0:00

This is a young adult woman who had multiple

0:05

episodes of tingling and paresthesias,

0:08

initially in the upper extremity and

0:10

then also in the lower extremity.

0:13

As we scroll the sagittal STIR sequences,

0:18

we see that there are areas of high signal

0:20

intensity in the cervical spinal cord

0:23

opposite C4, C5, C6,

0:26

as well as an additional lesion at T2.

0:29

What's different about these lesions is that, by and large,

0:33

they are not causing expansion of the spinal cord.

0:35

This T2 lesion may have a little bit of widening.

0:40

These are single-segment lesions.

0:43

When we extend our imaging to

0:45

the thoracic spinal cord,

0:47

we see additional areas of high signal intensity

0:50

without cord expansion in the mid thoracic region,

0:54

as well as the lower thoracic spinal cord.

0:58

On post-gadolinium-enhanced imaging,

1:02

there is no evidence of spinal cord enhancement

1:05

that corresponds to these lesions,

1:07

which would make it neoplasm much less likely.

1:10

So what's in our differential diagnosis?

1:12

You might think about neoplastic category,

1:15

except that the cord really isn't expanded,

1:18

and is not showing contrast enhancement.

1:20

We don't see very much in the way of

1:22

degenerative change. So at this juncture,

1:24

we probably go with the next most common

1:27

category of disease in the spinal cord,

1:31

and that is demyelination,

1:33

which is under our eye for idiopathic in our

1:36

VITAMIN C and D. So we would think, "Oh,

1:39

could this be a vascular lesion?"

1:40

No. Could it be an infectious lesion?

1:42

Unlikely. Could it be trauma? No.

1:44

Acquired? No. Metabolic? Unlikely.

1:46

Idiopathic is where we have demyelinating

1:49

disorders. Neoplasm? Definitely not. Congenital?

1:52

No. And drug-related? No.

1:53

So this is indeed multiple sclerosis of the

1:57

spinal cord with multiple lesions without cord

2:00

expansion and without demonstrating

2:03

contrast enhancement. As an aside,

2:05

you're seeing some venous vascular malformations

2:08

or hemangiomas of bone showing enhancement,

2:11

but that cord lesion is not enhancing.

2:14

Fortunately, we have the brain MRI scan.

2:18

So isolated spinal cord demyelination with

2:22

multiple sclerosis is very unusual.

2:25

You can get it with neuromyelitis optica.

2:28

So we would next scan the brain.

2:30

As we scan the brain with our sagittal

2:34

FLAIR imaging,

2:35

we see multiple periventricular and

2:39

subcortical white matter lesions

2:43

bilaterally in the brain.

2:48

The posterior fossa seems to be spared.

2:51

We'd have to get out our T2-weighted

2:53

imaging and look at the posterior fossa.

2:57

So by McDonald criteria,

3:00

we have periventricular and juxtaportical and

3:06

spinal cord white matter lesions that would

3:10

fulfill the dissemination in space

3:12

criteria for multiple sclerosis.

3:15

We'd have to look for enhancing lesions or new

3:18

lesions in order to fulfill the dissemination

3:22

in time criteria for multiple sclerosis.

3:26

So within the demyelinating category,

3:29

multiple sclerosis and neuromyelitis optica are

3:32

the most common of the lesions affecting the

3:35

spinal cord, and they are indeed intradural

3:39

intramedullary lesions.