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Case 37 - Spinal Cord Infarct

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One of the entities that one may be called upon to evaluate

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the patient for in the spine is a spinal cord infarct.

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These are incredibly uncommon and cause

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a lot of anxiety because, frankly,

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our pulse sequences to evaluate the spinal

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cord for infarction as opposed to myelitis

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have not yet reached mainstream as far as their quality.

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This is a diffusion tensor imaging of the spinal cord

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with the ADC map and T2-weighted scan.

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Most institutions and private practices probably do not have

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good pulse sequences for the evaluation for spinal cord

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infarct with diffusion weighted imaging

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or diffusion tensor imaging.

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Here you can see on the diffusion tensor imaging, B 1000

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map that there is bright signal intensity

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in the spinal cord at the

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C7-T1 level, which corresponds,

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although not a very good quality image, with

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dark signal intensity on the ADC map.

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Now,

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this would be the imaging findings that we would worry

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about for spinal cord infarct. A word about this case,

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you notice that there is decreased caliber to the

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spinal cord through this area of infarction,

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which is verified on the sagittal STIR image.

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The sagittal STIR image does not show bright signal intensity

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in this spinal cord. So initially, my evaluation said,

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well, this is an old injury because we have myelomalacia, indicative

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of an older injury because the caliber of the spinal cord is

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decreased. However, given the diffusion weighted scan,

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I had to worry about a superimposed infarction on

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a previously injured spinal cord.

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In point of fact.

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This patient had acute symptoms.

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So this is a little bit of a complicated case,

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but suffice it to say that diffusion weighted imaging is

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going to be our best means for identifying a spinal cord

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infarct in those very rare instances in which you're called

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upon to evaluate that in the emergency department.

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This was an individual who had acute onset of paraparesis

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and the CT scan of the cervical spine was unremarkable.

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So this is what we would call the SCIWORA,

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the cervical cord injury without radiographic abnormality.

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On the MRI scan, however,

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we see that from C4 through the upper C7 level,

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we have abnormal signal intensity in the spinal cord and

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you have surveyed ill-defined area of contrast enhancement.

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So in this individual with an expanded spinal

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cord and the abnormal signal and

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faint enhancement,

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you most likely be concerned about a myelitis or,

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in the appropriate age group, a demyelinating disorder.

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In this situation,

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I would be descriptive about the abnormality and recommend that

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there be correlation with CSF sampling in order to determine

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whether or not there is an infectious markers in the CSF,

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elevated white blood count,

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as well as looking for demyelinating markers in the

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cerebrospinal fluid. Well, this is a little bit of a trick case.

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This patient's symptoms started abruptly,

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and in the situation where you have abrupt onset of the

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patient's symptoms, you have to consider a spinal cord infarct.

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This is, in fact,

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the same case as the previous one that I just demonstrated,

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showing abnormal restricted diffusion.

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This was the acute episode where the diffusion weighted

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scan was not performed to identify a cord infarct.

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But on the follow up examination, we did the DWI and

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the cord was still bright in signal intensity on DWI,

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although it did show the myelomalacic change. So, vast

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majority of cases, we think of infectious or noninfectious

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myelitis. We think of demyelinating disorder.

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In this case, a longitudinally,

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extensive transverse myelitis or longitudinally extensive lesion,

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possibly from demyelination or inflammation.

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And in that rare instance, a spinal cord infarct.

Report

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Neuroradiology

Head and Neck

Emergency

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