Objective: To characterize the imaging features, pathological basis, and diagnostic approach to the spinal cord “snake-eyes sign”, with particular emphasis on its relevance to acute spinal cord ischemia.

Methods: The clinical presentation, neurological examination, imaging findings, and laboratory data of a woman with acute-onset myelopathy and the “snake-eyes sign” on cervical spinal cord MRI was retrospectively reviewed, and the imaging characteristics and differential diagnosis were discussed in conjunction with the literature.

Results: The patient developed sudden back pain followed within hours by quadriparesis and urinary retention. Cervical spinal cord MRI showed an intramedullary lesion at the C5-7 levels, with bilateral symmetric round hyperintensities in the anterior horns on axial images, consistent with the “snake-eyes sign”. Spinal angiography showed poor visualization of the anterior spinal artery. Cerebrospinal fluid routine and biochemical studies were unremarkable, and relevant immunological antibody tests were negative. Anterior spinal artery syndrome was considered the leading diagnosis. Follow-up MRI at 3 months showed a reduction in lesion extent.

Conclusion: The “snake-eyes sign” indicates selective involvement of the anterior horns but is not specific for spinal cord ischemia. In patients with acute, rapidly progressive motor, sensory, and autonomic dysfunction, anterior spinal artery territory ischemia should be strongly considered, while the clinical course, MRI, vascular imaging, cerebrospinal fluid findings, and immunological studies should be integrated to distinguish ischemic lesions from compressive, inflammatory, and other myelopathies.