Spinal cord infarction due to Adamkiewicz artery involvement: When thinking the worst leads to the right diagnosis

Background: Anterior spinal artery syndrome is an infrequent cause of acute ischemic myelopathy, often caused by aortic pathology involving the artery of Adamkiewicz. This case is presented due to its rarity and the complex decision-making required for treatment in a patient with multiple comorbidities. Case Presentation: We present a 79-year-old male with hypertension and ischemic heart disease admitted for progressive lower limb weakness and sphincter dysfunction. MRI revealed anterior spinal cord infarction (T9–L1). CT angiography showed a Stanford type B (DeBakey IIIb) aortic dissection extending to the infrarenal segment with a fusiform aneurysm and mural thrombus, likely compromising the artery of Adamkiewicz. Due to high surgical risk and unfavorable vascular anatomy, a multidisciplinary team opted for conservative management. Conclusions: Vascular involvement of the artery of Adamkiewicz must be considered in patients with acute myelopathy and cardiovascular risk. Conservative management combined with rehabilitation can be a reasonable alternative in patients with complex anatomy and high surgical risk, although the functional prognosis remains reserved.