MRI patterns in ischemic spinal cord injury after thoracoabdominal aorta repair: Narrative review with illustrative case series

BACKGROUND: Ischemic spinal cord injury (ISCI) is a serious complication following thoracoabdominal aortic aneurysm (TAAA) repair, whether by open (OR) or endovascular (TEVAR) approaches. Although MRI can detect spinal cord ischemia, it's not routinely used. Emerging evidence suggests MRI may offer insights into ISCI mechanisms, lesion pattern, and prognosis. This narrative review integrates published literature with our illustrative institutional case series to evaluate MRI's diagnostic and clinical role in postoperative ISCI. OBSERVATIONS: Records from October 2011 to August 2023 were reviewed and 10 patients (7 OR, 3 TEVAR) were identified who developed postoperative ISCI and underwent spinal MRI. Diffuse infarction patterns predominated (9/10 cases), and partial neurologic recovery occurred only in TEVAR patients. Prophylactic CSF drains were used in most OR cases (6/7), while rescue drains were more common in TEVAR cases (2/3). Across the literature, MRI classifications by Mawad, Tanaka, Yasuda, and others link lesion pattern and tissue involvement to prognosis, whereas experimental and anatomic studies highlight the influence of vascular variability and watershed physiology. CONCLUSIONS: MRI clarifies the mechanism, extent, and timing of spinal cord ischemia after aortic repair and helps differentiate infarction from other causes of myelopathy. Differences in recovery between OR and TEVAR likely reflect underlying vascular anatomy and ischemic dynamics. Future multicenter studies using standardized MRI and vascular mapping could refine risk stratification, optimize CSF drainage strategies, and improve outcomes in this high-risk population.