Cord Lesion, T2 Hyperintense, Central



Cord Lesion, T2 Hyperintense, Central


Lubdha M. Shah, MD



DIFFERENTIAL DIAGNOSIS


Common



  • Syringomyelia


  • Multiple Sclerosis, Spinal Cord


  • Acute Transverse Myelitis, Idiopathic


  • Infarction, Spinal Cord


  • Type I DAVF


Less Common



  • Acute Disseminated Encephalomyelitis, Spinal Cord


  • Viral Myelitis


  • Cavernous Malformation, Spinal Cord


  • Astrocytoma, Spinal Cord


  • Central Spinal Cord Syndrome


  • Radiation Myelopathy


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • T2 hypointensity ± susceptibility artifact on gradient echo recalled sequences to indicate hemorrhagic products


  • Abnormal enlarged flow voids along the surface of the cord suggest a vascular lesion


Helpful Clues for Common Diagnoses



  • Syringomyelia



    • Expanded cord with dilated or beaded cystic cavity & surrounding gliosis/myelomalacia


    • Contrast important to exclude tumor in complex cavitary lesion


    • Primary: Associated basilar invagination, Chiari 1 or 2 malformation


    • Secondary: Seen in 25% of cord injury



      • Extensive MR signal change in superior spinal cord parenchyma is ancillary sign of disease advancement in clinically progressive post-traumatic syringomyelia


    • “Cloak-like” pain & temporary sensory loss with preservation of position sense, proprioception, light touch


  • Multiple Sclerosis, Spinal Cord



    • Peripheral T2 hyperintensity with central enhancement (acute/subacute) classic



      • < 2 vertebral segments in length


      • < 1/2 cross-sectional area of cord, usually dorsolateral aspect


      • Cord atrophy


      • Cervical cord most often involved


    • May occur in any portion of cord


    • Up to 33% may have isolated cord lesions



      • 90% have intracranial lesions


    • Oligoclonal bands in CSF in 90%


  • Acute Transverse Myelitis, Idiopathic



    • Both halves of the cord result in bilateral motor, sensory, & autonomic dysfunction



      • Defined sensory level


      • CSF pleocytosis or elevated IgG index


    • Long cord segment involvement (> 2 vertebral segments) with > 2/3 of cross-sectional area of cord


    • Central T2 hyperintensity with patchy eccentric enhancement


  • Infarction, Spinal Cord



    • Focal T2 hyperintensity in slightly expanded cord



      • Gray matter, adjacent white matter, or cross-sectional cord may be involved


      • Classically, the anterior horn cells show T2 hyperintensity


      • Focal hemorrhage seen as T1 hyperintensity/T2 hypointensity


      • Adjacent anterior vertebral body infarction


    • Thoracic cord most frequently involved because of arterial border zone


    • Restricted diffusion on DWI


    • Acute onset of myelopathy; motor signs predominantly


  • Type I DAVF



    • Enlarged T2 hyperintense distal cord with dilated pial veins



      • Intradural, extramedullary flow voids at level of conus


    • “Flame-shaped” edema spares cord periphery



      • Venous hypertension from pial vessel engorgement results in reduced tissue perfusion & cord ischemia


    • 80% patients are men in 5th or 6th decade presenting with progressive lower extremity weakness



      • Acute myelopathy due to venous thrombosis: Foix-Alajouanine syndrome


Helpful Clues for Less Common Diagnoses



  • Acute Disseminated Encephalomyelitis, Spinal Cord



    • Multifocal white matter lesions with little mass effect or vasogenic edema


    • Punctate, ring-shaped, or fluffy enhancement



    • Concomitant supratentorial involvement is characteristic



      • Cranial nerve involvement with ADEM to help differentiate from MS


    • Autoimmune process producing inflammatory reaction


    • Delay between clinical onset and appearance of imaging findings


  • Viral Myelitis



    • Either immune-mediated or direct viral invasion



      • Echovirus, Coxsackie, CMV, varicella-zoster, HSV, EBV, hepatitis


    • Central T2 hyperintensity with variable enhancement



      • Enlarged edematous cord with segmental continuous involvement


      • Central T1 hypointensity is higher than CSF


  • Cavernous Malformation, Spinal Cord



    • Well-defined lesion with hemorrhage of various ages


    • Speckled signal with peripheral T2 hypointense rim (hemosiderin)


    • Enhancement absent/minimal


    • No edema, unless acute hemorrhage


    • 50% thoracic, 40% cervical, 10% conus


  • Astrocytoma, Spinal Cord



    • T2 hyperintense enhancing infiltrating mass, expanding cord


    • Usually < 4 segments, holocord with pilocytic astrocytoma



      • Cervical > thoracic cord


    • Diffuse or partial enhancement


  • Central Spinal Cord Syndrome

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Aug 7, 2016 | Posted by in NEUROLOGY | Comments Off on Cord Lesion, T2 Hyperintense, Central

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