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Neuroradiology Case of the Week
Case 288
Balasubramanya Kolar, MD and P-L Westesson, MD, PhD, DDS
Clinical
Presentation: Patient is a six-year-old boy who presented with bilateral areflexia, weakness and inability to walk. MR imaging of the brain and spine were done and patient was treated as a case of transverse myelitis. Subsequently after two years patient was reevaluated for persistent neurological deficits, bowel and bladder problems and residual motor weakness.
Imaging Findings: The initial cervical spine MRI showed signal hyperintensity on T2 weighted images from C5 to T1 levels (Fig. 1 and Fig. 2) causing slight expansion of the cord at these levels. The MRI brain and spine were unremarkable for any lesion. Follow up MRI showed focal atrophy of the cord (Fig. 3 and Fig. 4) at the same levels corresponding to the site of increased signal on the prior MRI.
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| Figure 1 |
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| Figure 2 |
Figures 1 & 2: Sagittal and axial T2 weighted image of cervical spine showing signal hyperintensity from C5 to T1 levels. |
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| Figure 3 |
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| Figure 4 |
| Figures 3 & 4: Sagittal and axial T2 weighted image showing focal atrophy of the cord at the same levels on follow up MRI. |
Diagnosis: Transverse myelitis with spinal cord atrophy
Discussion: Transverse myelitis is not a diagnosis, it is a condition of cord inflammation that occurs following a number of triggers (infective, inflammatory, and autoimmune) and is of unknown etiology [1].
Criteria for the diagnosis of ATM include: acutely developing paraparesis affecting motor and sensory systems as well as sphincters; spinal segmental level of sensory disturbance (excluding patients with patchy sensory deficit or Brown-Sequard syndrome); stable, nonprogressive clinical course [2]. History of previous radiation to the spine within the past 10 years or the presence of abnormal flow voids on the surface of the spinal cord consistent with an arteriovenous malformation have to be considered as exclusion criteria.
Spinal cord MRI abnormalities are seen frequently in transverse myelitis. Mild fusiform swelling is the most frequently seen abnormality; however, a wider range of abnormalities has been described, particularly hyperintensity of the anterior portion of the cord consistent with the anterior horns [1].
Magnetic resonance imaging scans have also revealed diffuse hypointense lesions in T1 which became hyperintense on T2 weighted images and patchy hyperintense lesions in both T1 and T2 sequences suggesting hemorrhage. There may also be patchy enhancement with gadolinium. The signal changes extend at least three segments above the sensory level and the extent of MRI signal alterations usually correlated with the outcome. MRI changes extending to 10 spinal segments or more usually correlated with poor outcomes [3].
The progression of these findings to spinal cord atrophy has also been described. This has also been associated with poor recovery of the patients [4].
References:
- Wilmshurst JM, Walker MC, Pohl KR. Rapid onset transverse myelitis in adolescence: implications for pathogenesis and prognosis. Arch Dis Child. 1999 Feb;80(2):137-42. [Medline]
- Berman M, Feldman S, Alter M, Zilber N, Kahana E. cute transverse myelitis: incidence and etiologic considerations. Neurology. 1981 Aug;31(8):966-71. [Medline]
- Misra UK, Kalita J, Kumar S. A clinical, MRI and neurophysiological study of acute transverse myelitis. J Neurol Sci. 1996 Jun;138(1-2):150-6. [Medline]
- Shen WC, Lee SK, Ho YJ, Lee KR, Mak SC, Chi CS. MRI of sequela of transverse myelitis. Pediatr Radiol. 1992;22(5):382-3. [Medline]
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