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Introduction
4. Infammatory
Vasculitis
5. Infection
Infection rarely involves the spinal cord.
Systematic approach
Whenever there is an abnormality in the spinal cord, we need a systematic
approach to analyse the findings.
Clinical findings can be helpful but can be quite similar in most spinal cord
disorders.
On MR look for the following:
Is there enhancement?
Many diseases show some enhancement, but the most important thing is
that astrocytoma has to be included in the differential diagnosis.
common in:
MS
uncommon in:
common in:
Neuromyelitis Optica
uncommon in:
MS
Transverse involvement
Transverse images are very helpful in the differential diagnosis.
You need high resolution images.
Look for how much is involved (both halves or not), which part is involved and
what is the form of the involvement.
Brain abnormalities
In many cases of myelopathy there will also be brain abnormalities and these
can be a diagnostic clue to the diagnosis.
Multiple Sclerosis
form.
ADEM can relapse and progress to MS.
The partial form of transverse myelitis
The MRI of the brain shows periventricular lesions and a lesion in the corpus
callosum.
These locations are very specific for MS.
MS
Now what can we expect in the spinal cord of patients with MS.
It is like in the brain.
Frequently the lesions are focal like we see on the left image.
Less commonly there are diffuse abnormalities and then we have a tough
differential diagnosis which will include TM and NMO.
In long standing cases atrophy will be seen.
One third of MS patients will have spinal symptoms.
One third of patients have isolated spinal MS without any findings in the brain.
However pathologic studies have shown that 95% of MS patients have spinal
cord lesions, whether they have spinal symptoms or not.
MS in the cord
On transverse images MS lesions typically have a round or triangular shape and
are located posteriorly or laterally.
When MS lesions are active, they can enhance, but enhancement is not as
common as in the brain.
The enhancement patterns are non-specific.
You can see ring enhancement, intense and less-intense enhancement.
The less intense or vague enhancement is the most common pattern.
Atrophy in longstanding MS
Some say that spinal cord atrophy is specific for primary progressive MS (PPMS).
The atrophy correlates very well with the clinical disability.
It is more prominent in the upper part of the spinal cord.
Duration of the disease is the most important determinant of cord atrophy.
Neuromyelitis Optica
Brain lesions do occur and often are distinct from those seen in MS.
Demyelination of the spinal cord looks like transverse myelitis, i.e. often
extensive over 4 -7 vertebral segments and the full transverse diameter.
Female:male = 9:1
On the left images of a child who presented with unilateral neuritis optica.
Images of the brain were otherwise normal.
Continue with MRI of the spine.
Patients who have one episode of optic neuritis or myelitis and who test positive
for NMO-IgG are at high risk for developing the full spectrum of NMO.
One month later this child presented with acute transverse myelopathy, i.e.
bilateral symptoms.
The images show abnormal signal in the spinal cord with swelling and some
enhancement.
An astrocytoma could very well present with these images, but given the history
of an optic neuritis and the acute myelopathy, we do not think of a tumor.
This proved to be NMO and the Ig-test for NMO was positive.
In the original description of Devic's disease the optic neuritis and the
myelopathy were simultaneously, but now we know that this is not always the
case.
ADEM
ADEM
key facts:
In 50% of ADEM patients the anti-MOG IgG test is positive and supports
the diagnosis. This is antibody-reactivity against Myelin Oligodendrocyte
Glycoprotein (MOG).
ADEM
First look at the images of the brain and decide what is different from MS-lesions.
What is typical for ADEM and uncommon for MS is:
ADEM - follow up
The follow up MR shows that the cord has returned to normal again.
key facts:
Imaging findings:
o
Focal enlargement.
T2WI hyperintensity
Enhancement + / -.
Typical for TM is that on the initial MR the abnormalities are usually extensive
and less or completely resolved on follow up scans.
Longitudinal case series of TM reveal that approximately 1/3 of patients recover
with little to no sequelae, 1/3 are left with moderate degree of permanent
disability, and 1/3 have severe disabilities.
Spinal astrocytoma
Astrocytoma
As we have just seen, the major differential of the spinal cord diseases that we
have discussed so far is an astrocytoma.
Astrocytoma is a diffusely infiltrating tumor, that is not mass-like.
Usually there is some patchy enhancement.
On the left an astrocytoma in a 66 year old patient who presented with
progressive sensory complaints.
Biopsy revealed astrocytoma.
Continue with the follow up.
Multiple ependymomas
The other two common spinal cord tumors are ependymoma and
hemangioblastoma and they just look like a tumor.
They present as enhancing masses and will not cause a differential problem.
All other cord tumors are uncommon.
The images are of a patient with neurofibromatosis who has multiple
ependymomas.
They present as multiple enhancing masses.
Vascular
Arterial infarction
Spinal cord ischemia is typically seen as a complication of aortic aneurysm
surgery or stenting.
The images are of a patient who developed a paraparesis after stenting of an
aortic aneurysm.
Notice the high signal ventrally in the chord, which is typical for arterial
infarction.
On transverse images a typical snake-eye appearance can be seen.
Vasculitis
The images are of a child with headache, fever, hyperalgesia and numbness of
the left side of the body.
There is also abducens nerve palsy.
The images are non-specific with multiple focal lesions and probably the first
The lesions are located dorsally and one of the lesions is enhancing.
Now if this was infection or metastases it would be strange that not all lesions
enhance.
MS is still on our list.
Continue with the MR of the brain.
Idiopathic Vasculitis
On the CE-T1WI only one lesion shows enhancement.
The location of the lesions and the enhancement could very well fit to the
diagnosis of MS, but this proved to be vasculitis.
Vasculitis can be idiopathic, but is also seen in SLE, Sj?gren and Behcet.
Normally you think of vasculitis as a disease of the vessels in the brain, but all
vasculitis can be seen in the spine as well.
It produces MS-like images.
Spinal AVF
The most common vascular malformation of the spinal cord is the dural AVfistula.
It consist of an abnormal connection between the artery and the veins , which
can lead to increased venous pressure and predisposes the cord to ischemia and
less commonly to hemorrhage.
AVF's are mostly seen in the elderly population and are believed to be the result
of trauma.
An accurate diagnosis is important because these lesions may represent a
reversible cause of myelopathy.
Notice the high signal in the lower thoracic cord and the surrounding dilated
vessels on the T2WI.
On the enhanced T1WI there is subtle enhancement.
Another patient with myelopathy and dilated vessels surrounding the cord.
Notice the hypointense areas on the T2WI which represents hemorrhage.
Although beyond the scope of this article, the most common cause of
myelopathy is cord compression as seen in trauma, metastatic disease and
epidural hemorrhage.
This patient has a fracture with posterior displacement.
There is myelopathy due to traumatic cord compression.