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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