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Case Challenge: Spine MRI Cases


Spine MRI Case Challenge Pre-Course Activities
2 topics

25b - Answer: History of multiple myeloma

David Yousem MBA, MD
David M Yousem, MBA, MD
Professor of Radiology, Vice Chairman and Associate Dean
Includes DICOM files

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Watch Dr. David Yousem review this case and similar cases on chronic inflammatory demyelinating polyneuropathy


Case Report

HISTORY: History of multiple myeloma.

RESULT:  Study: MRI brain without and with contrast.
MRI of the cervical spine with and without contrast.
MRI of the thoracic spine with and without contrast.
MRI lumbar spine with and without contrast.

Clinical Information: History of multiple myeloma. Known chronic inflammatory demyelinating polyneuropathy. Mass lesion on CT.

Comparison: CT head from 11/26/2010, CT abdomen and pelvis from 5/20/2010, CT thorax from 7/27/2009 and MRI lumbar spine from 1/5/2006

Sequences: Axial T1, axial T2, axial  STIR; diffusion-weighted imaging; axial, coronal and sagittal T1 post gadolinium.
Multiplanar T1, T2 and FLAIR sequences through the entire spine with and without IV contrast.

FINDINGS:

MRI brain:

There is a circular, well-defined, ring-enhancing mass lesion centered in the right thalamus measuring 2.3 x 2.5 x 2.6 cm AP by transverse by craniocaudal. The mass has a thick enhancing wall, thicker in the lateral aspect and demonstrates restricted diffusion. There is substantial perilesional vasogenic edema with resultant mass effect, effacement of the right lateral ventricle and approximately 8 mm of the right to left midline shift.

There are a few small foci of periventricular and subcortical white matter change, nonspecific in appearance but likely to be due to cerebrovascular small vessel disease.

The vascular flow-voids are present.  The craniocervical junction is normal.  The pituitary gland is normal in size.  The paranasal sinuses and mastoid air cells are well-aerated. Globes and retro-orbital structures appear within normal limits.  Osseous structures demonstrate normal cortical and medullary signal without evidence for lesion.

Cervical spine:

The alignment of the cervical spine is within normal limits. The marrow signal and vertebral body heights are normal without evidence for fracture or aggressive appearing osseous lesions.   The spinal cord signal and volume are normal.

There is extensive masslike soft tissue thickening of the nerve roots bilaterally, compatible with the patient's known history of chronic inflammatory demyelinating polyneuropathy. Multilevel degenerative disc disease noted.
C2-C3: Small central disc osteophyte complex. No significant canal or neuroforaminal stenosis.
C3-C4: Moderate-sized disc osteophyte complex which mildly indents the ventral surface of the cord. Mild bilateral uncovertebral spurring and facet joint arthropathy. This results in mild canal and mild bilateral neuroforaminal stenosis.
C4-C5: Small disc osteophyte complex. Mild bilateral uncovertebral spurring and facet joint arthropathy. This results in mild bilateral neuroforaminal stenosis.
C5-C6: Mild bilateral uncovertebral spurring. This results in mild bilateral neuroforaminal stenosis.
C6-C7: No significant canal or neuroforaminal stenosis.
C7-T1: No significant canal or neuroforaminal stenosis.

Thoracic spine:
The alignment of the thoracic spine is within normal limits. The marrow signal and vertebral body heights are normal without evidence for fracture or aggressive appearing osseous lesions.  The spinal cord signal and volume are normal.

There is extensive mass-like soft tissue thickening of the nerve roots bilaterally, compatible with the patient's known history of chronic inflammatory demyelinating polyneuropathy.

There is mild multilevel degenerative disc disease throughout the thoracic spine. This is most noticeable at T2-T3 where there is a moderate-sized right paracentral disc protrusion which results in mild right-sided neuroforaminal stenosis and moderate lateral recess stenosis and at T7-T8 where there is a moderate-sized central disc extrusion which
ventrally indents the cord and results in mild canal narrowing but no significant cord compromise. Nonetheless there is minimal cord signal abnormality at the level of this disc herniation without cord enlargement No significant canal or neuroforaminal stenosis at any other level.

Lumbar spine:
Appearances are stable from the prior MRI from 1/5/2006.
There is marked thickening of the nerve roots extending from L1 inferior without abnormal enhancement. The CSF is nearly completely effaced from L1 to L5 due to the nerve root thickening. In addition, there are innumerable non- enhancing T2 hyperintense masses along the exiting nerve roots in both psoas muscles, in the region of the sacral plexus, and along the visualized intercostal nerves.

There is slight anterolisthesis of L5 on S1. Otherwise, the vertebral bodies and articular facets are in normal anatomic alignment. The marrow is heterogeneous in signal intensity. The vertebral body heights are maintained. There is multilevel degenerative disc disease. The conus medullaris has normal signal intensity and terminates at L1-2.


At the T12-L1 level, the central canal and neural foramina are patent.
At the L1-2 level, there is marked thickening of the nerve roots with almost complete effacement of the CSF within the central canal. In addition, there are mild facet hypertrophic changes without significant
foraminal compromise.
At the L2-3 level, there is again marked thickening of the nerve roots with near complete effacement of the CSF. The neural foramina are patent.
At the L3-4 level, there is again marked thickening of the nerve roots with near complete effacement of the CSF. In addition, there is a mild disc bulge which indents the ventral thecal sac. There are also mild facet hypertrophic changes without significant foraminal compromise.
At the L4-5 level, there is again marked thickening of the nerve roots with near complete effacement of the CSF. In addition, there is a small disc bulge with associated right central annular tear. There are also mild facet hypertrophic changes without significant foraminal compromise.
At the L5-S1 level, there is thickening of the nerve roots. There is a mild disc bulge and mild facet hypertrophic changes without significant central canal or foraminal compromise. There is a small cyst in the lower pole of the left kidney.

IMPRESSIONS:

  1. Ring-enhancing lesion centered in the right thalamus with extensive perilesional vasogenic edema. Given the reduced diffusivity and thick enhancing wall, appearances are more consistent with an abscess then neoplastic lesion. However, a hypercellular tumor can result in this appearance. As such clinical correlation is advised to differentiate
    these entities.
  2. Substantial perilesional vasogenic edema with resultant mass effect, effacement of the right lateral ventricle and approximately 8 mm of the right to left midline shift.
  3. Extensive masslike soft tissue thickening of the nerve roots. Findings are likely compatible with the patient's known history of chronic inflammatory demyelinating polyneuropathy.
  4. Multilevel degenerative disc disease, as described above.

LESSON 6, TOPIC 15

Case Challenge: Spine MRI Cases

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