Case: Spinal Cord Infarct
HIDEInteractive Transcript
0:01
One of the entities that one may be called upon to evaluate
0:06
the patient for in the spine is a spinal cord infarct.
0:10
These are incredibly uncommon and cause
0:13
a lot of anxiety because, frankly,
0:15
our pulse sequences to evaluate the spinal
0:18
cord for infarction as opposed to myelitis
0:22
have not yet reached mainstream as far as their quality.
0:26
This is a diffusion tensor imaging of the spinal cord
0:31
with the ADC map and T2-weighted scan.
0:36
Most institutions and private practices probably do not have
0:40
good pulse sequences for the evaluation for spinal cord
0:44
infarct with diffusion weighted imaging
0:47
or diffusion tensor imaging.
0:49
Here you can see on the diffusion tensor imaging, B 1000
0:54
map that there is bright signal intensity
0:57
in the spinal cord at the
1:00
C7-T1 level, which corresponds,
1:02
although not a very good quality image, with
1:05
dark signal intensity on the ADC map.
1:08
Now,
1:09
this would be the imaging findings that we would worry
1:12
about for spinal cord infarct. A word about this case,
1:17
you notice that there is decreased caliber to the
1:22
spinal cord through this area of infarction,
1:25
which is verified on the sagittal STIR image.
1:28
The sagittal STIR image does not show bright signal intensity
1:32
in this spinal cord. So initially, my evaluation said,
1:36
well, this is an old injury because we have myelomalacia, indicative
1:42
of an older injury because the caliber of the spinal cord is
1:46
decreased. However, given the diffusion weighted scan,
1:51
I had to worry about a superimposed infarction on
1:55
a previously injured spinal cord.
1:59
In point of fact.
2:00
This patient had acute symptoms.
2:02
So this is a little bit of a complicated case,
2:04
but suffice it to say that diffusion weighted imaging is
2:07
going to be our best means for identifying a spinal cord
2:11
infarct in those very rare instances in which you're called
2:14
upon to evaluate that in the emergency department.
2:19
This was an individual who had acute onset of paraparesis
2:25
and the CT scan of the cervical spine was unremarkable.
2:31
So this is what we would call the SCIWORA,
2:34
the cervical cord injury without radiographic abnormality.
2:40
On the MRI scan, however,
2:41
we see that from C4 through the upper C7 level,
2:45
we have abnormal signal intensity in the spinal cord and
2:48
you have surveyed ill-defined area of contrast enhancement.
2:53
So in this individual with an expanded spinal
2:56
cord and the abnormal signal and
3:00
faint enhancement,
3:01
you most likely be concerned about a myelitis or,
3:04
in the appropriate age group, a demyelinating disorder.
3:08
In this situation,
3:09
I would be descriptive about the abnormality and recommend that
3:13
there be correlation with CSF sampling in order to determine
3:18
whether or not there is an infectious markers in the CSF,
3:21
elevated white blood count,
3:23
as well as looking for demyelinating markers in the
3:28
cerebrospinal fluid. Well, this is a little bit of a trick case.
3:31
This patient's symptoms started abruptly,
3:35
and in the situation where you have abrupt onset of the
3:39
patient's symptoms, you have to consider a spinal cord infarct.
3:43
This is, in fact,
3:44
the same case as the previous one that I just demonstrated,
3:48
showing abnormal restricted diffusion.
3:51
This was the acute episode where the diffusion weighted
3:55
scan was not performed to identify a cord infarct.
4:00
But on the follow up examination, we did the DWI and
4:03
the cord was still bright in signal intensity on DWI,
4:07
although it did show the myelomalacic change. So, vast
4:11
majority of cases, we think of infectious or noninfectious
4:15
myelitis. We think of demyelinating disorder.
4:19
In this case, a longitudinally,
4:20
extensive transverse myelitis or longitudinally extensive lesion,
4:25
possibly from demyelination or inflammation.
4:28
And in that rare instance, a spinal cord infarct.
David M Yousem, MD, MBA
Professor of Radiology, Vice Chairman and Associate Dean
Johns Hopkins University
© 2024 Medality. All Rights Reserved.