0:01

One of the entities that one may be called upon to evaluate

0:06

the patient for in the spine is a spinal cord infarct.

0:10

These are incredibly uncommon and cause

0:13

a lot of anxiety because, frankly,

0:15

our pulse sequences to evaluate the spinal

0:18

cord for infarction as opposed to myelitis

0:22

have not yet reached mainstream as far as their quality.

0:26

This is a diffusion tensor imaging of the spinal cord

0:31

with the ADC map and T2-weighted scan.

0:36

Most institutions and private practices probably do not have

0:40

good pulse sequences for the evaluation for spinal cord

0:44

infarct with diffusion weighted imaging

0:47

or diffusion tensor imaging.

0:49

Here you can see on the diffusion tensor imaging, B 1000

0:54

map that there is bright signal intensity

0:57

in the spinal cord at the

1:00

C7-T1 level, which corresponds,

1:02

although not a very good quality image, with

1:05

dark signal intensity on the ADC map.

1:08

Now,

1:09

this would be the imaging findings that we would worry

1:12

about for spinal cord infarct. A word about this case,

1:17

you notice that there is decreased caliber to the

1:22

spinal cord through this area of infarction,

1:25

which is verified on the sagittal STIR image.

1:28

The sagittal STIR image does not show bright signal intensity

1:32

in this spinal cord. So initially, my evaluation said,

1:36

well, this is an old injury because we have myelomalacia, indicative

1:42

of an older injury because the caliber of the spinal cord is

1:46

decreased. However, given the diffusion weighted scan,

1:51

I had to worry about a superimposed infarction on

1:55

a previously injured spinal cord.

1:59

In point of fact.

2:00

This patient had acute symptoms.

2:02

So this is a little bit of a complicated case,

2:04

but suffice it to say that diffusion weighted imaging is

2:07

going to be our best means for identifying a spinal cord

2:11

infarct in those very rare instances in which you're called

2:14

upon to evaluate that in the emergency department.

2:19

This was an individual who had acute onset of paraparesis

2:25

and the CT scan of the cervical spine was unremarkable.

2:31

So this is what we would call the SCIWORA,

2:34

the cervical cord injury without radiographic abnormality.

2:40

On the MRI scan, however,

2:41

we see that from C4 through the upper C7 level,

2:45

we have abnormal signal intensity in the spinal cord and

2:48

you have surveyed ill-defined area of contrast enhancement.

2:53

So in this individual with an expanded spinal

2:56

cord and the abnormal signal and

3:00

faint enhancement,

3:01

you most likely be concerned about a myelitis or,

3:04

in the appropriate age group, a demyelinating disorder.

3:08

In this situation,

3:09

I would be descriptive about the abnormality and recommend that

3:13

there be correlation with CSF sampling in order to determine

3:18

whether or not there is an infectious markers in the CSF,

3:21

elevated white blood count,

3:23

as well as looking for demyelinating markers in the

3:28

cerebrospinal fluid. Well, this is a little bit of a trick case.

3:31

This patient's symptoms started abruptly,

3:35

and in the situation where you have abrupt onset of the

3:39

patient's symptoms, you have to consider a spinal cord infarct.

3:43

This is, in fact,

3:44

the same case as the previous one that I just demonstrated,

3:48

showing abnormal restricted diffusion.

3:51

This was the acute episode where the diffusion weighted

3:55

scan was not performed to identify a cord infarct.

4:00

But on the follow up examination, we did the DWI and

4:03

the cord was still bright in signal intensity on DWI,

4:07

although it did show the myelomalacic change. So, vast

4:11

majority of cases, we think of infectious or noninfectious

4:15

myelitis. We think of demyelinating disorder.

4:19

In this case, a longitudinally,

4:20

extensive transverse myelitis or longitudinally extensive lesion,

4:25

possibly from demyelination or inflammation.

4:28

And in that rare instance, a spinal cord infarct.

Case 37 - Spinal Cord Infarct

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