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6b - Answer: A patient with history of intracranial AVM came with Hyperreflexia

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

Learn more about this case by reading the case report below. Additional instruction is provided in the Case Summary section of the course.

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Case Report

HISTORY: History of intracranial AVM. Hyper-reflexia

TECHNIQUE:

Sagittal T1 weighted, sagittal T2 weighted, sagittal STIR, axial T1 weighted, and axial T2 weighted scans were performed through the cervical spine.

FINDINGS:
MRI cervical spine contrast:

The cervical spine is well aligned. Slight deformity of the C5 and C6 vertebral bodies likely on a degenerative basis. Mild narrowing of the C4-C5 and to a lesser extent C5-C6 disc spaces. The signal intensity of the bone marrow is within normal limits. There is T2 hyperintensity extending from the craniocervical junction to C3. On the postcontrast images, there is patchy enhancement in the right side of the cord at the C1-C2 level. There is minimal expansion of the
cord. Findings are new since the prior MRI.

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 thecal sac. Mild left neural foraminal narrowing secondary to uncovertebral hypertrophy.
At C5-C6, there is no connection spinal canal or neural foraminal narrowing.
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 stenoses.

The right internal carotid artery demonstrates a partial retropharyngeal course between the C2 and C5 levels.

IMPRESSION:

Evidence of myelitis involving the spinal cord from the craniocervical junction to C3. Findings are consistent with neuromyelitis optica in this patient with positive NMO/AQP4-IgG antibodies. Areas of patchy enhancement indicate active inflammation/demyelination.

Additional Report corresponding to the "Launch Case Part 2" images:

Ill-defined areas of abnormal T2/FLAIR hypersignal intensity are noted involving the left sided pons and inferior midbrain, floor of the 4th ventricle, and left sided inferior cerebellar peduncle (series 12, images 12 through 15). Associated diffusion restriction (series 3, image 54) and low ADC values (series 4, image 13) are demonstrated in the left inferior cerebellar peduncle indicative of acute ischemic changes. After injection of contrast, heterogenous areas of parenchymal vascular enhancement are seen in the Pons (dominantly left lower pons), floor of 4th ventricle and left inferior cerebellar peduncle (series 18, image 15) along with prominent anterior pontomesencephalic and left pontomedullary veins (series 17, image 84), in favor of a brain-stem arteriovenous malformation complicated with left inferior cerebellar peduncular infarct. Further angiographic examination of the posterior circulation is recommended for better mapping of the feeding arteries and draining veins, also possible embolization.

LESSON 3, TOPIC 3

Case Challenge: Spine MRI Cases - I-MED Study

Content reviewed: May 12, 2022