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IDEM Infectious and Inflammatory Abormalities

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Well, up till now we have discussed the neoplastic category of

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diseases with schwannomas and meningiomas dominating.

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We've talked about congenital lesions and discussed

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various cysts, as well as lipomas and the various

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congenital lesions including epidermoids and dermoids.

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We also discussed the entities associated with

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vascular malformations of the spinal cord.

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I want to conclude this section with some discussion

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about infectious inflammatory etiologies,

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the so-called "I" of VITAMIN C and D.

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So within the infectious inflammatory etiologies, we're

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usually talking about some form of meningitis or neuritis.

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And this is usually manifested as nerve root enhancement

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of the cauda equina nerve roots and there are

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various etiologies of that enhancement.

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We're going to start off by talking about

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infectious inflammatory lesions.

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You can have enhancement of the nerve roots purely

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on the basis of operative irritation.

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This is what we sometimes call arachnoiditis,

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or adhesive arachnoiditis.

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We have Guillain Barré syndrome,

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which is kind of an autoimmune entity that

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is associated with a previous infection.

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You can have irritation from chemicals such as pantopaque,

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which is one of the agents that we used to use for

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myelography that irritates the nerve roots.

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And of course,

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we have the subarachnoid seeding neoplastic category,

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which we've already described.

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And here you see, once again, that patient who had the

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breast cancer with the enhancing nerve roots

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at the cauda equina and conus medullaris.

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When we think about infectious causes of nerve root

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enhancement, there are a variety of etiologies,

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most common of which are going to be viral etiologies.

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So West Nile virus, Cytomegalovirus, and Herpes Zoster, are three

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viruses that will lead to irritation of the nerve roots

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and a secondary neuritis and/or meningitis.

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With respect to the infectious bacterial diseases,

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we would worry about things like

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Lyme's disease or tuberculosis.

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You may have fungal infections also and there may be

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other bacterial infections that are associated with

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patients having a discitis or osteomyelitis in the

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extradural compartment. Here we have an example of

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thickened nerve roots that are very faintly enhancing.

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And this was cryptococcus,

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a type of fungal infection that was leading to

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the cauda equina syndrome. As I mentioned,

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Guillain-Barré syndrome is syndrome that kind of crosses

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the boundaries between infectious and autoimmune

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inflammatory condition, sometimes called an acquired

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demyelinating polyneuropathy.

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This is typically manifested by diffused

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nerve root enhancement.

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It tends to favor the motor nerves

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over the sensory nerves.

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And that's why you may see selective anterior

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nerve root enhancement. With treatment,

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and the treatment is usually sort

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of immunosuppressive treatment,

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you may see diminution in the contrast enhancement.

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Many of these patients have a GI infection,

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a Campylobacter infection, that may

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be the antecedent infection.

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That leads to the autoimmune reaction on the cauda equina

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nerve roots, the peripheral nerve roots.

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And here you see a pretty dramatic example.

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This looks like a child based on

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the configuration of the spine.

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But you see this diffuse enhancement on the conus medullaris

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extending to the nerve roots of the cauda equina.

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Of the noninfectious inflammatory conditions,

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we usually think about sarcoidosis.

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Sarcoidosis, like lymphoma,

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can affect all parts of the spinal canal.

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So it can be extradural in the bone,

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it can be intradural extramedullary affecting the nerve roots,

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and it can be intramdulary with an inflammatory

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condition that leads to a myelitis.

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The signal intensity is variable. Most of the time

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you'll see this on the surface of the spinal cord

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or on the surface of the nerve roots.

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And the spinal abnormality may or may not be

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associated with intracranial involvement.

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Here's an example of a patient who had sarcoidosis in

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which there was manifestation on the surface of the

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spinal cord which eventually grew into the cord.

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So this is both superficial intradural extramedullary,

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as well as intramedullary involvement with sarcoidosis.

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The same phenomenon can occur in the brain where we

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initially see the sarcoidosis affecting the

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meninges, and then in its severe form,

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it grows into the parenchyma of the brain, as well.

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This is another example of sarcoidosis, but in this case,

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basically mostly affecting the cauda equina nerve roots.

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These all look alike, so this could be Guillain-Barré,

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this could be subarachnoid seeding.

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It's effectively enhancement of the nerve

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roots and sparing of the spinal cord, in this example.

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I'm showing this as an intracranial manifestation

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of sarcoidosis where the patient had fifth nerve

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enhancement, as well as right third

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nerve enhancement intracranially.

Report

Description

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Spine

Non-infectious Inflammatory

Neuroradiology

Musculoskeletal (MSK)

MRI

Infectious

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