Spinovascular disease is rare compared with cerebrovascular disease. It includes spinal cord infarction, hemorrhage, transient ischemic attack, and venous disease. The clinical symptoms of spinovascular disease usually begin abruptly and vary in severity and rate of onset, depending on the affected vessel, the level of the lesion (most commonly, the lower thoracic cord and conus medullaris), and underlying disease. Spinovascular diseases should be differentiated from spinal cord compression (primary or metastatic tumors, epidural or subdural hematoma, acute extradural abscess, spinal tuberculosis, disc prolapse, spinal trauma, and spondylosis), transverse myelitis (often occurring with local pain followed by paraparesis or paraplegia, numbness, and urinary retention in association with cerebrospinal fluid [CSF] lymphocytic pleocytosis and increased protein), Guillain-Barré syndrome (progressive weakness during a period of several days or a few weeks, occurring diffusely or beginning in the legs and spreading proximally, involving first the trunk, then the arms, neck, respiration, and cranial muscles with characteristic electromyography and CSF findings), syringomyelia (typically segmental dysfunction with bilateral and, occasionally, unilateral loss of cutaneous sensation and dissociated sensory loss but sparing the sense of touch, position, and vibration), subacute combined degeneration (often presenting with a gait disorder and lower motor neuron signs, loss of position and vibration senses, no clear motor or sensory level, and associated with vitamin B₁₂ deficiency and pernicious anemia), and Friedreich’s ataxia (a genetic disorder that gradually results in ataxia of the limbs and trunk with areflexia and dysarthria; Babinski signs; and, occasionally, pes cavus, optic atrophy, nystagmus, cardiomyopathy, and scoliosis). The diagnosis is suggested by the patient’s history and is confirmed by magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA). Myelography, CSF analysis, spinal arteriography, and computed tomography (CT) are indicated in selected cases. CSF analysis may be useful in evaluating for the presence of an inflammatory disorder. Selective spinal arteriography is indicated when an arteriovenous malformation (AVM) or a dural arteriovenous fistula (AVF) is either suggested clinically but not seen on MRI/MRA or is suggested and seen on the MRI/MRA. CT myelography may be helpful for suspected intramedullary space-occupying lesions. Special coagulation studies should also be performed in young patients with no other apparent cause. Transesophageal echocardiography or CT with contrast may be used to evaluate for thoracic segment aortic dissections, and abdominal CT may be useful for abdominal aortic abnormalities.

The general principles outlined for the treatment of cerebrovascular disease (see Chapters 11, 12, 13, 14, 15, 16, 17) may be applied to cases in which analogies to vascular diseases of the spinal cord can be made, with additional attention to bladder and
skin care and physical therapy. For subdural and epidural spinal hemorrhage, immediate surgery is often necessary. An intramedullary hemorrhage from an AVM or cavernous malformation may be removed, followed by successful resection of the malformation; hematomyelia that results from trauma with no imaging evidence of an associated compressive lesion is usually treated conservatively.