Normally you think of vasculitis as a disease of the vessels in the brain, but all vasculitis can be seen in the spine as well. It produces MS-like images.
The most common vascular malformation of the spinal cord is the dural AV-fistula. It consist of an abnormal connection between the artery and the veins , which can lead to increased venous pressure and predisposes the cord to ischemia and less commonly to hemorrhage. AVF's are mostly seen in the elderly population and are believed to be the result of trauma. An accurate diagnosis is important because these lesions may represent a reversible cause of myelopathy.
Notice the high signal in the lower thoracic cord and the surrounding dilated vessels on the T2WI. On the enhanced T1WI there is subtle enhancement. Another patient with myelopathy and dilated vessels surrounding the cord. Notice the hypointense areas on the T2WI which represents hemorrhage. Although beyond the scope of this article, the most common cause of myelopathy is cord compression as seen in trauma, metastatic disease and epidural hemorrhage. This patient has a fracture with posterior displacement.
There is myelopathy due to traumatic cord compression. Another case of cord compression in a patient who was treated with anticoagulantia. There is myelopathy as a result of compression by a dorsally located epidural hemorrhage. The most common cause of cord compression is metastatic disease. Notice the abnormal signal in the vertebral body as a result of a metastasis which extends into the vertebral canal.
Differential Diagnosis in Neuroimaging: Spine
Differential diagnosis Demyelinating diseases The first question is usually is it MS? Does it look like spinal cord MS and does the brain look like MS. If both halves of the cord are involved than think of Transverse Myelitis TM which is not a specific diagnosis, but merely a reaction of the cord to various autoimmune and infectious stimuli. Tumor The major differential of demyelinating diseases is an astrocytoma, especially if there is swelling and some enhancement of the cord and when the symptoms are more slowly progressive.
The other common spinal cord tumors like ependymoma and hemangioblastoma do not cause differential diagnostic problems, because in most cases they just look like a tumor.
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Metastases to the cord are very uncommon. Vascular Acute ischemia is typically seen as a complication of aortic aneurysm surgery or catheterisation. Cord ischemia due to venous hypertension or arterial steal can be seen in vascular malformations like AV-fistula.
So always look for abnormal vessels around the cord. Infammatory Vasculitis Infection Infection rarely involves the spinal cord. Systematic approach Whenever there is an abnormality in the spinal cord, we need a systematic approach to analyse the findings. On MR look for the following: Short or Long segment? In MS there is typically a short segment involved, i. In other diseases like Transverse Myelitis, NMO and ischemia there is usually a long segment involved. How much of the cord is involved on tranverse images? Partial involvement is typically seen in MS.
Location of the involvement on transverse images? Use high resolution transverse images to detect the location within the cord. Is it posterior like in MS, vitamin B12 deficiensy, lateral like in MS or anterior like in arterial infarction. Is the cord swollen? Is there enhancement? Many diseases show some enhancement, but the most important thing is that astrocytoma has to be included in the differential diagnosis.
Short or long segment involvement Short segment involvement common in: MS uncommon in: Transverse myelitis - partial form Long segment involvement common in: Transverse myelitis - complete form Neuromyelitis Optica uncommon in: MS.
Transverse involvement Transverse images are very helpful in the differential diagnosis. MS typically is triangular in shape and mostly located dorsally or laterally. However MS can look like anything and may uncommonly involve the whole transverse diameter or only the anterior part. Ischemia as a result of arterial infarction is typically located in the anterior parts, but may involve the entire transverse diameter.
Transverse myelitis and Neuromyelitis optica typically involve the whole cord. Multiple lesions disseminated over time and space. Brain lesions are typically in periventricular, subcortical and cerebellar white matter and also in brainstem and corpus callosum. CSF: monoclonal bands. NMO preferentially affects the optic nerve and spinal cord. Brain lesions do occur and often are distinct from those seen in MS.
Demyelination of the spinal cord looks like transverse myelitis, i. The location of the brain lesions in NMO is only around the ventricles. The images show abnormal signal around the third and frontal horns of the lateral ventricles. Mostly seen in young children. On the left images of a teenage child with a typical history: Three weeks after respiratory infection sudden onset of neurological symptoms.
Dysarthria, dysphagia, tetraplegia. Eye movement disturbance and impairment in consciousness. First look at the images of the brain and decide what is different from MS-lesions.
DIFFERENTIAL DIAGNOSIS IN NEUROIMAGING: SPINE
Involvement of the basal ganglia. The follow up MR shows that the cord has returned to normal again. Focal enlargement. These patients are at risk of developing MS. Diseases associated with Transverse Myelitis Transverse myelitis may occur in isolation or in the setting of another illness.
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Family history of MS. Brain lesions on MR. Oligoclonoal bands in CSF. When there is enhancement, it can be difficult to differentiate TM from an astrocytoma. Meyers, Differential Diagnosis in Neuroimaging: Head and Neck is a stellar guide for identifying and diagnosing head and neck disease based on location and neuroimaging results.
The succinct text reflects more than 25 years of hands-on experience gleaned from advanced training and educating residents and fellows in radiology, neurosurgery, and otolaryngology. Meyers's lengthy career, presenting an unsurpassed visual learning tool. The distinctive 'three-column table plus images' format is easy to incorporate into clinical practice, setting this book apart from larger, disease-oriented radiologic tomes. This layout enables readers to quickly recognize and compare abnormalities based on more than 1, high-resolution images. Chapters cover skull imaging, temporal bone imaging, orbital imaging, paranasal imaging, suprahyoid neck imaging, and infrahyoid neck imaging, for a full spectrum of head and neck pathologies.
This visually rich resource is a must-have diagnostic tool for residents, fellows, and practitioners in radiology, otolaryngology-head and neck surgery, and neurosurgery. The highly practical format makes it ideal for daily rounds, as well as a robust study guide for physicians preparing for board exams. Yes, I would like to receive email newsletters with the latest news and information on products and services from Thieme Medical Publishers, Inc and selected cooperation partners in medicine and science regularly about once a week.
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