MR Imaging of Spinal Neurofibromatosis

The MR findings in 7 patients with neurofibromatosis involving the spine were evaluated. Six patients had paraspinal tumors at multiple levels. In 4 they were bilateral. Five patients had multiple intraspinal lesions, frequently with growth through the neural foramen. In one patient paraspinal tumors were found in the lumbar sacral plexus and in another bony dysplasia and meningoceles but no tumors were disclosed. In 2 patients the lesions were associated with bilateral acoustic neuromas and multiple intracranial meningeomas. In one of these a spinal meningeoma with signal characteristics close to spinal cord was found. The other tumors had a signal that was equal to or slightly lower than the spinal cord and slightly higher than muscle on T1-weighted images. On T2-weighted images the tumors had a markedly increased signal compared to surrounding tissue. In 3 patients with tumors larger than 4 cm the signal intensity was inhomogeneous with decreased signal in the center on T2-weighted images, indicating the presence of increased fibrous tissue. Gadolinium-DTPA was given to one patient with marked increase in intensity of small tumors on T1-weighted images. The study shows that MR imaging is the modality of choice for evaluating most aspects of spinal and paraspinal neurofibromatosis.

Mr Imaging of Spinal Lymphoma

Fourteen patients with spinal lymphoma examined by MR imaging were reviewed. Thirteen of them also had extraspinal lymphoma. Vertebral involvement was found in 12 patients, epidural in 10, and paraspinal in 8 patients. On the basis of MR imaging at 0.3 T, spinal lymphoma may be divided into three types of growth pattern according to the main location: paraspinal, vertebral, and epidural. Most frequently, all three locations were found simultaneously on MR (7/14). In one patient the location was vertebral with epidural extension, in one paraspinal with vertebral extension, in 3 it was entirely vertebral, and in 2 entirely epidural. Multiple plane T1-weighted imaging gave complete information about the extent of spinal lymphoma. The signal intensity was lower than or equal to muscle and lower than bone marrow in paraspinal and vertebral lesions on T1-weighted images and high on T2-weighted images. Epidural lesions showed a hypo- or isointense signal relative to the cord on T1-weighted images except in one case and a hyperintense signal on T2-weighted images. Compression of the cord and cauda equina due to bulging of diseased vertebral bodies and epidural lesions was well demonstrated. MR imaging was also found useful in the follow-up of treatment.

Magnetic Resonance Imaging of Malignant Extradural Tumors with Acute Spinal Cord Compression

Thirty-six cancer patients with extradural spinal metastatic disease and acute symptoms of spinal cord compression underwent magnetic resonance (MR) imaging at 1.5 T. Cord involvement was found in all 36, 7 of whom had lesions at 2 different sites. Vertebral metastases in addition to those corresponding to the cord compressions were detected in 27 patients, and 18 of these had widespread deposits. MR displayed the extent of the tumors in the craniocaudal and lateral directions. The ability to identify multiple sites of cord and vertebral involvement and to delineate tumor accurately makes MR the examination of choice in cancer patients with suspected spinal cord compression. It obviates the need for myelography and postmyelography CT in this group of patients.

Diagnosis and Management of Spinal Epidural Abscess

Twenty-five patients with spinal epidural abscess were treated at the University of Western Ontario hospitals between July 1980 and July 1990. There were eighteen males (72%) and seven females (28%), with a median age of 60 years. Concurrent illness resulting in immunocompromise was present in 60%. Eleven presented with complete myelopathy, thirteen had limb weakness, and one had no neurological deficit. In twenty cases the abscess consisted of frankly purulent material, while in five the epidural collection consisted of chronic granulation tissue. Staphylococcus aureus was isolated in 64% of the abscesses. Twenty-seven surgical procedures were performed on 21 patients. Ten cases occurred in the cervical spine (40%), seven in the thoracic spine (28%), three in both the cervical and thoracic spine (12%) and five in the lumbosacral spine (20%). Fourteen patients (56%) retained or recovered ambulation and there were five deaths (20%). The progression from back and radicular pain to weakness and eventual paralysis continues to be characteristic of spinal epidural infection. Morbidity and mortality remain unacceptably high because of delay in diagnosis and treatment. Magnetic resonance imaging is the radiological investigation of choice for the diagnosis of spinal epidural abscess. Prompt intervention, before the development of severe neurological deficits, can improve outcome. Immediate surgical drainage combined with antibiotics remains the treatment of choice.

Longitudinal myelitis associated with systemic lupus erythematosus: clinical features and magnetic resonance imaging of six cases

Myelopathy is a rare central nervous system (CNS) complication associated with systemic lupus erythematosus (SLE). Acute transverse myelitis (ATM) is the most frequent form of SLE-related myelopathy. Magnetic resonance imaging (MRI) typically shows increased signal intensity in T2-weighted images and cord swelling. In the present paper, we describe six cases of SLE-related myelopathy with multiple increased signals in the T2-weighted images involving continuous levels of the cervical and thoracic spinal cord, a distinctive feature recently named 'longitudinal myelitis'. The clinical and laboratory findings are similar to those presented by ATM patients, including paraparesis, sensory level and sphincter disturbances. Four patients had positive antiphospholipid antibodies (aPL) suggesting that this could be a characteristic of longitudinal myelitis. Treatment in all cases included high doses of corticosteroids and immunosuppressive agents (intravenous (i.v.) cyclophosphamide). Anticoagulation therapy was given to one patient and two others received low doses of aspirin. The outcome was mainly unfavorable with slow improvement in only one case, no improvement in two and relapse of the myelopathy in the remaining three. In conclusion, longitudinal myelitis is an unusual form of SLE-related myelopathy, it might be associated with aPL and it has a poor prognosis.

A Staphylococcus aureus paraspinal abscess associated with epidural analgesia in labour

A case is described in which a parturient developed a Staphylococcus aureus paraspinal abscess following epidural analgesia in labour. We compared this case with other reported cases of paraspinal abscesses in obstetric patients. The presentation, diagnosis and management of these cases were reviewed. Anaesthetists need to be aware that non-spinal-epidural abscesses can occur in patients with an associated labour epidural.

Epidural hematoma producing Brown-Séquard syndrome: a case due to ruptured hemangioma with magnetic resonance imaging findings

A man developed spontaneous spinal epidural hematoma secondary to ruptured hemangioma with a clinical picture resembling acute partial Brown-Séquard syndrome. Diagnosis by magnetic resonance imaging (MRI) allowed prompt surgical decompression and complete reversal of the neurological deficits. The diagnosis, etiology, and MRI findings of spinal epidural hematomas are discussed.

Management of spontaneous extramedullary spinal haematomas: results in eight patients after MRI diagnosis and surgical decompression

Spinal cord compression due to extradural and subdural haemorrhage is a neurosurgical emergency. Differences in clinical presentation in relation to localisation of the haematoma, value of MRI as a diagnostic tool, surgical treatment, and prognosis were investigated in a retrospective case series of eight patients with extradural (n = four) and subdural (n = four) haematomas. Results of MRI were compared with operative findings and proved to be of high sensitivity in defining the type of bleeding and delineating craniocaudal extension and ventrodorsal location. Surgical treatment by decompressive laminectomy, haematoma evacuation, and postoperative high dose corticosteroids resulted in resolution of symptoms in five patients and improvement in the clinical situation in two patients. One patient with a chronic subdural haematoma had a second operation because of arachnoidal adhesions. One patient presented with a complete cord transection syndrome due to an acute subdural haematoma and remained paraplegic. It is concluded that prompt, reliable, and non-invasive diagnosis by MRI leads to efficient surgical treatment and a favourable outcome in this rare condition.

Spinal epidural haematoma: report of 11 cases and review of the literature

Spinal epidural haematomas (SEH) are rare; most are caused by trauma, anticoagulant therapy, vascular anomalies, hypertension, blood dyscrasias, epidural anaesthesia or, rarely, spinal surgery. We report 11 cases and review the literature (16 cases). The clinical picture is that of acute spinal cord compression. MRI characteristics are quite specific. On sagittal sections, the SEH appears as a biconvex mass, dorsal to the thecal sac, clearly outlined and with tapering superior and inferior margins. The dura mater is seen as curvilinear low signal separating the haematoma from the cord. Within 24 h of onset, the haematoma is isointense with the cord on T1-weighted images and heterogeneous on T2-weighted images. Later, it gives high signal on both T1- and T2-weighted images. Differential diagnosis must include subdural haematoma, epidural neoplasm and abscess. Complete neurological recovery rapidly follows laminectomy and removal of the clot. In three of our cases, the haematoma resolved spontaneously. MRI is the best examination for diagnostic and follow-up.

The management of acute spinal cord compression

Images

Acute transverse myelitis in a 15-month-old girl: report of a case with MRI findings

A 15-month-old girl demonstrated progressive weakness in all limbs. Magnetic resonance imaging (MRI) on admission revealed (1) diffuse and symmetric cervical cord swelling, (2) diffuse decrease and increase in signal intensity within the affected cord on T1- and T2-weighted images, respectively, (3) preserved anatomic structure of gray and white matter of the cord, and (4) lack of gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA) enhancing effect. She showed rapid clinical improvement in response to steroid therapy, and repeat MRI showed marked reduction in the degree of cord swelling and abnormal signal intensity. Based on the above clinical and MRI findings, the diagnosis of acute transverse myelitis was made. Although various pathologic conditions also could produce similar cord swelling and abnormal signal intensity on MRI, the third and fourth findings mentioned above suggested that the lesion was inflammatory rather than neoplastic. Our case indicates that MRI may be informative in differentiating acute transverse myelitis from other intramedullary disorders.

MRI in cervical disk herniation

Eleven operated herniated disks in 10 patients were evaluated preoperatively with plain films, myelography and magnetic resonance imaging. Plain X-ray was a valuable supplement to MRI for studying the bony changes. Myelography showed 7 of 11 herniated disks while MRI gave correct diagnosis in all. It is concluded that MRI can replace myelography and computerized tomography in the preoperative evaluation of cervical herniated disk. The other examinations may be supplementary in some cases.