History

Fact Explanation
Back pain Acute onset back pain is a common presenting complain of acute infarction of the spinal cord. This is due to ischemia of the spinal cord. However some patients may not manifest with pain. [2]
Weakness Patient complains of bilateral symmetrical weakness (paraparesis or tetraparesis) or paralysis (paraplegia or tetraplegia) of the body. [3,5,7]
Sensory loss There is bilateral and symmetrical sensory loss or impairment. [2,5]
Bladder dysfunction Depending on the area of the spinal cord involved, incontinence or retention of urine can also be associated with infarction. [6]
Fecal incontinence Fecal incontinence develops with spinal infarction. [8]
Risk factors Diabetes, hypertension, coagulopathies and hypercholestrolemia are risk factors for the development of vascular infarctions. Presence of arteriovenous fistula, polyarteritis nodosa, and carotid or vertebral artery dissection also put the patients at risk of spinal cord infarction. These conditions are common associations of spinal infarction among young patients. Spinal surgery, cardiac surgery, surgery of the descending and thoracoabdominal aorta, arteriography and fibrocatilagenous embolism also increase the risk. Presence of cardiac arrest and transient ischemic attacks also increases the risk of spinal cord infarction because of generalized hypotension. Fibrocartilagenous emboli, arterial vascular malformations and syphilitic arteritis can also lead to spinal cord infarction. [1,3,4,7]
History of spinal disease Patients with a prior history of compression fractures of the spinal cord, spondylolisthesis, chronic arachonoiditis and chronic cervical disk protrusion can develop acute infarction of the spinal cord. [4,7]
References
  1. ROVIRA A, PEDRAZA S, COMABELLA M, ALVAREZ J, SALGADO A. Magnetic resonance imaging of acute infarction of the anterior spinal cord. Journal of Neurology, Neurosurgery & Psychiatry [online] 1998 February, 64(2):279-281 [viewed 15 September 2014] Available from: doi:10.1136/jnnp.64.2.279
  2. MASSON C. Spinal cord infarction: clinical and magnetic resonance imaging findings and short term outcome. Journal of Neurology, Neurosurgery & Psychiatry [online] 2004 October, 75(10):1431-1435 [viewed 15 September 2014] Available from: doi:10.1136/jnnp.2003.031724
  3. WAN I. Prevention of spinal cord ischaemia during descending thoracic and thoracoabdominal aortic surgery. [online] 2001 February, 19(2):203-213 [viewed 16 September 2014] Available from: doi:10.1016/S1010-7940(00)00646-1
  4. EDWARDS A, CLAY EL, JEWELLS V, ADAMS S, CRAWFORD RD, REDDING-LALLINGER R. A 19-year-old man with sickle cell disease presenting with spinal infarction: a case report J Med Case Rep [online] :210 [viewed 16 September 2014] Available from: doi:10.1186/1752-1947-7-210
  5. FOO D, ROSSIER AB. Anterior spinal artery syndrome and its natural history. Paraplegia [online] 1983 Feb, 21(1):1-10 [viewed 16 September 2014] Available from: doi:10.1038/sc.1983.1
  6. NANCE JR, GOLOMB MR. Ischemic spinal cord infarction in children without vertebral fracture Pediatr Neurol [online] 2007 Apr, 36(4):209-216 [viewed 16 September 2014] Available from: doi:10.1016/j.pediatrneurol.2007.01.006
  7. EL-OSTA BASSEL, GHOZ ALI, SINGH VINAY KUMAR, SAED ELRASHEID, ABDUNABI MURAD. Spontaneous spinal cord infarction secondary to embolism from an aortic aneurysm mimicking as cauda equina due to disc prolapse: a case report. Array [online] 2009 December [viewed 16 September 2014] Available from: doi:10.4076/1757-1626-2-7460
  8. LYNCH KAREN, OSTER JOEL, APETAUEROVA DIANA, HREIB KINAN. Spinal Cord Stroke: Acute Imaging and Intervention. Case Reports in Neurological Medicine [online] 2012 December, 2012:1-3 [viewed 16 September 2014] Available from: doi:10.1155/2012/706780

Examination

Fact Explanation
Body Mass Index (BMI) Obesity is an independent risk factor for the development of vascular infarctions. [5]
Features suggestive of metabolic syndrome Acanthosis nigricans, obesity, high blood pressure and pheripheral stigmata of hyperlipidemia (xantholesma, xanthomata) should be looked for. [6]
Muscle mass Muscle mass is not changed at the acute presentation. If muscle wasting, atrophy and fasciculations are evident other possible diagnosis should be considered of. However muscle wasting can be seen later, due to disuse atrophy in spinal cord infarction. [7]
Muscle tone During the period of spinal shock, the muscles are flaccid. Once the spinal shock is recovered patient develops signs of upper motor neuron lesion. Muscle tone increases below the level of the infarct. [3,4]
Muscle power Muscle power is markedly diminished. [3,4]
Tendon reflexes After the resolution of the spinal shock deep tendon reflexes become exaggerated below the level of the lesion. At the level of the lesion tendon reflexes are absent (lower motor neuron lesion). [3,4]
Vibration and proprioception Spinal cord infarction commonly involves the anterior columns with preserved posterior columns. So the vibration and proprioception, which is transmitted via the posterior column are usually preserved, so called dissociated sensory impairment. [1,2]
Touch, temperature and pain sensation Touch, temperature and pain sensation are absent below the level of the lesion. [2]
References
  1. ROVIRA A, PEDRAZA S, COMABELLA M, ALVAREZ J, SALGADO A. Magnetic resonance imaging of acute infarction of the anterior spinal cord. Journal of Neurology, Neurosurgery & Psychiatry [online] 1998 February, 64(2):279-281 [viewed 15 September 2014] Available from: doi:10.1136/jnnp.64.2.279
  2. MASSON C. Spinal cord infarction: clinical and magnetic resonance imaging findings and short term outcome. Journal of Neurology, Neurosurgery & Psychiatry [online] 2004 October, 75(10):1431-1435 [viewed 15 September 2014] Available from: doi:10.1136/jnnp.2003.031724
  3. ADAMS M M, HICKS A L. Spasticity after spinal cord injury. Spinal Cord [online] December, 43(10):577-586 [viewed 16 September 2014] Available from: doi:10.1038/sj.sc.3101757
  4. SMITH P.M., JEFFERY N.D.. Spinal Shock-Comparative Aspects and Clinical Relevance. [online] 2005 November, 19(6):788-793 [viewed 16 September 2014] Available from: doi:10.1111/j.1939-1676.2005.tb02766.x
  5. HUBERT H. B., FEINLEIB M., MCNAMARA P. M., CASTELLI W. P.. Obesity as an independent risk factor for cardiovascular disease: a 26- year follow-up of participants in the Framingham Heart Study. Circulation [online] 1983 May, 67(5):968-977 [viewed 20 September 2014] Available from: doi:10.1161/01.CIR.67.5.968
  6. DWIVEDI S, JHAMB R. Cutaneous markers of coronary artery disease World J Cardiol [online] 2010 Sep 26, 2(9):262-269 [viewed 20 September 2014] Available from: doi:10.4330/wjc.v2.i9.262
  7. SCHERBAKOV N, DOEHNER W. Sarcopenia in stroke--facts and numbers on muscle loss accounting for disability after stroke J Cachexia Sarcopenia Muscle [online] 2011 Mar, 2(1):5-8 [viewed 20 September 2014] Available from: doi:10.1007/s13539-011-0024-8

Differential Diagnoses

Fact Explanation
Acute disseminated encephalomyelitis Acute disseminated encephalitis is an acute widespread demyelination of the brain. This is an acute monophasic disease, with complete recovery. Patients can present with hemiparesis, cranial nerve palsies, and paraparesis. [2]
Guillain-Barré syndrome (GBS) GBS is a demyelinating disease which progresses over days. Maximum duration of disease progression is four weeks. Duration of the disease is the main differentiating feature of GBS from infarction of the spinal cord. Motor weakness ascends progressively and tendon reflexes are either reduced or absent. [3]
Arteriovenous malformations (AVM) AVMs are focal abnormal connections between arterioles and venules which are fragile so bleed easily. Bleeding from intracranial AVMs leads to the development of stroke and acute paralysis. [4]
Epidural hematoma Epidural hematoma is a rare occurance which may occur secondary to trauma, surgery, epidural catheterisation or coagulation abnormalities. Sudden onset severe back pain precede the onset of neurological symptoms (muscle weakness or paralysis and sensory impairment) [5]
Neurosyphilis Neurosyphilis is now very rarely seen due to wide use of penicillin. It causes slow and progressive destruction of the brain and spinal cord. Neurological symptoms typically evolve slowly over a long period. [6]
Tuberculous meningitis Tuberculous meningitis is a subacute disease commonly caused by reactivation of TB. Prodromal phase consists of low-grade fever, malaise, headache, dizziness, vomiting, and personality changes. Later on severe headache, altered mental status, stroke, hydrocephalus, and cranial nerve palsies develop. [7]
Aortic dissection [1] Patients with acute dissection presents with severe tearing type of chest pain which radiates to the back. [8]
References
  1. ROVIRA A, PEDRAZA S, COMABELLA M, ALVAREZ J, SALGADO A. Magnetic resonance imaging of acute infarction of the anterior spinal cord. Journal of Neurology, Neurosurgery & Psychiatry [online] 1998 February, 64(2):279-281 [viewed 15 September 2014] Available from: doi:10.1136/jnnp.64.2.279
  2. GARG R K. Acute disseminated encephalomyelitis. [online] 2003 January, 79(927):11-17 [viewed 16 September 2014] Available from: doi:10.1136/pmj.79.927.11
  3. HADDEN R. D M. MANAGEMENT OF INFLAMMATORY NEUROPATHIES. [online] 2003 June, 74(90002):9ii-14 [viewed 16 September 2014] Available from: doi:10.1136/jnnp.74.suppl_2.ii9
  4. FRIEDLANDER ROBERT M.. Arteriovenous Malformations of the Brain. N Engl J Med [online] 2007 June, 356(26):2704-2712 [viewed 16 September 2014] Available from: doi:10.1056/NEJMcp067192
  5. DUFFILL J. Can spontaneous spinal epidural haematoma be managed safely without operation? a report of four cases. [online] 2000 December, 69(6):816-819 [viewed 16 September 2014] Available from: doi:10.1136/jnnp.69.6.816
  6. OMER TAHA A, FITZGERALD DEIRDRE E, SHEEHY NIALL, DOHERTY COLIN P. Neurosyphilis presenting with unusual hippocampal abnormalities on magnetic resonance imaging and positron emission tomography scans: a case report. Array [online] 2012 December [viewed 16 September 2014] Available from: doi:10.1186/1752-1947-6-389
  7. MARX GRACE E., CHAN EDWARD D.. Tuberculous Meningitis: Diagnosis and Treatment Overview. Tuberculosis Research and Treatment [online] 2011 December, 2011:1-9 [viewed 16 September 2014] Available from: doi:10.1155/2011/798764
  8. JUANG D., BRAVERMAN A. C., EAGLE K.. Aortic Dissection. Circulation [online] December, 118(14):e507-e510 [viewed 18 September 2014] Available from: doi:10.1161/CIRCULATIONAHA.108.799908

Investigations - for Diagnosis

Fact Explanation
Full blood count Full blood count is helpful in diagnosing an infective etiology for the spinal infarction. White blood cell count is elevated in infections. Thrombocytopenia can be the causative factor for hemorrhagic infarction. [4]
Serum electrolytes Elevated potassium levels can cause periodic paralysis and even acute flaccid paralysis. Hypokalemia is also associated with paralysis. [6,7]
Fasting blood sugar Fasting blood sugar should be assessed in order to diagnose diabetes mellitus. [8,9]
Lipid profile Hypercholestrolemia is a risk factor for the development of vascular infarcts. [10,11]
Cerebro-spinal fluid (CSF) full report In vasculitic etiologies, the opening pressure of CSF is increased. CSF protein and lymphocyte count are elevated. CSF sugar can be reduced in the presence of bacterial infection. [5]
Autoantibodies Antineutrophil cytoplasmic antibody (ANCA) is strongly associated with the presence of vasculitis. [12,13]
CT CT scan can detect the presence of arterial thrombi which favors the diagnosis of ischemic infarction. [3]
MRI MRI is useful to exclude other sinister and potentially reversible causes like epidural hematoma, vertebral fracture and other space occupying lesions. [2]
Spinal angiography Spinal angiography is useful in detecting the site of the lesion. [1]
References
  1. RENOWDEN S. A.. Normal anatomy of the spinal cord. Practical Neurology [online] December, 12(6):367-370 [viewed 16 September 2014] Available from: doi:10.1136/practneurol-2012-000247
  2. EL-OSTA BASSEL, GHOZ ALI, SINGH VINAY KUMAR, SAED ELRASHEID, ABDUNABI MURAD. Spontaneous spinal cord infarction secondary to embolism from an aortic aneurysm mimicking as cauda equina due to disc prolapse: a case report. Array [online] 2009 December [viewed 16 September 2014] Available from: doi:10.4076/1757-1626-2-7460
  3. IZUMI M, TERAOKA S, YAMASHITA K, MATSUMOTO K, MURONOI T, IZAWA Y, YONEKAWA C, ANO M, SUZUKAWA M. Successful management of aortic thrombi resulting in spinal cord infarction in a patient with antiphospholipid antibody syndrome and acute cholecystitis Int Med Case Rep J [online] :93-96 [viewed 16 September 2014] Available from: doi:10.2147/IMCRJ.S26618
  4. NANCE JR, GOLOMB MR. Ischemic spinal cord infarction in children without vertebral fracture Pediatr Neurol [online] 2007 Apr, 36(4):209-216 [viewed 20 September 2014] Available from: doi:10.1016/j.pediatrneurol.2007.01.006
  5. ROACH E. S., GOLOMB M. R., ADAMS R., BILLER J., DANIELS S., DEVEBER G., FERRIERO D., JONES B. V., KIRKHAM F. J., SCOTT R. M., SMITH E. R.. Management of Stroke in Infants and Children: A Scientific Statement From a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke [online] December, 39(9):2644-2691 [viewed 20 September 2014] Available from: doi:10.1161/STROKEAHA.108.189696
  6. Part 10.1: Life-Threatening Electrolyte Abnormalities. Circulation [online] 2005 November, 112(24_suppl):IV-121-IV-125 [viewed 20 September 2014] Available from: doi:10.1161/CIRCULATIONAHA.105.166563
  7. AGRAWAL P, CHOPRA D, PATRA SK, MADAAN H. Periodic paralysis: An unusual presentation of drug-induced hyperkalemia J Pharmacol Pharmacother [online] 2014, 5(1):63-66 [viewed 20 September 2014] Available from: doi:10.4103/0976-500X.124429
  8. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. The Lancet [online] 2010 June, 375(9733):2215-2222 [viewed 20 September 2014] Available from: doi:10.1016/S0140-6736(10)60484-9
  9. YEBOAH JOSEPH, BERTONI ALAIN G., HERRINGTON DAVID M., POST WENDY S., BURKE GREGORY L.. Impaired Fasting Glucose and the Risk of Incident Diabetes Mellitus and Cardiovascular Events in an Adult Population. Journal of the American College of Cardiology [online] 2011 July, 58(2):140-146 [viewed 20 September 2014] Available from: doi:10.1016/j.jacc.2011.03.025
  10. SOLANO M. P.. Lipid Management in Type 2 Diabetes. Clinical Diabetes [online] 2006 January, 24(1):27-32 [viewed 20 September 2014] Available from: doi:10.2337/diaclin.24.1.27
  11. LACOSTE L., LAM J. Y.T., HUNG J., LETCHACOVSKI G., SOLYMOSS C. B., WATERS D.. Hyperlipidemia and Coronary Disease : Correction of the Increased Thrombogenic Potential With Cholesterol Reduction. Circulation [online] 1995 December, 92(11):3172-3177 [viewed 20 September 2014] Available from: doi:10.1161/01.CIR.92.11.3172
  12. GROSS W. L.. Diagnosis and evaluation of vasculitis. [online] 2000 March, 39(3):245-252 [viewed 20 September 2014] Available from: doi:10.1093/rheumatology/39.3.245
  13. WIIK A.. Rational use of ANCA in the diagnosis of vasculitis. [online] 2002 May, 41(5):481-483 [viewed 20 September 2014] Available from: doi:10.1093/rheumatology/41.5.481

Investigations - Followup

Fact Explanation
Activated partial thromboplastin time (aPTT) aPTT should be monitored in patients who are anticoagulated. [1]
Psychiatric follow up Mood disorders, especially depression can be commonly occur after stroke due to sudden transition of life from being healthy to immobile and bed bound. Presence of mood disorders may adversely influence on physical, functional, and cognitive recovery. Early detection and treatment of mood disorders are really important in further management of patient. [2]
Group therapy Group therapy is one treatment modality used in rehabilitation of stroke patients. This enables emotional ventilation and encourages to do more physical activities with lesser stress. Group therapy can be combined with music and simple games to make it more interesting. [3,4]
Physiotherapy Physiotherapy should be continued till the patient achieves adequate functional recovery. [5]
References
  1. IZUMI M, TERAOKA S, YAMASHITA K, MATSUMOTO K, MURONOI T, IZAWA Y, YONEKAWA C, ANO M, SUZUKAWA M. Successful management of aortic thrombi resulting in spinal cord infarction in a patient with antiphospholipid antibody syndrome and acute cholecystitis Int Med Case Rep J [online] :93-96 [viewed 18 September 2014] Available from: doi:10.2147/IMCRJ.S26618
  2. O'ROURKE S., MACHALE S., SIGNORINI D., DENNIS M.. Detecting Psychiatric Morbidity After Stroke : Comparison of the GHQ and the HAD Scale. Stroke [online] 1998 May, 29(5):980-985 [viewed 22 September 2014] Available from: doi:10.1161/01.STR.29.5.980
  3. WEST TANYA, BERNHARDT JULIE. Physical Activity in Hospitalised Stroke Patients. Stroke Research and Treatment [online] 2012 December, 2012:1-13 [viewed 22 September 2014] Available from: doi:10.1155/2012/813765
  4. VAN VUGT FT, RITTER J, ROLLNIK JD, ALTENMüLLER E. Music-supported motor training after stroke reveals no superiority of synchronization in group therapy Front Hum Neurosci [online] :315 [viewed 22 September 2014] Available from: doi:10.3389/fnhum.2014.00315
  5. THOMPSON A J. Clinical management of spasticity. Journal of Neurology, Neurosurgery & Psychiatry [online] 2005 April, 76(4):459-463 [viewed 16 September 2014] Available from: doi:10.1136/jnnp.2004.035972

Management - General Measures

Fact Explanation
Initial monitoring Once the spinal cord infarction is suspected, initial imaging should be done to diagnose spinal infarction. Initial neuroprotective strategies include, avoidance of hypotension as this can aggravate spinal ischemia. [6]
Health education Patient education is important in managing spinal cord infarction, as immobility related to spinal infarction can lead to various complications like, urinary tract infections, pressure sores and muscle contractures. Family members should also be educated about the prevention of possible complications of spinal cord infarction (maintenance of bladder care, skin care, and necessity of limb physiotherapy). Dietary modifications that should be adhered to include, avoidance of high fat diet (fried food, processed meat, margarine) and increment of food and vegetables in diet. [7]
Psychological Support Spinal cord infarction results in significant psychological stress to the victim and to the family. Enough psychological support should be provided with empathy, encouraging patients to face the acute stress in their life. Patients should be referred to councilors, peer discussions and psychotherapy where necessary. [8]
Occupational therapy Patients should be referred to occupational therapy to make them independent in their day-to-day activities. [8]
Deep vein thrombosis (DVT) prophylaxis Compression stockings and low molecular weight heparin can be used in DVT prophylaxis. [1,2]
Bladder care Intermittent catheterization is superior to indwelling catheters in minimizing the risk of catheter associated urinary tract infection. A closed catheter drainage system should me maintained always and indwelling catheters should be changed on time. [3,4,5]
Skin care Pressure sores can occur secondary to prolonged immobilization. Patient should be turned every 2 hours to maintain adequate skin perfusion. [5]
Peptic ulcer prophylaxis Use of H2 receptor antagonists or proton-pump inhibitors for 6 weeks reduces the incidence of stress related peptic ulcerations. [5]
References
  1. LEIZOROVICZ A.. Preventing Venous Thromboembolism in Medical Patients. Circulation [online] 2004 December, 110(24_suppl_1):IV-13-IV-19 [viewed 18 September 2014] Available from: doi:10.1161/01.CIR.0000150640.98772.af
  2. RIKLIN C, BAUMBERGER M, WICK L, MICHEL D, SAUTER B, KNECHT H. Deep vein thrombosis and heterotopic ossification in spinal cord injury: a 3 year experience at the Swiss Paraplegic Centre Nottwil. Spinal Cord [online] 2003 March, 41(3):192-198 [viewed 18 September 2014] Available from: doi:10.1038/sj.sc.3101421
  3. HOOTON T. M., BRADLEY S. F., CARDENAS D. D., COLGAN R., GEERLINGS S. E., RICE J. C., SAINT S., SCHAEFFER A. J., TAMBAYH P. A., TENKE P., NICOLLE L. E.. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical Infectious Diseases [online] 2010 March, 50(5):625-663 [viewed 18 September 2014] Available from: doi:10.1086/650482
  4. MITCHELL BRETT, WARE CHRIS, MCGREGOR ALISTAIR, BROWN SAFFRON, WELLS ANNE, STUART RHONDA L., WILSON FIONA, MASON MATTHEW. ASID (HICSIG)/AICA Position Statement: Preventing catheter-associated urinary tract infections in patients. Healthcare Infection [online] 2011 December [viewed 18 September 2014] Available from: doi:10.1071/HI11007
  5. BONNER S., SMITH C.. Initial management of acute spinal cord injury. Continuing Education in Anaesthesia, Critical Care & Pain [online] December, 13(6):224-231 [viewed 18 September 2014] Available from: doi:10.1093/bjaceaccp/mkt021
  6. MILLICHAP JJ, SY BT, LEACOCK RO. Spinal Cord Infarction with Multiple Etiologic Factors J Gen Intern Med [online] 2007 Jan, 22(1):151-154 [viewed 20 September 2014] Available from: doi:10.1007/s11606-006-0029-8
  7. BALTA S, DEMIRKOL S, CELIK T. Lifestyle Change Programs in the Management of Hyperlipidemia Oman Med J [online] 2012 Nov, 27(6):511 [viewed 20 September 2014] Available from: doi:10.5001/omj.2012.123
  8. GORDON N. F.. Physical Activity and Exercise Recommendations for Stroke Survivors: An American Heart Association Scientific Statement From the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Stroke [online] 2004 April, 35(5):1230-1240 [viewed 20 September 2014] Available from: doi:10.1161/01.STR.0000127303.19261.19

Management - Specific Treatments

Fact Explanation
Limb physiotherapy Limb physiotherapy is indicated for every patient. This is helpful to prevent the occurrence of contractures and improves the final functional outcome. [1]
Aspirin Aspirin is an antiplatelet drug used only in ischemic spinal infarction. It inhibits platelet aggregation and prevent the progression of thrombus. Low dose aspirin (75 mg daily) is effective in reducing the risk of recurrent ischemic events. [2,3,4]
Clopidogrel Similar to aspirin clopidogrel also inhibits the activation of platelets, and inhibits the progression of the already formed thrombus. Combination of aspirin and clopidogrel can also be used in the treatment of ischemic strokes. However since this significantly increase the risk of bleeding combined treatment should only be given to patients with very low risk of spontaneous bleeding and hemorrhagic stroke. [2,5,6]
Low molecular weight heparin Anticoagulation is indicated for the treatment of ischemic infarction of the spinal cord. (It should not be used for the hemorrhagic strokes) [2,3]
References
  1. THOMPSON A J. Clinical management of spasticity. Journal of Neurology, Neurosurgery & Psychiatry [online] 2005 April, 76(4):459-463 [viewed 16 September 2014] Available from: doi:10.1136/jnnp.2004.035972
  2. NANCE JR, GOLOMB MR. Ischemic spinal cord infarction in children without vertebral fracture Pediatr Neurol [online] 2007 Apr, 36(4):209-216 [viewed 18 September 2014] Available from: doi:10.1016/j.pediatrneurol.2007.01.006
  3. IZUMI M, TERAOKA S, YAMASHITA K, MATSUMOTO K, MURONOI T, IZAWA Y, YONEKAWA C, ANO M, SUZUKAWA M. Successful management of aortic thrombi resulting in spinal cord infarction in a patient with antiphospholipid antibody syndrome and acute cholecystitis Int Med Case Rep J [online] :93-96 [viewed 18 September 2014] Available from: doi:10.2147/IMCRJ.S26618
  4. PATRONO C., ROTH G. J.. Aspirin in Ischemic Cerebrovascular Disease : How Strong Is the Case for a Different Dosing Regimen?. Stroke [online] 1996 April, 27(4):756-760 [viewed 21 September 2014] Available from: doi:10.1161/01.STR.27.4.756
  5. GORELICK P. B., HANLEY D. F.. Clopidogrel and Its Use in Stroke Patients. Stroke [online] 1998 August, 29(8):1737-1737 [viewed 21 September 2014] Available from: doi:10.1161/01.STR.29.8.1737
  6. ALBERS G. W., AMARENCO P.. Combination Therapy With Clopidogrel and Aspirin: Can the CURE Results Be Extrapolated to Cerebrovascular Patients?. Stroke [online] 2001 December, 32(12):2948-2949 [viewed 22 September 2014] Available from: doi:10.1161/hs1201.100829