Classic Case

Spontaneous spinal cord ischemia is extremely rare, especially in pediatric patients. The spinal cord is supplied by 3 longitudinal arteries—a single anterior spinal artery (ASA) and 2 posterior spinal arteries (PSAs)—and ASA syndrome is the most common (~95%). ASA syndrome results from ischemia of the anterior two-thirds of the spinal cord and includes complete motor paralysis below the level of the lesion, loss of pain and temperature at and below the level of the lesion, and autonomic dysfunction. Bladder and bowel dysfunction may arise depending on the level of injury. The classic neuroimaging findings of ASA syndrome consist of primary involvement of the anterior horns, with prominent high T2 signal resulting in pencil-like hyperintensities extending over a number of levels (A, arrows). On axial imaging, this appears as 2 bright dots, giving the appearance of an owl's eyes (quiz image). In the acute phase, the affected areas show restricted diffusion on DWI and ADC map (B and C, arrows).