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This is a 56-year-old woman who presented

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with both motor and sensory symptoms in

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the lower extremity,

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as well as difficulty with urinary incontinence.

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We have a sagittal T1-weighted,

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a sagittal T2-weighted,

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and a sagittal FLAIR scan

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demonstrated here.

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What one sees is abnormal signal intensity

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within the spinal cord,

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which seems a little bit discontinuous

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but extends over at least four segments

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of the lower cervical and upper thoracic spine.

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I think this sagittal STIR image probably

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shows the abnormality the

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best with disease,

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which is extending at least over three

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vertebral body segments and seems to

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spare the upper cervical spine,

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but begins at approximately C7 and

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goes down to the T3 level.

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Let's look at the axial scans

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through this lower

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cervical region.

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So the initial cervical spine axial

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scans look pretty normal.

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And then we get to the C7 level where

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there is diffuse signal intensity

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abnormality throughout the spinal cord.

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So here you see that there is signal

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intensity abnormality that's involving

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the entirety of the spinal cord.

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Continuing to scroll more inferiorly

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below C7, T1,

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you see that there is continued

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abnormality in the spinal cord that

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affects the posterior cord.

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And then once again we have another area

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where greater involvement of the spinal

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cord more to the left than to the right

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occurs down in the T3 level.

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This is the postgadolinium enhanced scan

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where one can see that there is

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involvement of the spinal cord with

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more central contrast enhancement.

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So what we're seeing is,

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are these areas of spotty enhancement.

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This is 234567, T1, T2, T3,

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T4,

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where there is

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abnormal contrast enhancement over

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basically four thoracic levels.

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The cord abnormality, as you can see,

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corresponds to those areas from C7

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going down to T4 on the T2-weighted imaging.

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When one sees this,

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there is a very broad differential diagnosis.

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Effectively the patient is presenting

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with transverse myelitis.

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Transverse myelitis is not a

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specific diagnosis itself.

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It is a symptom complex and therefore it

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behooves us to try to identify

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the differential diagnosis.

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Is so in this situation,

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we would question whether or not the

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patient has any visual problems to suggest

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neuromyelitis optica spectrum disorder.

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Because this is longitudinally extensive

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involvement over multiple segments,

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this is not a pattern that would be

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typical of multiple sclerosis.

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We would also do the examination of the

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various this immunologic test to identify

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whether the patient has an autoimmune

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disorder, rheumatoid,

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a collagen vascular disorder, lupus,

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for example.

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CSF might be obtained to exclude an

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infectious cause of transverse myelitis.

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There are a number of viral etiologies,

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most commonly being CMV

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or Herpes myelitis,

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and we would also obviously check for HIV

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status because of the possibility

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of vacuolar myelopathy,

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which is associated with AIDS.

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Ischemic etiologies would be examined,

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but ischemic etiologies very rarely will

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show contrast enhancement

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of the spinal cord.

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Some programs are performing diffusion

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weighted imaging of the spinal cord which

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might help in diagnosing an ischemic

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transverse myelitis.

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Finally, we have the autoimmune disorders that

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can cause transverse myelitis.

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If we have the situation where we never

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identify an etiology for the

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transverse myelitis,

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you may see the term used IATM idiopathic

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acquired transverse myelitis.

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This has an intermediate prognosis.

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It is usually treated with

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immunosuppressives beginning

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with steroids,

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and the patient may resolve completely.

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However,

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one should consider that this may be the

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first episode of a polyphasic disorder

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such as acute disseminated

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encephalomyelitis with MDEM multifasic,

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multiphasic disseminated

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encephalomyelitis,

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or it may be a manifestation

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of the first episode.

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So the term that you may see is IATM

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Idiopathic Acquired Transverse Myelitis,

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which was the final diagnosis

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on this case.

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This is one of the selective demyelinating

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disorders of the spinal cord.