Unilateral Posterior Spinal Cord Ischemia Due to a Floating Aortic Thrombus: A Case Report
, Anna Gardin 1,†, Teresa Brizzi 1,†, Carmela Casella 1, Maria Carolina Fazio 1, Karol Galletta 3, Enricomaria Mormina 3, Sergio Lucio Vinci 3, Rosa Fortunata Musolino 1, Paolino La Spina 1,‡ and Antonio Toscano 1,*,‡
Round 1
Reviewer 1 Report
This is a case report on a rare condition of posterior spinal artery embolic infarct in the cervical spinal cord with a clinical presentation of stroke and a possibile aetiology of aortic thrombus. Generally, the materials presented were above average, but some unclear expressions could be improved. The followings are my suggestions:
> In the Abstract/ Case Presentation:
/ The patient had sensory deficit below the seventh "thoracic" vertebral level? How does it correlate with the MRI detected lesion in C4-C6? Should there be an alternative lesion in the thoracic spine?
> Case Presentation:
/ A patient in their mid-70s is not specific. The information should be the same as in the abstract section (75-year-old male).
/ Since there is a 3-month follow up for a ischemic stroke patient, the Modified Rankin Scale could be provided if there was proper documentation.
/The thinking process of differential diagnosis of the cervical cord lesion is lacking. A brief exclusion of other possible diseases such as multiple sclerosis, transverse myelitis should be added; either from clinical, laboratory or imaging point of views.
All Figures
/ The "blue" arrows seems red to me.
Figure 1
/ Sagittal "projection" is not advised since MRI slices were not obtained as X-ray projections. Sagittal view, image or slice are better wordings
/ Advise changing wordings to the involvement of both grey (posterior horn) and white matter (lateral corticospinal tract, dorsal column-medial lemniscus) in right upper panel; and not referring the lateral corticospinal tract on sagittal DWI. Advise using hyperintensity lesion but not ischemic lesion on T2-FFE.
/ Is there an ADC map (or measured value) to better demonstrate diffusion restriction rather than T2-shine-through effect causing DWI brightness?
Fig 3
/ view"s"
Fig 4
/ An oblique sagittal reformation view is more proper.
/ How do you determine this lesion as a free-floating thrombus rather than an atheromatic plaque? Also less mobile? Please provide your objective imaging measurements of the lesions to better justify your presumptions. The images currently provided were small and both lesions appeared sessile to me. The reference #3 should contain their methods for the definitions.
Discussion
/ It should be mentioned more clearly that in this case, the lesion at dorsal column-lateral lemiscus (tactile and proprioception) and lateral corticospinal tract (motor) causes symptoms ipsilaterally. Which is aligned to our current neuro-anatomical knowledge.
/ The expression of the following content is unclear: (line 94 until the end of first paragraph) A transient lesion expansion on MRI after SCI has been previously reported as pencil-shaped necrosis ... ... the spinal cord with peripheral sparing (7,8).
Is there lesion expansion, vasogenic edema, longitudinally extensive, or spondylosis with significant spinal stenosis in this case?
Please revise and add relevance to this case.
/ Wordings in the conclusions should be more precise, advise changes for
line 147: Spinal cord MRI "with DWI" (which is the main advantage in your article)
line 149: unilateral "posterior" infarcts
line 125: posterior spinal artery (not posterior spinal cord artery)
Supplemental table
Very good collections as a review of the literature.
However, please check spelling errors and use upper case letters for names, including but not limited to the follwings:
horner's syndrome; wallenberg syndrome; righ; pathestaesia; tue; proprioceptoin; statine
spelling errors
Author Response
Dear Editor and dear Reviewer,
Thank you very much for your careful reading of the manuscript entitled “Unilateral Posterior Spinal Cord Ischemia due to a Floating Aortic Thrombus: a case Report” by Dr. Giammello et al. We appreciated your helpful suggestions and modified the manuscript following your review, which have improved the quality of the presentation.
Reviewer #1:
This is a case report on a rare condition of posterior spinal artery embolic infarct in the cervical spinal cord with a clinical presentation of stroke and a possible aetiology of aortic thrombus. Generally, the materials presented were above average, but some unclear expressions could be improved.
Response: We would like to thank the reviewer for the thorough and detailed review and helpful comments, which have improved our manuscript. We provided the required corrections, as described below in detail.
The followings are my suggestions:
> In the Abstract/ Case Presentation: The patient had sensory deficit below the seventh "thoracic" vertebral level? How does it correlate with the MRI detected lesion in C4-C6? Should there be an alternative lesion in the thoracic spine?
Response: We apologize for the clerical error and corrected the definition, using the standardized dermatome assessments in order to avoid confounding terms [ASIA and ISCoS International Standards Committee. The 2019 revision of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)-What's new? Spinal Cord. 2019 Oct;57(10):815-817. doi: 10.1038/s41393-019-0350-9. Epub 2019 Sep 17. PMID: 31530900.; Kirshblum S, Snider B, Rupp R, Read MS; International Standards Committee of ASIA and ISCoS. Updates of the International Standards for Neurologic Classification of Spinal Cord Injury: 2015 and 2019. Phys Med Rehabil Clin N Am. 2020 Aug;31(3):319-330. doi: 10.1016/j.pmr.2020.03.005. Epub 2020 Jun 3. PMID: 32624097].
> Case Presentation:
/ A patient in their mid-70s is not specific. The information should be the same as in the abstract section (75-year-old male).
/ Since there is a 3-month follow up for a ischemic stroke patient, the Modified Rankin Scale could be provided if there was proper documentation.
Response: We specified the required information in the main text.
/The thinking process of differential diagnosis of the cervical cord lesion is lacking. A brief exclusion of other possible diseases such as multiple sclerosis, transverse myelitis should be added; either from clinical, laboratory or imaging point of views.
Response: We agree with your suggestion, and therefore we listed the excluded diseases for the differential diagnosis of both spinal cord ischemia and free-floating thrombus in the Introduction section and in the case description, as required. In addition, we discussed the role of DWI and ADC for the differential diagnosis in the Discussion section (see below).
All Figures
/ The "blue" arrows seems red to me.
Response: We thank the reviewer for correction, and we fixed our slip.
Figure 1
/ Sagittal "projection" is not advised since MRI slices were not obtained as X-ray projections. Sagittal view, image or slice are better wordings
/ Advise changing wordings to the involvement of both grey (posterior horn) and white matter (lateral corticospinal tract, dorsal column-medial lemniscus) in right upper panel; and not referring the lateral corticospinal tract on sagittal DWI. Advise using hyperintensity lesion but not ischemic lesion on T2-FFE.
/ Is there an ADC map (or measured value) to better demonstrate diffusion restriction rather than T2-shine-through effect causing DWI brightness?
Fig 3
/ view"s"
Response: We apologize for the erroneous choice of words, and therefore rephrase as it follows: “Right panel: on the upper row, T2-FFE (fast field echo) sequences (axial view) showing the ischemic lesion of the left posterior cord, involving both grey (posterior horn) and white matter (lateral corticospinal tract, dorsal column-medial lemniscus) (red arrow); on the lower row, DWI (diffusion-weighted imaging) sequences (sagittal projection) showing the hyperintense lesion corresponding to decreased apparent diffusion coefficient in an area of 22 mm2 within a larger TR hyperintensity (ADC average infarct core/average normal cord 1.0/1.86 ×10−3 mm2/s; ADC ratio 53.8%)”. Furthermore, we added measured ADC value with ratio, as for your suggestion, and discussed the importance of diffusion restriction with relative ADC decreasing in the discussion section (see below). Finally, we corrected misspellings and slips.
Fig 4
/ An oblique sagittal reformation view is more proper.
/ How do you determine this lesion as a free-floating thrombus rather than an atheromatic plaque? Also less mobile? Please provide your objective imaging measurements of the lesions to better justify your presumptions. The images currently provided were small and both lesions appeared sessile to me. The reference #3 should contain their methods for the definitions.
Response: We thank the reviewer for their valuable feedback and for the suggestion. The floating thombus was suspected with transthoracic echocardiogram, as previously reported [Campanile A, Sardone M, Pasquino S, Cagini A, Di Manici G, Cavallini C. Surgical management of a free-floating thrombus in the ascending aorta. Asian Cardiovascular and Thoracic Annals. 2019;27(3):221-223. doi:10.1177/0218492318804956], but the patient was not collaborative enough to be assessed with transesophageal echocardiogram for confirmation. However, we agree with your suggestion, and therefore performed a volume rendering reconstruction of the aorta with CT scan at baseline and after 3 months, in order to illustrate a clearer image of the lesion with segmentation of the lesion, using the definition that you suggested, adding the images in the Figure 4 and in Figure 5 for comparison (lower panels). Furthermore, we defined the shape of the free-floating thrombus and measured the break-off risk ratio (boRR), describing the required information in the caption of the Figure 4.
Discussion
/ It should be mentioned more clearly that in this case, the lesion at dorsal column-lateral lemiscus (tactile and proprioception) and lateral corticospinal tract (motor) causes symptoms ipsilaterally. Which is aligned to our current neuro-anatomical knowledge.
Response: We agree with your suggestion, and therefore we included the sentence mentioning the clinic-anatomical correlation.
/ The expression of the following content is unclear: (line 94 until the end of first paragraph) A transient lesion expansion on MRI after SCI has been previously reported as pencil-shaped necrosis ... ... the spinal cord with peripheral sparing (7,8).
Is there lesion expansion, vasogenic edema, longitudinally extensive, or spondylosis with significant spinal stenosis in this case? Please revise and add relevance to this case.
Response: We agree with your suggestion, and therefore clarify this part of discussion as it follows, “DWI has the highest sensitivity showing hyperintense signal changes and abnormalities that could be detected within 3 hours. A marked diffusion restriction may provide another indicator leading to the specific diagnosis of SCI. In fact, a mild hyperintensity could be seen on DWI of myelitis or tumors, allowing the differential diagnosis of infarction from inflammatory cord lesions and intramedullary tumors, by the different range of ADC values (2). A transient lesion expansion on MRI after SCI has been previously reported as pencil-shaped necrosis (7), with a length usually limited to several vertebral segments (8). Actually, vasogenic edema in the spinal cord may occur from the acute phase, when a cervical cord compression due to cervical spondylosis causes secondary venous congestion (9). Venous congestion is a known cause of longitudinally extensive spinal cord swelling, and may initially mimic a peripheral nerve disorder, but T2-hyperintense lesion is most often seen in the center of the spinal cord with peripheral sparing (9,10). In our case, the marked hyperintensity on DWI associated with decreased ADC, within the brightness due to the T2-shine-through effect, allowed us to differentiate between the cytotoxic edema, due to the acute infarction, and the vasogenic component of the edema, most likely depending on the venous congestion”. We added literature, accordingly.
/ Wordings in the conclusions should be more precise, advise changes for
line 147: Spinal cord MRI "with DWI" (which is the main advantage in your article)
line 149: unilateral "posterior" infarcts
line 125: posterior spinal artery (not posterior spinal cord artery)
Response: We apologize for the lack of accuracy and we provided for proper corrections.
Supplemental table
Very good collections as a review of the literature. However, please check spelling errors and use upper case letters for names, including but not limited to the follwings:
horner's syndrome; wallenberg syndrome; righ; pathestaesia; tue; proprioceptoin; statine
Response: We would like to thank the reviewer for the thorough review and for the positive comment on our article. We corrected the spelling errors, as you kindly suggested.
Reviewer 2 Report
The manuscript entitled "Unilateral Posterior Spinal Cord Ischemia due to a Floating 2 Aortic Thrombus: A case Report" by Giammello et al. discusses a case of Spinal Cord Ischemia due to a floating thrombus in the ascending aorta. Considering the rarity of the condition, it presents a valuable and informative article in the field of clinical neuroscience. The case report is well organized, thorough, and informative. Before the manuscript is deemed fit for publication, I would suggest addressing the following concerns in its present form:
1) The introduction could be more elaborative, covering the detailed background of the condition and related pathologies.
2) The gender of the patient is not mentioned in the case presentation section, even though it is mentioned in the abstract. I would suggest the case presentation be more descriptive about the patient's details.
Further, there are some minor grammatical mistakes and suggestions that need to be corrected, for example:
i)"former strong smoking habit" - could be rephrased to "previous history of heavy smoking habit."
ii) "showing high triglyceridemia" could be rephrased to "hypertriglyceridemia."
iii) "differently from the classical spinal cord syndromes" could be rephrased to "unlike classical spinal cord syndromes"
iv) "anticoagulation or antiplatelet therapy should be considered when aortic thrombus were detected after stroke or peripheral embolism" replace "were" with "is".
Overall, the manuscript is very well written and presented, and incorporating these minor refinements should render it suitable for publication.
Author Response
Dear Editor and dear Reviewer,
Thank you very much for your careful reading of the manuscript entitled “Unilateral Posterior Spinal Cord Ischemia due to a Floating Aortic Thrombus: a case Report” by Dr. Giammello et al. We appreciated your helpful suggestions and modified the manuscript following your review, which have improved the quality of the presentation.
Reviewer #2:
The manuscript entitled “Unilateral Posterior Spinal Cord Ischemia due to a Floating 2 Aortic Thrombus: A case Report” by Giammello et al. Discusses a case of Spinal Cord Ischemia due to a floating thrombus in the ascending aorta. Considering the rarity of the condition, it presents a valuable and informative article in the field of clinical neuroscience. The case report is well organized, thorough, and informative. Before the manuscript is deemed fit for publication, I would suggest addressing the following concerns in its present form.
Response: We would like to thank the reviewer for the thorough review and for the positive comment on our article. We provided the required corrections, as described below in detail.
- The introduction could be more elaborative, covering the detailed background of the condition and related pathologies.
Response: We agree with your suggestion, and therefore we listed the excluded diseases for the differential diagnosis of both spinal cord ischemia and free-floating thrombus in the Introduction section and in the case description, as required. In addition, we discussed the role of DWI and ADC for the differential diagnosis in the Discussion section.
- The gender of the patient is not mentioned in the case presentation section, even though it is mentioned in the abstract. I would suggest the case presentation be more descriptive about the patient’s details.
Response: We specified the required information in the main text, as well.
Further, there are some minor grammatical mistakes and suggestions that need to be corrected, for example:
i)”former strong smoking habit” – could be rephrased to “previous history of heavy smoking habit.”
- ii) “showing high triglyceridemia” could be rephrased to “hypertriglyceridemia.”
iii) “differently from the classical spinal cord syndromes” could be rephrased to “unlike classical spinal cord syndromes”
- iv) “anticoagulation or antiplatelet therapy should be considered when aortic thrombus were detected after stroke or peripheral embolism” replace “were” with “is”.
Overall, the manuscript is very well written and presented, and incorporating these minor refinements should render it suitable for publication.
Response: We would like to thank the reviewer for the thoughtful comment, which underlines our efforts. We apologize for the lack of accuracy, and we provided for proper corrections.
Reviewer 3 Report
In general, the clinical case is presented in a structured manner and contains all the necessary information for a full understanding of the patient and his disease.
The authors present the case logically with proper discussion.
This case is rare, so I consider it appropriate to publish it, the relevance of such a clinical case is due to the small number of similar studies presented in the literature.
From the minimal points, I recommend to authors detail the process of differential diagnosis of its clinical case.
Author Response
Dear Editor and dear Reviewer,
Thank you very much for your careful reading of the manuscript entitled “Unilateral Posterior Spinal Cord Ischemia due to a Floating Aortic Thrombus: a case Report” by Dr. Giammello et al. We appreciated your helpful suggestions and modified the manuscript following your review, which have improved the quality of the presentation.
Reviewer #3:
In general, the clinical case is presented in a structured manner and contains all the necessary information for a full understanding of the patient and his disease.
The authors present the case logically with proper discussion.
This case is rare, so I consider it appropriate to publish it, the relevance of such a clinical case is due to the small number of similar studies presented in the literature.
From the minimal points, I recommend to authors detail the process of differential diagnosis of its clinical case.
Response: We would like to thank the reviewer for taking the time and effort necessary to review the manuscript. Agreeing with their suggestion, we listed the excluded diseases for the differential diagnosis of both spinal cord ischemia and free-floating thrombus in the Introduction section and in the case description, as required. In addition, we discussed the role of DWI and ADC for the differential diagnosis in the Discussion section.
Reviewer 4 Report
This case report presents a rare and interesting case of SCI due to a floating thrombus in an AA.
The report also highlights the clinical features and treatment considerations of SCI.
However, as this is a single case, more research and data are needed to further understand how the disease occurs and the best treatment.
Figures 1 and 2 show arrows in red, but descriptions in blue?
Please fix the consistency and add cited references.
Strengths of the report demonstrates a comprehensive diagnostic approach, including brain and spinal cord imaging, blood tests, cardiac assessment, and contrast-enhanced CT angiography, which helped identify the underlying cause of the patient's condition.
Treatment Considerations: The report discusses potential treatment options, highlighting the complexities and variations in management approaches based on the patient's condition, thrombus morphology, and physician experience.
In summary, the paper highlights the importance of cervical proprioception in neck pain, discusses its impairment mechanisms, proposes sensorimotor control tests for evaluation, and suggests exercises for management. The use of this information can enhance the assessment and treatment strategies for patients with neck pain.
Author Response
Dear Editor and dear Reviewer,
Thank you very much for your careful reading of the manuscript entitled “Unilateral Posterior Spinal Cord Ischemia due to a Floating Aortic Thrombus: a case Report” by Dr. Giammello et al. We appreciated your helpful suggestions and modified the manuscript following your review, which have improved the quality of the presentation.
Reviewer #4:
This case report presents a rare and interesting case of SCI due to a floating thrombus in an AA.
The report also highlights the clinical features and treatment considerations of SCI.
However, as this is a single case, more research and data are needed to further understand how the disease occurs and the best treatment.
Figures 1 and 2 show arrows in red, but descriptions in blue?
Please fix the consistency and add cited references.
Response: We would like to thank the reviewer for taking the time and effort necessary to review the manuscript. We provided the required corrections and added a note about the limitation of a single case report description, as suggested.
Strengths of the report demonstrates a comprehensive diagnostic approach, including brain and spinal cord imaging, blood tests, cardiac assessment, and contrast-enhanced CT angiography, which helped identify the underlying cause of the patient's condition.
Treatment Considerations: The report discusses potential treatment options, highlighting the complexities and variations in management approaches based on the patient's condition, thrombus morphology, and physician experience.
Response: We would like to thank the reviewer for the thoughtful comment, which underlines the importance of the topic.
Round 2
Reviewer 1 Report
The quality of the manuscript and figures have been significantly improved after addressing the previously raised questions.
Minor issues are still remaining as follows:
1. Changes have been made in the case presentation (seventh thoracic vertebral level -> C5 dermatome); however, it was not changed in the abstract. Please correct it.
2. line 93:
"within a larger TR hyperintensity": it is difficult to understand the wordings; advise simply omit these words.
Author Response
Dear Editor and dear Reviewer,
Thank you very much for your careful reading of the manuscript entitled “Unilateral Posterior Spinal Cord Ischemia due to a Floating Aortic Thrombus: a case Report” by Dr. Giammello et al. We appreciated your helpful suggestions and modified the manuscript following your review, which have improved the quality of the presentation.
Reviewer #1:
The quality of the manuscript and figures have been significantly improved after addressing the previously raised questions.
Response: We would like to thank the reviewer for the thorough review and for the positive comment on our effort.
Minor issues are still remaining as follows:
1. Changes have been made in the case presentation (seventh thoracic vertebral level -> C5 dermatome); however, it was not changed in the abstract. Please correct it.
Response: We thank the reviewer for correction, and we fixed our slip.
2. line 93:
"within a larger TR hyperintensity": it is difficult to understand the wordings; advise simply omit these words.
Response: We agree with the reviewer's suggestion, and therefore we omitted these words in the figure 1 caption.
