0:00

All right, so this may not be the top one or

0:03

two case that I've ever seen,

0:05

but this ranks in the top ten for sure.

0:08

So let's look at this lesion.

0:09

So here we are with a patient who is Hispanic,

0:13

who had new onset of

0:18

interosseous muscle weakness in the hands and

0:21

was not able to open a can and was complaining

0:25

about weakness as far as the grip strength.

0:28

Here we have a T1-weighted scan,

0:31

and what one sees is an abnormality in the

0:33

central aspect of the spinal cord,

0:36

and it is opposite the 2, 3, 4, 5, C5-6 disc level.

0:42

On the T2-weighted scan,

0:44

we see the lesion appears to be cystic and has

0:48

surrounding edema, and is clearly an

0:52

intradural intramedullary lesion.

0:55

You can see the CSF narrowing at the level

0:57

of the widened spinal cord.

0:59

And here we see it on the STIR images.

1:03

And this was a solitary lesion.

1:06

If we look at the post-gadolinium enhanced scan...

1:11

and I will mag this up,

1:14

you see the lesion has a periphery

1:18

of contrast enhancement.

1:20

The curious feature here is how small this

1:23

is in association with the spinal cord.

1:27

So, could this be a metastasis?

1:30

It could be a metastasis.

1:31

We usually do not see ring-enhancing lesions

1:34

of this type in a spinal cord for a metastatic disease.

1:38

The other etiologies that we would think about

1:40

would be demyelinating disorder.

1:42

This was a solitary lesion,

1:44

and

1:46

the ring enhancement in the spinal cord

1:48

is unusual, but could be seen as well.

1:51

So when we start thinking, all right, vascular, infectious...

1:54

We'll come back to traumatic, acquired, metabolic

1:56

idiopathic, neoplastic. Congenital lesion?

1:59

Not really.

2:00

Doesn't work with the contrast enhancement.

2:02

Drug-related? Unlikely.

2:04

Not really in a radiation zone because the bone

2:08

marrow would be bright in signal intensity.

2:10

So I want to drill down for just a

2:13

moment on the T2-weighted scan.

2:18

What we see here is a very curious

2:21

little central dot amidst the

2:26

cystic lesion,

2:27

and that may correspond to a small area of

2:34

enhancement eccentrically in the posterior

2:38

aspect of the cord lesion.

2:39

Let's see whether I can see this on the

2:42

axial post-contrast scans as well.

2:46

So this is axial.

2:49

So basically it looks like peripheral

2:53

enhancement. This little dot, however,

2:56

was the key to the diagnosis,

2:57

because based on this little dot in the

3:00

cystic lesion in the spinal cord,

3:02

I suggested the possibility of cysticercosis.

3:06

And indeed, that is the final diagnosis for this case.

3:09

That represents the scolex of an active cysticercus lesion

3:15

within the spinal cord. And as you recall,

3:19

this is due to some of the dietary habits

3:21

of some of the Hispanic population, in particular.

3:25

Although it can occur anywhere in the world.

3:28

So this was cysticercosis with an active cysticercus lesion,

3:33

with a scolex seen on the T2-weighted scan

3:38

as an infectious myelitis.