Transvers myelitis

1. ACUTE TRANSEVERSE
MYELITIS
Dr Mahin Binte Anwar
Phase- B Resident
Department of Radiology and Imaging, BSMMU

2. • Acutely developing and rapidly progressing
inflammatory demyelinating process involving
spinal cord associated with a clinical syndrome of
bilateral motor, sensory and autonomic disturbances
• Age group: All age groups
• Gender predilection: None

3. ETIOLOGY
1. Acute infection:
i. Viral- Common; HSV, Coxsackie virus, Polio virus, EBV,
HIV
ii. Bacterial- Rare; pyogenic, tuberculous, syphilitic
iii. Others- Schistosomiasis, fungal
2. Post- infection
3. Post- vaccination
4. Autoimmune: SLE, Multiple sclerosis

4. CLINICAL FEATURE
• Monophasic
• Acute to subacute onset of symptoms
• Motor- Bilateral spastic paraparesis with exaggerated
tendon reflexes and extensor plantar response
• Sensory- Bilateral impairment of all modalities of sensation
with a definite upper level
• Autonomic- Bowel and bladder involvement
• Fever
• Back pain

5. INVESTIGATIONS
• CBC- Leukocytosis, elevated ESR
• CSF study- Elevated protein and lymphocyte count
• X-ray of spine
• MRI of spine
• MRI of brain

6. IMAGING FINDINGS
• MRI- modality of choice
May be normal in acute stages
Location: Any segment of spinal cord can be affected; slight
predilection for thoracic cord
Extension: Central, involving both gray and white matter;
>2 vertebral segments in length; > half of cross sectional
area of cord
Number: Usually single
Margin: Ill defined

7. Signal intensity:
T1WI- Iso to hypointense; focal cord enlargement
T2WI- Hyperintense
Post-contrast- Patchy , diffuse or peripheral
enhancement
DWI- no restriction

10. • MRI Brain- Normal
• CT- Focal cord enlargement; variable enhancement

11. DIFFERENTIAL DIAGNOSES
• Multiple sclerosis
• Neuromyelitis optica
• ADEM
• Astrocytoma
• Cord infart

12. Features Acute
transverse
myelitis
Multiple
sclerosis
Neuromyelitis
optica
ADEM Astrocytoma Cord infarct
Pathology Inflammatory
demyelination
Autoimmune
demyelination in
genetically
susceptible
individuals
Autoimmune
demyelination;
variant of
multiple
sclerosis
Autoimmune
demyelination
WHO grade I
malignant
neoplasm
Arterial or
rarely venous
occlusion
Age Any age Typically 15-50
years; peak in
3rd & 4th decades
Same as
multiple
sclerosis
Any age, more
in children
and young
adults
9 months- 70
years;
median age
21 years
Any age
Gender
predilection
None F>M
particularly in
children
F:M= 9:1 None None None
Disease
progression
Monophasic;
acute to
subacute
onset; rapid
progression
Prolonged
relapsing &
remitting; then
chronic
progressive
Prolonged
relapsing &
remitting; then
chronic
progressive
Monophasic;
subacute
onset; rapid
progression
Slowly
progressing
Acute onset

13. Features Acute
transverse
myelitis
Multiple
sclerosis
Neuromyelitis
optica
ADEM Astrocytoma Cord infarct
Number &
shape of lesion
Single; ill
defined
Multiple
plaques; ill
defined
Multiple
plaques; ill
defined
Single; ill
defined
Single; ill
defined
Single; ill
defined
Location Any segment
of cord, slight
predilection
for dorsal
Any segment,
predilection
for cervical
cord in early
stage
Any segment Dorsal
segment
Cervical
followed by
dorsal
segment
Upper
thoracic or
thoracolumbar
junction
Extent Central; gray
& white
matter; >2
vertebral
segments in
length; > half
of cross
sectional area
of cord
Dorsolateral;
gray & white
matter; <2
vertebral
segments in
length; < half
of cross
sectional area
of cord
More extensive;
gray & white
matter; > 3
vertebral
segments in
length
Same as
acute
transverse
myelitis
At least 7
vertebral
segments in
length
Paired
anterior
horns; paired
posterior
horns;
corticospinal
tracts; entire
cord
Long segment

14. Features Acute
transverse
myelitis
Multiple
sclerosis
Neuromyelitis
optica
ADEM Astrocytoma Cord infarct
Other sites
involved
None Brain-
periventricular
white matter,
corpus
callosum,
brainstem and
cerebellum in
children
Optic nerves Cerebrum &
brainstem
--- According to
cause
X- ray spine Normal Normal Normal Normal Normal; mild
scoliosis;
widened
spinal canal
Features of
trauma or
infection
Myelography Focal cord
enlargement
with reduced
subarachnoid
space
Cord
enlargement
in early stage;
atrophy in
later stage
Cord
enlargement in
early stage;
atrophy in
later stage
Focal cord
enlargement
with reduced
subarachnoid
space
Cord
enlargement
with reduced
subarachnoid
space
Focal cord
atrophy in
chronic stage

15. Features Acute
transverse
myelitis
Multiple
sclerosis
Neuromyelitis
optica
ADEM Astrocytoma Cord infarct
CT Focal cord
enlargement
Cord
enlargement
in early stage;
atrophy in
later stage
Cord and optic
nerve
enlargement in
early stage;
atrophy in later
stage
Focal cord
enlargement
Widened
spinal canal
Features of
trauma or
infection
MRI spine-
T1WI
Iso to
hypointense;
focal cord
enlargement
Cord atrophy Cord atrophy Iso to
hypointense;
focal cord
enlargement
Iso to slightly
hypointense
Focal atrophy,
myelomalacia
T2WI Hyperintense Hyperintense Hyperintense Hyperintense Heterogene-
ously
hyperintense;
intratumoura
l cysts; syrinx
Hyperintense
DWI No restriction No restriction No restriction No restriction No restriction Restriction in
acute &
subacute
stage

16. Features Acute
transverse
myelitis
Multiple
sclerosis
Neuromyelitis
optica
ADEM Astrocytoma Cord infarct
Post-
contrast CT
and MRI
Patchy ,
diffuse or
peripheral
enhancement
Nodular or
rim
enhancement
of acute
plaques
Nodular or rim
enhancement of
acute plaques
Variable
enhancement
Moderate
heterogene-
ous
enhancement
Irregular
peripheral
enhancement
in late acute &
subacute
stages
Imaging of
brain
Normal 3 or more; 5
mm or larger;
iso or
hypodense;
T1WI iso to
hypointense,
T2WI
hyperintense;
nodular or rim
enhancement
of active
lesions
Bilateral
asymmetrical
T2WI
hyperintensity
in both optic
nerves; nerve
enlargement in
acute stage;
atrophy in
chronic stage
Bilateral
asymmetrical
confluent;
T2WI
hyperintense;
variable
enhancement
--- According to
cause

17. MULTIPLE SCLEROSIS

18. ADEM

19. ASTROCYTOMA

20. CORD INFARCT

21. THANK YOU