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Neuroradiology Case of the Week

Case 399

April 2009

Chandler Shyu, MD, MPH, and PL Westesson, MD, PhD, DDS

Clinical Presentation: Patient is a 34-year-old male with a history of weakness in his hands and feet.  MR exam was requested to evaluate for intramedullary lesion in his cervical spine.

Imaging Findings: Sagittal T1 images demonstrated mild cord expansion without abnormal signal. Sagittal GRE T2 images revealed abnormal intramedullary signal at the cord expansion site spanning C4-C7. Post-contrast T1 images revealed enhancement predominantly along the dorsal aspect of the abnormal cord.

Diagnosis: Cervical spine neurosarcoidosis

Differential Diagnosis: Metastasis, demyelinating disease, inflammatory myelitis, cord AVM.

Discussion: Sarcoidosis is a idiopathic non-caseating granulomatous disease that can affect multiple organ systems, including the central nervous system. In the spinal cord, sarcoid is generally seen in the intramedullary cord when located in the cervical or upper thorax spine. It tends to be located extramedullary and intradural at the lower spine.
     MR findings include focal or diffuse cord expansion with isointense T1, hyperintense T2, and leptomeningeal or peripheral enhancement pattern on post-contrast. However there is a wide differential with this imaging appearance, and definitive diagnosis is made by biopsy or presence of systemic disease in other organs.

References:

1. Ross J, Brant-Zawadzki M, Moore K, et al. Diagnostic Imaging: Spine. Amirsys 2004. Section 3:2; pgs 16-19.