Intramedullary Lesion, T2 Hyperintense, T1 Isointense



Intramedullary Lesion, T2 Hyperintense, T1 Isointense


Lubdha M. Shah, MD



DIFFERENTIAL DIAGNOSIS


Common



  • Multiple Sclerosis, Spinal Cord


  • Neuromyelitis Optica


  • Secondary Acute Transverse Myelitis


  • Acute Transverse Myelitis, Idiopathic


  • Contusion-Hematoma, Spinal Cord


  • Ependymoma, Cellular, Spinal Cord


  • Astrocytoma, Spinal Cord


  • Type I DAVF


Less Common



  • Hemangioblastoma, Spinal Cord


  • ADEM, Spinal Cord


  • Infarction, Spinal Cord


  • Viral Myelitis


Rare but Important



  • Metastases, Spinal Cord


  • Abscess/Myelitis, Spinal Cord


  • Vitamin B12 Deficiency, Spinal Cord


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Evaluate supratentorially, including cranial nerves


  • Hemorrhagic products & flow voids can be seen in certain lesions


Helpful Clues for Common Diagnoses



  • Multiple Sclerosis, Spinal Cord



    • T1 hypointensity may represent axonal loss, gliosis, white matter atrophy, & therefore motor disability


    • Cervical cord T1 relaxation time may be influenced by tissue damage upstream (i.e., cerebral damage)


    • Well-circumscribed T2 hyperintense lesions (complete demyelination) vs. ill-defined (partial demyelination)


    • Wedge-shaped lesions with apex directed centrally


  • Neuromyelitis Optica



    • Revised diagnostic criteria (99% sensitive, 90% specific)


    • Myelitis: Longitudinally extensive cord lesion, 3 or more segments in length


    • Optic neuritis


    • Onset brain MR nondiagnostic for MS


    • Seropositivity for neuromyelitis optica immunoglobin G



      • Targets aquaporin 4 water channel


  • Secondary Acute Transverse Myelitis



    • T2 hyperintense lesion with mild cord expansion


    • No significant enhancement


    • Mild T1 hyperintensity due to petechial hemorrhage


    • Etiologies: Collagen vascular disease, infectious/post-infectious, post-vaccination, post-irradiation, AVM, paraneoplastic


  • Acute Transverse Myelitis, Idiopathic



    • Smooth cord expansion < T2 signal abnormality


    • T2 hyperintensity more than 2 vertebral segments in length


    • Central gray matter surrounded by edema, “central dot sign”


  • Contusion-Hematoma, Spinal Cord



    • Acute contusion: T1 iso-/hypointense, T2 hyperintense with cord swelling


    • Hemorrhage T1 hyperintense with metHB, blooming on GRE sequences


    • ± Traumatic disc herniation, osseous or vascular injury


  • Ependymoma, Cellular, Spinal Cord



    • T2 hyperintense, T1 iso-/slightly hypointense


    • Polar & intratumoral cysts (50-90%)


    • Syrinx


    • Hemosiderin cap (20-64%)


    • Central canal widening (20%) & posterior vertebral scalloping


  • Astrocytoma, Spinal Cord



    • T2 hyperintense, solid portion T1 iso-/hypointense


    • Usually < 4 segments


    • Diffuse tumor infiltration, absence of hemorrhage, & intrinsic neoplastic syrinx cavity favor astrocytoma over ependymoma


    • Concurrent combination of intramedullary cord tumor & nerve sheath tumor is highly suggestive of NF1


  • Type I DAVF



    • Flame-shaped central edema spares the periphery


    • Low peripheral T2 signal is compatible with venous hypertensive myelopathy


    • Cord is enlarged & T1 hypointense



    • Multiple small vascular flow voids are seen on the cord pial surface


    • ± Patchy cord enhancement


    • Most commonly at level of conus


Helpful Clues for Less Common Diagnoses



  • Hemangioblastoma, Spinal Cord



    • Small lesions T2 hyperintense/T1 hypointense


    • Syrinx > 50%, hyperintense to CSF


    • Lesions > 2.5 cm show flow voids


    • ± Peritumoral edema


  • ADEM, Spinal Cord



    • Multifocal T1 hypointense/T2 hyperintense lesions with slight cord swelling


    • Little mass effect or edema


    • Concomitant brain involvement


  • Infarction, Spinal Cord



    • T2 hyperintensity involving the gray matter ± adjacent white matter


    • Increased T2 signal in the adjacent anterior vertebral body or in deep medullary portion near endplate


    • Cord enlargement in acute phase


    • More common in thoracic cord because of arterial border zone


  • Viral Myelitis



    • Expanded cord with T1 hypointensity & diffuse T2 hyperintensity


    • Long, contiguous segmental involvement


    • Acute myelopathy


Helpful Clues for Rare Diagnoses



  • Metastases, Spinal Cord



    • Enlarged cord with diffuse T2 hyperintensity


    • Rarely, syrinx or hemorrhagic products (i.e., thyroid, melanoma)


    • Well-circumscribed < 1.5 cm enhancing lesion


  • Abscess/Myelitis, Spinal Cord



    • Abscess core appears T1 hypointense/T2 hyperintense with surrounding edema


    • Idiopathic or hematogenous source in adults; direct extension from dysraphism in children


  • Vitamin B12 Deficiency, Spinal Cord



    • Axial T2 show “upside-down V-shaped” hyperintensity along dorsal columns


    • Accumulation of methylmalonic acid thought to cause myelin toxicity


    • Subacute combined degeneration also occurs in the setting of some types of severe anemia


    • Neurologic findings may precede the anemia


    • Treatment with parenteral B12 may improve symptoms, but imaging abnormalities may not completely resolve



SELECTED REFERENCES

1. Wingerchuk DM et al: Revised diagnostic criteria for neuromyelitis optica. Neurology. 66(10):1485-9, 2006

2. Vaithianathar L et al: Magnetic resonance imaging of the cervical spinal cord in multiple sclerosis—a quantitative T1 relaxation time mapping approach. J Neurol. 250(3):307-15, 2003

3. Losseff NA et al: T1 hypointensity of the spinal cord in multiple sclerosis. J Neurol. 248(6):517-21, 2001

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Aug 7, 2016 | Posted by in NEUROLOGY | Comments Off on Intramedullary Lesion, T2 Hyperintense, T1 Isointense

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