Spinal Cord Infarction as an Atypical Thromboembolic Complication of First-Diagnosed Atrial Fibrillation

Background: Atrial fibrillation (AF) is the most common sustained arrhythmia and a major contributor to systemic thromboembolism, typically manifesting as ischemic stroke or peripheral arterial occlusion. Although spinal cord infarction (SCI) represents a rare form of ischemic injury, accounting for only 1-2% of all stroke events, its consequences are often devastating. The pathophysiological link between AF and SCI is poorly recognized, particularly in the setting of concurrent pulmonary embolism and hemodynamic instability. Case Summary: We report the case of a 91-year-old woman with chronic comorbidities who presented with first-diagnosed, asymptomatic AF and was found to have a submassive pulmonary embolism. Following initiation of anticoagulation, she developed acute flaccid paraplegia and hypotension. Spinal magnetic resonance imaging revealed a longitudinally extensive anterior-predominant T2 hyperintensity from T6 to the conus medullaris, consistent with acute anterior spinal artery territory infarction. Despite aggressive hemodynamic support, the patient's condition deteriorated and she died shortly thereafter. Conclusion: SCI is a rare but catastrophic complication of AF. In patients with AF-especially those with concomitant venous thromboembolism or hypotension-new-onset paraplegia should prompt urgent spinal MRI to exclude ischemic myelopathy. Early recognition may guide supportive strategies, although prognosis remains poor in extensive thoracolumbar infarctions.