A Case of Anterior Spinal Artery (ASA) Syndrome After Vaccination -Coincidence or Causality?

ABSTRACT

Objective: To describe a case of Anterior Spinal Artery (ASA) syndrome after vaccination -coincidence or causality? Background: As efforts to improve SARS-CoV-2 vaccination continue, more questions safety of the vaccination continues to be raised. Ischemic stroke, intracerebral hemorrhage, and cerebrovascular venous sinus thrombosis have been reported in the literature after COVID -19 mRNA vaccination. Although rare cases of acute transverse myelitis have also been reported, literature regarding post-COVID vaccination ASA syndrome is even rarer. Design/Methods: A 32-year-old female with no significant past medical history presented with acute onset of bilateral extremity weakness and numbness that started 2 weeks ago. Result(s) Patient was awake, alert, and oriented. Physical examination showed decreased tone in wrist bilaterally. Motor examination was normal except for 1/5 handgrip, 2/5 wrist, and 3/5 triceps bilaterally. Triceps and brachioradialis reflexes were absent bilaterally. Sensory examination showed absent pinprick sensations C7 and below. Vibration and proprioception sensations were intact. Patient was recently admitted at outside hospital for same complaint. Neurological work was unremarkable except of an enlarged 4th ventricle for which she underwent left frontal ventriculostomy. Lumbar puncture showed normal IgG index and negative serum NMO Ab. She was treated with IVIG for presumed inflammatory disorder with minimal improvement. Patient underwent a repeat neurological workup at our facility due to ongoing symptoms. EKG showed normal sinus rhythm CT head showed prominent 4th ventricle. CT spine were unremarkable. MRI of the brain showed Postprocedural changes associated with recent prior left trans frontal ventriculostomy catheter. MRI of the cervical and thoracic spine showed T2 hyperintense lesion extending from C3/4 to T1 with central predominance rostrally, whole cord involvement at C5, and with anterior predominance caudally with extent to the upper thoracic level of T1;shows patchy enhancement. TTE was unremarkable. Infectious and hypercoagulable workup was also unremarkable. Patient-reported receiving first dose of Moderna mRNA Covid vaccine 2 weeks prior to onset of symptoms. She was discharged to rehab on aspirin and atorvastatin. Conclusion(s) Our patient presented with symptoms and imaging consistent with ASA syndrome 2/2 infarct of an anterior spinal artery C5-T1. Extensive neurological, infectious, rheumatological, and hypercoagulable workup was negative for etiology. The patient had onset of symptoms after receiving her first dose of mRNA COVID-19 vaccine, however, unclear if the presentation is consistent with postvaccination vaccine ASA syndrome or idiopathic.