0:01

Let's have a look at this follow-up case of a

0:04

75-year-old man who was basically diplegic,

0:09

had very little motor control

0:12

of his lower extremities.

0:13

This is a patient who's been followed at Hopkins

0:16

for a considerable amount of time.

0:18

How do we decipher this scan?

0:20

Well,

0:20

we see that the patient has a lesion in the

0:23

spinal cord where there are areas of bright

0:27

signal intensity on T1-weighted scan and you

0:30

can see that they appear to

0:32

be serpigenous areas.

0:34

So these likely represent vessels that are

0:39

thrombosed with subacute blood products.

0:42

We see that there also is bright signal

0:44

intensity within the CONUS medullaris and the

0:47

patient has already undergone some procedure

0:49

which has ferromagnetic artifact.

0:52

So we want to obviously go into the electronic

0:54

medical record and try to figure out what's

0:56

going on with this individual.

0:58

Here we have the T2-weighted scan above the area of abnormality,

1:02

you see bright signal intensity

1:03

in the spinal cord. However,

1:06

below we have areas that are outside the spinal

1:09

cord as well as within the spinal cord.

1:12

You have hemorrhagic,

1:13

blood prox and potentially flow voids within

1:17

the spinal cord. On the STIR image, again,

1:22

we get a sense of these thrombosed vessels

1:25

along the periphery of the spinal cord.

1:28

We have the post-treatment effect with

1:32

ferromagnetic artifact as well as the bright

1:34

signal intensity in the spinal cord.

1:36

And then we have the unusual cord signal itself,

1:40

which has areas that likely

1:42

represent hemosiderin.

1:43

So this is a patient who's

1:45

already had hematomyelia,

1:48

that is hemorrhage in the spinal cord.

1:51

The post-contrast image may be useful in this

1:54

individual because now we see that

1:57

on post-contrast imaging.

2:00

There are some vascular structures that are

2:04

enhancing that were not bright previously.

2:08

So this area right here we're going to call a

2:10

thrombosed vein and that corresponds here.

2:14

However,

2:15

above it we see contrast-enhancing vessels that

2:20

are coursing on the surface of these spinal cord

2:23

that were not present on the pre-contrast.

2:25

And then we also have this horrible-looking

2:28

enhancement within the spinal cord itself.

2:31

And,

2:33

here again,

2:34

you see some of that enhancement that is showing

2:38

bright signal on the post-gad that was

2:40

not present on the pre-gad imaging.

2:43

Let's just take a quick look at one

2:45

of the axial T2-weight images.

2:48

And again,

2:49

we see that hemosiderin in blood vessels

2:52

as well as within the spinal cord.

2:54

We see the cord volume loss.

2:58

We see some metallic artifact.

3:00

Fact.

3:02

And again,

3:03

some areas of

3:06

blood products within the spinal cord as well as

3:12

within

3:15

the adjacent PIA. So what to do about this case?

3:22

So, this is a patient who had an arterial venous

3:26

malformation within the spinal cord,

3:28

a type two arteriovenous malformation,

3:31

intramedullary lesion in which there was

3:35

an attempt at thrombosing the nidus

3:41

and portions of it that were extramedullary.

3:45

Nonetheless,

3:46

the patient had hematomyelia into the spinal

3:51

cord, as seen by the hemosytrin,

3:53

and ultimately, the cord was severely damaged,

3:57

leading to the patient's diplodia.

4:01

So, type two arterial malformations, as opposed to

4:04

type one dural arteriovenous fistulas, present with

4:08

a catastrophic bleed in the spinal cord that

4:12

is associated with the hematomyelia

4:14

and not progressive myelopathy,

4:17

which is the typical presentation of patients

4:22

with dural or extra arteriovenous fistula.