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Murphy OC, Barreras P, Villabona-Rueda A, Mealy M, Pardo CA. Identification of specific causes of myelopathy in a large cohort of patients initially diagnosed with transverse myelitis. J Neurol Sci 2022; 442:120425. [PMID: 36191573 DOI: 10.1016/j.jns.2022.120425] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/12/2022] [Accepted: 09/14/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND AND OBJECTIVES Identifying the etiologic diagnosis in patients presenting with myelopathy is essential in order to guide appropriate treatment and follow-up. We set out to examine the etiologic diagnosis after comprehensive clinical evaluation and diagnostic work-up in a large cohort of patients referred to our specialized myelopathy clinic, and to explore the demographic profiles and symptomatic evolution of specific etiologic diagnoses. METHODS In this retrospective study of patients referred to the Johns Hopkins Myelitis and Myelopathy Center between 2006 and 2021 for evaluation of "transverse myelitis", the final etiologic diagnosis determined after comprehensive evaluation in each patient was reviewed and validated. Demographic characteristics and temporal profile of symptom evolution were recorded. RESULTS Of 1193 included patients, 772 (65%) were determined to have an inflammatory myelopathy and 421 (35%) were determined to have a non-inflammatory myelopathy. Multiple sclerosis/clinically isolated syndrome (n = 221, 29%) and idiopathic myelitis (n = 149, 19%) were the most frequent inflammatory diagnoses, while spinal cord infarction (n = 197, 47%) and structural causes of myelopathy (n = 108, 26%) were the most frequent non-inflammatory diagnoses. Compared to patients with inflammatory myelopathies, patients with non-inflammatory myelopathies were more likely to be older, male and experience chronic symptom evolution (p < 0.001 for all). Hyperacute symptom evolution was most frequent in patients with spinal cord infarction (74%), while chronic symptom evolution was most frequent in patients with structural causes of myelopathy (81%), arteriovenous fistula or arteriovenous malformation (81%), myelopathy associated with rheumatologic disorder (71%), and sarcoidosis-associated myelopathy (61%). CONCLUSIONS Patients initially diagnosed with "transverse myelitis" are eventually found to have a more specific inflammatory or even non-inflammatory cause, potentially resulting in inappropriate treatment and follow-up. Demographic characteristics and temporal profile of symptom evolution may help inform a differential diagnosis in these patients. Etiological diagnosis of myelopathies would provide better therapeutic decisions.
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Affiliation(s)
- Olwen C Murphy
- Johns Hopkins Myelitis and Myelopathy Center, Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Paula Barreras
- Johns Hopkins Myelitis and Myelopathy Center, Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Andres Villabona-Rueda
- Johns Hopkins Myelitis and Myelopathy Center, Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Maureen Mealy
- Johns Hopkins Myelitis and Myelopathy Center, Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Carlos A Pardo
- Johns Hopkins Myelitis and Myelopathy Center, Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA.
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Gailloud P, Deib G, Pearl MS, Khoshnoodi M, Johansen MC. Intersegmental artery dissection resulting in spinal infarction. Neurol Clin Pract 2021; 10:535-537. [PMID: 33520416 DOI: 10.1212/cpj.0000000000000766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 09/09/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Philippe Gailloud
- Division of Interventional Neuroradiology (PG, GD, MSP) and Department of Neurology (MK, MCJ), The Johns Hopkins Hospital, Baltimore, MD
| | - Gerard Deib
- Division of Interventional Neuroradiology (PG, GD, MSP) and Department of Neurology (MK, MCJ), The Johns Hopkins Hospital, Baltimore, MD
| | - Monica S Pearl
- Division of Interventional Neuroradiology (PG, GD, MSP) and Department of Neurology (MK, MCJ), The Johns Hopkins Hospital, Baltimore, MD
| | - Mohammed Khoshnoodi
- Division of Interventional Neuroradiology (PG, GD, MSP) and Department of Neurology (MK, MCJ), The Johns Hopkins Hospital, Baltimore, MD
| | - Michelle C Johansen
- Division of Interventional Neuroradiology (PG, GD, MSP) and Department of Neurology (MK, MCJ), The Johns Hopkins Hospital, Baltimore, MD
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3
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Murphy OC, Gailloud P, Newsome SD. Spinal Claudication Secondary to Anterior Disco-Osteo-Arterial Conflict and Mimicking Stiff Person Syndrome. JAMA Neurol 2019; 76:726-727. [PMID: 31058924 DOI: 10.1001/jamaneurol.2019.1007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Olwen C Murphy
- Division of Neuroimmunology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Philippe Gailloud
- Division of Interventional Neuroradiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Scott D Newsome
- Division of Neuroimmunology, Johns Hopkins Hospital, Baltimore, Maryland
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4
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Spinal Cord Infarction. Neuroradiology 2019. [DOI: 10.1016/b978-0-323-44549-8.00031-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Kunam VK, Velayudhan V, Chaudhry ZA, Bobinski M, Smoker WRK, Reede DL. Incomplete Cord Syndromes: Clinical and Imaging Review. Radiographics 2018; 38:1201-1222. [DOI: 10.1148/rg.2018170178] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Vamsi K. Kunam
- From the Department of Radiology, SUNY Downstate Medical Center, University Hospital of Brooklyn, 450 Clarkson Ave, Brooklyn, NY 11203 (V.K.K., V.V., Z.A.C., D.L.R.); Department of Radiology, University of California Davis Health System, Sacramento, Calif (M.B.); and Department of Radiology, University of Iowa Hospital and Clinics, Iowa City, Iowa (W.R.K.S.)
| | - Vinodkumar Velayudhan
- From the Department of Radiology, SUNY Downstate Medical Center, University Hospital of Brooklyn, 450 Clarkson Ave, Brooklyn, NY 11203 (V.K.K., V.V., Z.A.C., D.L.R.); Department of Radiology, University of California Davis Health System, Sacramento, Calif (M.B.); and Department of Radiology, University of Iowa Hospital and Clinics, Iowa City, Iowa (W.R.K.S.)
| | - Zeshan A. Chaudhry
- From the Department of Radiology, SUNY Downstate Medical Center, University Hospital of Brooklyn, 450 Clarkson Ave, Brooklyn, NY 11203 (V.K.K., V.V., Z.A.C., D.L.R.); Department of Radiology, University of California Davis Health System, Sacramento, Calif (M.B.); and Department of Radiology, University of Iowa Hospital and Clinics, Iowa City, Iowa (W.R.K.S.)
| | - Matthew Bobinski
- From the Department of Radiology, SUNY Downstate Medical Center, University Hospital of Brooklyn, 450 Clarkson Ave, Brooklyn, NY 11203 (V.K.K., V.V., Z.A.C., D.L.R.); Department of Radiology, University of California Davis Health System, Sacramento, Calif (M.B.); and Department of Radiology, University of Iowa Hospital and Clinics, Iowa City, Iowa (W.R.K.S.)
| | - Wendy R. K. Smoker
- From the Department of Radiology, SUNY Downstate Medical Center, University Hospital of Brooklyn, 450 Clarkson Ave, Brooklyn, NY 11203 (V.K.K., V.V., Z.A.C., D.L.R.); Department of Radiology, University of California Davis Health System, Sacramento, Calif (M.B.); and Department of Radiology, University of Iowa Hospital and Clinics, Iowa City, Iowa (W.R.K.S.)
| | - Deborah L. Reede
- From the Department of Radiology, SUNY Downstate Medical Center, University Hospital of Brooklyn, 450 Clarkson Ave, Brooklyn, NY 11203 (V.K.K., V.V., Z.A.C., D.L.R.); Department of Radiology, University of California Davis Health System, Sacramento, Calif (M.B.); and Department of Radiology, University of Iowa Hospital and Clinics, Iowa City, Iowa (W.R.K.S.)
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Kozlov BN, Panfilov DS, Ponomarenko IV, Miroshnichenko AG, Nenakhova AA, Maksimov AI, Shipulin VM. The risk of spinal cord injury during the frozen elephant trunk procedure in acute aortic dissection. Interact Cardiovasc Thorac Surg 2018; 26:972-976. [DOI: 10.1093/icvts/ivx432] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 09/13/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Boris N Kozlov
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - Dmitri S Panfilov
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - Igor V Ponomarenko
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - Andrey G Miroshnichenko
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - Aleksandra A Nenakhova
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - Alexander I Maksimov
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - Vladimir M Shipulin
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
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Vargas MI, Barnaure I, Gariani J, Boto J, Pellaton A, Dietemann JL, Kulcsar Z. Vascular Imaging Techniques of the Spinal Cord. Semin Ultrasound CT MR 2017; 38:143-152. [DOI: 10.1053/j.sult.2016.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Anterior disco-osteo-arterial conflict as a cause of intersegmental arterial flow impairment and spinal cord ischemia. Neuroradiology 2016; 58:1109-1115. [DOI: 10.1007/s00234-016-1739-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 08/10/2016] [Indexed: 10/21/2022]
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Vuong SM, Jeong WJ, Morales H, Abruzzo TA. Vascular Diseases of the Spinal Cord: Infarction, Hemorrhage, and Venous Congestive Myelopathy. Semin Ultrasound CT MR 2016; 37:466-81. [PMID: 27616317 DOI: 10.1053/j.sult.2016.05.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Vascular pathologies of the spinal cord are rare and often overlooked. This article presents clinical and imaging approaches to the diagnosis and management of spinal vascular conditions most commonly encountered in clinical practice. Ischemia, infarction, hemorrhage, aneurysms, and vascular malformations of the spine and spinal cord are discussed. Pathophysiologic mechanisms, clinical classification schemes, clinical presentations, imaging findings, and treatment modalities are considered. Recent advances in genetic and syndromic vascular pathologies of the spinal cord are also discussed. Clinically relevant spinal vascular anatomy is reviewed in detail.
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Affiliation(s)
- Shawn M Vuong
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - William J Jeong
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Humberto Morales
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH; Comprehensive Stroke Center, University of Cincinnati Neuroscience Institute, Cincinnati, OH
| | - Todd A Abruzzo
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH; Comprehensive Stroke Center, University of Cincinnati Neuroscience Institute, Cincinnati, OH; Department of Radiology, Cincinnati Children's Hospital and Medical Center, Cincinnati, OH.
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Weidauer S, Nichtweiß M, Hattingen E, Berkefeld J. Spinal cord ischemia: aetiology, clinical syndromes and imaging features. Neuroradiology 2014; 57:241-57. [PMID: 25398656 DOI: 10.1007/s00234-014-1464-6] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 11/03/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The purpose of this study was to analyse MR imaging features and lesion patterns as defined by compromised vascular territories, correlating them to different clinical syndromes and aetiological aspects. METHODS In a 19.8-year period, clinical records and magnetic resonance imaging (MRI) features of 55 consecutive patients suffering from spinal cord ischemia were evaluated. RESULTS Aetiologies of infarcts were arteriosclerosis of the aorta and vertebral arteries (23.6%), aortic surgery or interventional aneurysm repair (11%) and aortic and vertebral artery dissection (11%), and in 23.6%, aetiology remained unclear. Infarcts occurred in 38.2% at the cervical and thoracic level, respectively, and 49% of patients suffered from centromedullar syndrome caused by anterior spinal artery ischemia. MRI disclosed hyperintense pencil-like lesion pattern on T2WI in 98.2%, cord swelling in 40%, enhancement on post-contrast T1WI in 42.9% and always hyperintense signal on diffusion-weighted imaging (DWI) when acquired. CONCLUSION The most common clinical feature in spinal cord ischemia is a centromedullar syndrome, and in contrast to anterior spinal artery ischemia, infarcts in the posterior spinal artery territory are rare. The exclusively cervical location of the spinal sulcal artery syndrome seems to be a likely consequence of anterior spinal artery duplication which is observed preferentially here.
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Affiliation(s)
- Stefan Weidauer
- Department of Neurology, Sankt Katharinen Hospital, Teaching Hospital of the Goethe - University, Frankfurt / Main, Seckbacher Landstraße 65, D 60389, Frankfurt / Main, Germany,
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Vargas MI, Gariani J, Sztajzel R, Barnaure-Nachbar I, Delattre BM, Lovblad KO, Dietemann JL. Spinal cord ischemia: practical imaging tips, pearls, and pitfalls. AJNR Am J Neuroradiol 2014; 36:825-30. [PMID: 25324492 DOI: 10.3174/ajnr.a4118] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Ischemia of the spinal cord is a rare entity with a poor prognosis. Brain ischemia is no longer a diagnostic challenge; on the contrary, ischemia of the spinal cord remains difficult, particularly in children. In this article, we illustrate the principal causes in children and adults, clinical presentation, different techniques for the diagnosis by MR imaging (diffusion, spinal MR angiography, and 1.5 versus 3T), pathophysiology, and differential diagnosis. We will discuss current knowledge, perspectives, and pitfalls.
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Affiliation(s)
- M I Vargas
- From the Divisions of Neuroradiology (M.I.V., I.B.-N., K.O.L.)
| | | | - R Sztajzel
- Neurology (R.S.), Geneva University Hospitals, Geneva, Switzerland
| | | | | | - K O Lovblad
- From the Divisions of Neuroradiology (M.I.V., I.B.-N., K.O.L.)
| | - J-L Dietemann
- Division of Radiology (J.-L.D.), Strasbourg University Hospitals, Strasbourg, France
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12
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Gailloud P, Gregg L, Galan P, Becker D, Pardo C. Periconal arterial anastomotic circle and posterior lumbosacral watershed zone of the spinal cord. J Neurointerv Surg 2014; 7:848-53. [PMID: 25280570 DOI: 10.1136/neurintsurg-2014-011408] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 09/10/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND The existence of spinal cord watershed territories was suggested in the 1950s. Segmental infarcts within the junctional territories of adjacent radiculomedullary contributors and isolated spinal gray matter ischemia constitute two well-recognized types of watershed injury. This report describes the existence of another watershed territory related to the particular configuration of the spinal vasculature in the region of the conus medullaris. METHODS The anatomical bases underlying the concept of a posterior lumbosacral watershed zone are demonstrated with angiographic images obtained in a 16-year-old child. The clinical importance of this watershed zone is illustrated with MRI and angiographic data of three patients with a conus medullaris infarction. RESULTS In all three cases of spinal ischemia an intersegmental artery providing a significant radiculomedullary contribution for the lower cord was compromised by a compressive mechanism responsible for decreased spinal cord perfusion (diaphragmatic crus syndrome in two cases, disk herniation in one). The ischemic injury, located at the junction of the anterior and posterior spinal artery territories along the dorsal aspect of the conus medullaris, was consistent with a watershed mechanism. This zone is at risk because of the caudocranial direction of flow within the most caudal segment of the posterior spinal arterial network which, from a functional standpoint, depends on the anterior spinal artery. CONCLUSIONS The posterior thoracolumbar watershed zone of the spinal cord represents an area at increased risk of ischemic injury, particularly in the context of partial flow impairment related to arterial compression mechanisms.
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Affiliation(s)
- Philippe Gailloud
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Lydia Gregg
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Peter Galan
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Daniel Becker
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Carlos Pardo
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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