Wk 3, Case 4 - Review

Patient History
70 yo woman with visual disturbance, b/l cataracts, HTN, HLD, CAD (MI s/p stent '13), who presents to ED with 3d of gradual onset right-sided weakness and numbness.

Findings
MR brain:

No diffusion restriction is identified. Redemonstration of the foci of T2/FLAIR hyperintensity within the central pons and midbrain. Mild periventricular and subcortical white matter T2/FLAIR hyperintensity , nonspecific and likely sequelae of chronic microvascular ischemic changes . Unchanged appearance of the angle of vessels along the right inferior frontal lobe. Chronic infarct of the left cerebellum. The ventricles are normal in size and symmetric. The basilar cisterns are patent. No extra-axial fluid is identified. No intracranial hemorrhage is present. No mass effect or midline shift is identified. The major intracranial vascular flow voids are preserved. No abnormal parenchymal or meningeal enhancement is present. The paranasal sinuses are clear. No mastoid effusion is identified.

MR orbits:

There is mild persistent hyperintensity in the left optic nerve, as best seen on the coronal T2-weighted sequences. No abnormal enhancement is identified. The extraocular muscles are normal in size and symmetric. Bilateral lacrimal glands are unremarkable. No proptosis is present.

MR cervical spine:

Focus of apparent enhancement is identified in the right aspect of the anterior medulla on the sagittal post contrast sequences, not appreciated on the axial images and related to partial volume averaging from adjacent enhancing vessels. Areas of T2/FLAIR hyperintensity are identified within the central cord extending from the craniocervical junction to approximately C3-C4, smaller in craniocaudal and axial extension compared to prior exam (previously extended to level of C4-C5 ). There is persistent ill-defined patchy enhancement in the upper spinal cord at the level of C2 . No additional abnormal signal intensity is identified in the spinal cord. Mild degenerative changes in the cervical spine appear unchanged. Partial retropharyngeal course of the internal carotid arteries. Mildly prominent adenoid tissue.

Impressions
Multifocal brainstem areas of abnormal signal intensity without enhancement. Chronic small vessel ischemic changes in the white matter. 2. Long segment intramedullary lesion involving the upper cervical spinal cord and cervicomedullary junction with mild degree of enhancement compared to prior exam.

Findings
MRI cervical spine with contrast:

Limited study due to motion artifact.Compare to the prior study, there is a considerable interval increase in the extent of T2 hyperintensity in the upper cervical spinal cord, which is now extending from the medulla to the level of C6. Also, there is slight interval increased expansion of the spinal cord. In the post contrast study, there has been significant interval increase in the abnormal enhancement, which has also increased in craniocaudal extent, now extending from the craniocervical junction to C4-C5 level.The cervical spine is anatomically aligned. Decreased vertebral body height at C5-C6, unchanged. Narrowing of C4-C5 and C5-C6 disc space. No suspicious abnormal signal intensity of the bone marrow on STIR sequence.At C2-C3, there is no significant spinal canal or neural foraminal stenosis.At C3-C4, there is no significant spinal canal or neural foraminal stenosis.At C4-C5, there is small disc bulge indenting the ventral thecal sac and minimal ligamentum flavum thickening, contributing to mild narrowing of the spinal canal. Mild bilateral neural foramina narrowing secondary to uncovertebral hypertrophy.At C5-C6, there is no significant spinal canal stenosis. Mild ligamentum flavum thickening. No substantial narrowing of the neural foramina.At C6-C7, there is no significant spinal canal or neural foraminal stenosis.At C7-T1, there is no significant spinal canal or neural foraminal stenosis.Retropharyngeal course of the distal right common carotid artery.

MRI thoracic spine with contrast:

Limited study due to motion artifact, with severe limitations of the axial images of the thoracic spine.No definite abnormal signal intensity within the thoracic spinal cord. No definite abnormal enhancement is detected.Scoliosis of the thoracic spine to the left. Slight increase in kyphotic curvature of the thoracic spine, unchanged. The vertebral body and disc height is preserved. The no suspicious abnormal signal intensity of the bone marrow on STIR sequence.No substantial narrowing of the spinal canal or neural foramina. No evidence of spinal cord compression.Conus medullaris terminated normally L1. The signal intensity of the conus medullaris is within normal limits.

Impressions
Limited study due to motion artifact, especially of the thoracic spine compared to the prior MRI, there is considerable interval progression of the inflammatory disease in the cervical spinal cord. Interval increase in the extent of T2 hyperintensity in the upper cervical spinal cord which is now extending from the medulla to the level of C6.

Slight interval increased expansion of the cervical spinal cord. Interval progression of the enhancement in the upper cervical spinal cord, extending from the craniocervical junction to C4-C5 level. No definite abnormal signal intensity or enhancement within the thoracic spinal cordMild degenerative changes of the cervical spine. No substantial narrowing of the spinal canal or neural foramina.