient’s symptoms rather than irreversible ischemic damage. This case illustrates the diagnostic challenge of SCI and highlights venous congestion and thrombosis as the pathophysiologic mechanisms behind the observed radiological findings.