Teaching NeuroImages: Restricted diffusion “snake eyes appearance” in acute spinal cord ischemia

An 81-year-old man presented with sudden-onset, painless flaccid tetraparesis, mild lower limbs hyperreflexia, right extensor plantar reflex, without sensory abnormalities. MRI (7 hours later) revealed a restricted diffusion lesion with "snake eyes appearance" (SEA) in the cervical spinal cord (C5-C7) (figure). Investigation revealed a gastric adenocarcinoma-related prothrombotic state, bilateral vertebral artery origin stenosis, and mild C6-C7 cord compression. SEA in T2-weighted imaging was described in several conditions,[1] but restricted diffusion SEA is highly suggestive of vascular nature. Although a compression-related venous infarct cannot be excluded,[2] the underlying mechanism is probably ischemia in the terminal territory of sulcocommissural arteries.