This document discusses various pathologies that can cause damage to the spinal cord as seen on MRI. It focuses on diseases that appear as high signal on T2-weighted imaging. The most common etiologies are degenerative compressive myelopathy, inflammatory disorders, and demyelinating diseases such as multiple sclerosis. Imaging is important for determining the location, extent, and severity of abnormalities in order to accurately diagnose the underlying cause and guide treatment.

2. • The term myelopathy describes pathologic conditions that
cause spinal cord, meningeal or peri meningeal space damage or
dysfunction.
• Spinal cord injuries usually have devastating consequences such
as quadriplegia, paraplegia and severe sensory deficits.
• Imaging is of great importance in order to home in on the
diagnosis and classify the etiology appropriately.

3. In this presentation we will focus on spinal cord diseases that
are characterized by high signal within the cord onT2WI.
The most common causes are degenerative compressive
myelopathy, inflammatory and demyelinating disorders.

4. If we exclude myelopathy due to cord compression as seen in
trauma, degeneration and metastatic disease, which is usually not a
diagnostic dilemma, then the most common diseases of the spinal
cord are Demyelinating diseases.
AND
Multiple Sclerosis is by far the most
common demyelinating disease.

5. Differential diagnosis

6. Whenever there is an abnormality in the spinal cord, we
need a systematic approach to analyze the findings

7. Transverse involvement

9. Degenerative compressive myelopathy may be classified
according to the compression site, most common in
elderly patients.
Post traumatic compressive myelopathy is most common
among males between 16 and 30 years of age. 50% due to
motor vehicle accidents. C5-7 andT10-L2.

10. • MR imaging is of vital importance in approaching spinal
cord trauma because it shows location, extension and
severity very clearly, and also reveals edema and
intramedullary bleeding.
• Some studies have shown that hemorrhage and longer
hematomas are associated with a lower rate of motor
recovery.

16. MS: short segment focal wedge-shaped involvement of the posterior
column of the spinal cord with typical periventricularWM-lesions.

17. Usually in cervical
spine

19. On transverse images MS lesions typically have a round or triangular
shape and are located posteriorly or laterally

21. So can we exclude MS if a lesion is located anteriorly?
Unfortunately not.
MS is the great mimicker and can also be located anteriorly like in this patient who has a
lesion in the typical location (blue arrow) but also a lesion laterally in the cord (red
arrow).
This is uncommon, but we can not exclude MS.

22. When MS lesions are active, they can enhance, but enhancement is not as
common as in the brain.The enhancement patterns are non-specific.
We can see ring enhancement, intense and less-intense enhancement.
The less intense enhancement is the most common pattern.

23. Diffuse abnormalities that can look like transverse myelitis or extensive
astrocytoma are sometimes seen.
This pattern is more common in primary progressive and secondary
progressive MS.

24. Atrophy in longstanding MS; associated with 70% axonal loss

26. • It is often mistaken with MS, although clinical, radiological and
immunopathological tests suggest that they are different.
• The identification of the specific antigen of the neuromyelitis
optica immunoglobulin G/aquaporin 4 antibody implies humoral
immunity, which makes it different from MS.

29. NMO presenting with neuritis optica (arrows).The brain is normal

30. One month later this child presented with acute transverse myelopathy, i.e. bilateral
symptoms.
The images show abnormal signal in the spinal cord with swelling and some enhancement.
An astrocytoma could very well present with these images, but given the history of an optic
neuritis and the acute myelopathy, we do not think of a tumor.
This proved to be NMO and the Ig-test for NMO was positive.

31. Previously it was thought that in NMO the brain was spared, but now we
know, that brain lesions do occur.
They are often distinct from those seen in MS.
The location of the brain lesions in NMO is only around the ventricles.

32. It is also possible to have large lesions in the corpus callosum of patients
with NMO .
So in any CNS disease with optic nerve and spinal cord involvement it is
good to do the test for NMO-IgG.

36. • Bilateral but typically asymmetric multifocal white matter lesions,
with or without damage of the grey matter
• Extensive disease of several spinal segments with expansion.
• Low signal inT1 sequences
• Well defined with a high signal inT2 sequences; gadolinium
enhancement is variable.
• All patients with spinal involvement have brain damage.

37. These are images of a teenage child with a typical history of respiratory tract infectionThere is
swelling and cord involvement and no enhancement
The imaging findings and clinical history is typical of ADEM

38. What is typical forADEM and uncommon for MS is:
• Massive involvement of the pons.
• Involvement of the basal ganglia.

40. The follow up MR shows that the cord has returned to normal again

41. Another case of ADEM.
Notice the typical involvement of the pons and basal ganglia.

42. On follow up scan almost complete normalisation.

44. • Imaging findings

45. • Sensory, motor or autonomic dysfunction of spinal origin.
• • Bilateral signs and symptoms.
• • Clearly defined sensory level.
• • Spinal inflammation (CSF pleocytosis or high immunoglobulin G
levels, or gadolinium enhancement).
• • Maximum progression during a period ranging between four
hours and four weeks.

46. The sagittal image shows a large segment of hyperintensity onT2WI.
The transverse image shows that most of the cord is involved.

47. These images are of a 31 year old male
The images show a long segment myelopathy with full transverse involvement.
There is no swelling and no enhancement.
It does not look like MS or tumor, so we should think of acute transverse myelitis.

48. • Transverse myelitis may occur in isolation or in the setting of another
illness.
•
When it occurs without apparent underlying cause, it is referred to as
idiopathic.
•
Idiopathic transverse myelitis is assumed to be the result of abnormal
activation of the immune system against the spinal cord.
• Patients with an acute short segmentTM (or APTM) are at risk of
developing MS if there is one of the following:
 PartialTM, i.e. short segmentTM.
 Family history of MS. Brain lesions on MR.
 Oligoclonoal bands in CSF.

50. Here images of a typical case ofTM.
There is multisegment high signal on STIR andT2WI with some swelling.
There is no enhancement, which is usually the case inTM.When there is enhancement, it
can be difficult to differentiateTM from an astrocytoma.

51. • Myelopathy may be the initial manifestation of a
malignancy in up to 20% of cases where the only systemic
symptom is weight loss.
• Tumors compressing the spinal cord may be divided into
extradural and intradural.
• Most common spinal cord tumor is ependymoma followed
by astrocytoma. Both these are typically intradural
intramedullary lesions.

52. • Forty per cent of patients present with radiculopathy and
myelopathy associated with sub acute dorsal pain that worsens in
decubitus position. MRI may reveal the cause of the myelopathy
and help guide the approach to the primary tumor.

54. This is a case of astrocytoma.T2 hyperintense expansion of the thoracic
cord is demonstrated. Post contrast images demonstrate patchy
irregular peripheral enhancement of this lesion, and central low
intensity

56. The images are of a patient with neurofibromatosis who has multiple
ependymomas.
They present as multiple enhancing masses.

58. owl eye
appearance
• Posterior spinal artery --- unilateral predominantly
involving dorsal column

59. The images are of a patient who developed a paraparesis after stenting of an aortic aneurysm. Notice the high signal
ventrally in the cord, which is typical for arterial infarction On transverse images a typical snake-eye appearance can be
seen.

61. The images are of a child .The images are non-specific with multiple focal lesions and probably
the first choise would be MS.
The differential diagnosis would include inflammation, infection and metastases.
In such cases always perform a transverse image of the spine to look for the exact location and
perform a MRI of the brain.

62. The lesions are located dorsally and one of the lesions is enhancing.
Now if this was infection or metastases it would be strange that not all lesions enhance.
MS is still on our list.
We continue with brain images in next slide

63. On the CE-T1WI only one lesion shows enhancement.
The location of the lesions and the enhancement could very well fit to the diagnosis of MS, but
this proved to be vasculitis.

64. • Many of the processes affecting the spinal cord may be
reversible if recognized and treated early.
• Imaging is of great importance in order to home in on the
diagnosis and classify the etiology appropriately.
• The vast majority of spinal cord diseases may be treated
medically, with surgical treatment reserved for
compressive disorders, which constitute a neurological
emergency.