Imaging CNS autoimmune and inflammatory disease

Spine Inflammatory Disease

This is the fourth lecture in a case based review of imaging of the brain and spine for autoimmune and inflammatory conditions. We will cover the MRI findings of some of the common conditions and some potential pitfalls and mimics.

This lecture covers two inflammatory diseases which can occur in the spinal cord: transverse myelitis and sarcoidosis. Multiple sclerosis can also cause an inflammatory myelitis, but it usually is associated with intracranial MS and has shorter segment lesions.

Transverse myelitis 

Transverse myelitis is a common infectious or inflammatory cause of myelopathy in the cervical or thoracic spine. This is most commonly manifested with long segment T2 abnormality (more than one vertebral body in length). It is commonly central and may have enhancement, particularly in the acute phase. It is often associated with a recent viral illness and can be caused by direct viral infection or as inflammatory post-viral syndrome. Treatment is largely limited to symptomatic control and immune suppression similar to treatment of multiple sclerosis.

Sarcoidosis

Sarcoid can affect the spine although it is less common that involvement of the brain. The most common manifestation in the spine is long segment T2 hyperintensity with associated enhancement. The enhancement pattern is often nodular and peripheral, which can help differentiate it from other causes of abnormal cord signal. As with sarcoidosis in the brain, you may also see nodular areas of enhancement or sarcoidomas. The diagnostic workup is similar. You should start by imaging the brain and chest to look for other potential areas of sarcoid involvement. ACE levels or IL-2 surface antigen can also be useful when available.  

Summary and Conclusion

In summary, when you have longer segment T2 hyperintense lesions in the spine, you should think about transverse myelitis or sarcoidosis. There is a broader differential which includes multiple sclerosis, lymphoma, and other tumors (such as astrocytoma or ependymoma). You may not be able to tell without other diagnostic clues, which makes imaging of the brain and correlation with the clinical scenario important.

The level of this lecture is appropriate for radiology residents, radiology fellows, and trainees in other specialties, such as neurology, who have an interest in neuroradiology or may see patients with CNS demyelinating or inflammatory conditions.

Other videos on the autoimmune and demyelinating playlist are found here

Imaging CNS autoimmune and inflammatory disease

Introduction/Demyelinating disease

This is the first lecture in a case based review of imaging of the brain and spine for autoimmune and inflammatory conditions. We will cover the MRI findings of some of the common conditions and some potential pitfalls and mimics.

This first lecture covers demyelinating disease, with the most common being multiple sclerosis (or MS), neuromyelitis optica (NMO), and acute disseminated encephalomyelitis (ADEM). These are all demyelinating/autoimmune conditions in which the brain loses its normal myelination.

Multiple sclerosis

MS is the most common demyelinating disease, affecting women more than men, with 2 age distribution peaks in younger and middle age women. MS commonly presents with optic nerve or visual symptoms, affects the brain more commonly than the spine, and can result in short segment spine lesions.

Neuromyelitis optica

Neuromyelitis optica, or NMO, is an autoimmune disease characterized by predominantly optic nerve and spine lesions. It is often associated with an antibody to aquaporin 4.

Acute disseminated encephalomyelitis (ADEM)

ADEM is an acute fulminant demyelinating syndrome characterized by acute onset and often many supratentorial lesions. The majority of patients recover, although some may have residual symptoms and it can even progress to death.

Acute hemorrhagic encephalomyelitis (AHEM)

AHEM is a closely related variant of ADEM which is associated with hemorrhage.

Susac syndrome

Susac syndrome is a small vessel vasculitis with small vessel infarcts, most commonly in the retina, cochlea, and periventricular white matter and corpus callosum. It can frequently mimic demyelinating disease because the distribution of lesions is similar.

Summary and Conclusion

The level of this lecture is appropriate for radiology residents, radiology fellows, and trainees in other specialties, such as neurology, who have an interest in neuroradiology or may see patients with CNS demyelinating or inflammatory conditions.

Imaging CNS autoimmune and inflammatory disease

This playlist is a case-based review of autoimmune and inflammatory conditions that can be seen in neuroradiology. MRI findings in the brain and spine are discussed. Common conditions are covered, including demyelinating disease, encephalitis, masslike disease like sarcoid and orbital inflammatory disease, spine inflammatory disease, amyloid, and vascular processes.

Be sure to watch them all to get the complete overview of imaging findings of common autoimmune and inflammatory conditions.

Noncontrast MRI cervical spine search pattern

Magnetic resonance imaging (MRI) of the cervical spine is a very commonly encountered test which can be performed for a variety of indications, including degenerative disease, trauma, demyelinating disease, and metastatic disease. Most of these cases will be done without contrast, as most of the information is there on a non-contrast exam.

This video will walk you through a step-by-step approach to evaluating an MRI of the cervical spine. The optimal approach is to use select sequences to evaluate each part of the study in the following order:

Alignment
Vertebral bodies
Marrow signal
Intervertebral discs
Spinal cord/canal
Soft tissues
Individual levels

Each sequence in the study has strengths at looking at one or more of these things. As we walk through, we’ll take a look at how to use each one.

The level of this lecture is appropriate for medical students, junior residents, and trainees in other specialties who have an interest in neuroradiology or may see patients with spine diseases.

See this and other videos on our Youtube channel.

Board Review 2 – Case 19

Neuroradiology board review. This lecture is geared towards the ABR core exam for residents, but it would be useful for review for the ABR certifying exam or certificate of added qualification (CAQ) exam for neuroradiology.

More description and the answer (spoiler!) are seen below the video.

This case shows a trauma patient with disruption of the arch of C1 on a CT of the cervical spine. There are injuries to both the anterior and posterior arch.

After presentation, the patient developed posterior fossa symptoms such as nausea and vertigo

The diagnosis is: Jefferson fracture with vertebral artery injury

A number of fractures in the neck have eponyms, and the Jefferson fracture is when the arch of C1 is fractured. It commonly involves injury to both the anterior and posterior arch, although this isn’t a requirement.

After high energy trauma, it is common to have injury to arteries in the neck, so it is important to consider this if a patient develops new symptoms. This patient had a traumatic wall injury of the left vertebral artery which is demonstrated on a T1 weighted fat saturated image of the neck, which showed T1 hyperintense methemoglobin in the wall.

Traumatic arterial injury is often graded using the Denver grading scale, which is as follows:

  • Grade I – < 25% narrowing
  • Grade II – > 25% narrowing or dissection flap
  • Grade III – pseudoaneurysm
  • Grade IV – occlusion
  • Grade V – transection/active extravasation

Injury can be evaluated with either CTA (more common) or MRA.

Board Review 2 – Case 16

Neuroradiology board review. This lecture is geared towards the ABR core exam for residents, but it would be useful for review for the ABR certifying exam or certificate of added qualification (CAQ) exam for neuroradiology.

More description and the answer (spoiler!) are seen below the video.

This case shows a mass within the spinal canal of the upper thoracic spine. For any spinal canal mass, your first step is to determine if it is:

  • intramedullary (in the spinal cord)
  • intradural extramedullary (inside the dura, but outside the spinal cord)
  • extradural

This mass appears to be extramedullary but intradural. The main differential considerations are meningioma, nerve sheath tumor/schwannoma, or metastasis. This mass has a relatively benign appearance and enhances avidly and homogenously.

The diagnosis is: meningioma

Spinal meningiomas are extramedullary masses that share an imaging appearance with intracranial meningiomas. They are often homogenous and enhance avidly. They can have calcification. The treatment, if symptomatic, is surgical resection.

Board Review 2 – Case 15

Neuroradiology board review. This lecture is geared towards the ABR core exam for residents, but it would be useful for review for the ABR certifying exam or certificate of added qualification (CAQ) exam for neuroradiology.

More description and the answer (spoiler!) are seen below the video.

This case shows a trauma patient who had a significant fall and now has lower extremity symptoms. On the MRI, there are a few compression fractures that you can see, but in addition there is T1 hyperintense fluid in the dorsal epidural space. In the setting of trauma, this is likely to be an epidural hematoma.

The diagnosis is: fracture with spinal epidural hematoma

Epidural hematoma is a dreaded complication of spine trauma that can cause worsening cord injury. It requires close monitoring and possibly surgical drainage if this may improve the symptoms. Look for intraspinal fluid collections after trauma, as they can be hard to identify.

Board Review 2 – Case 13

Neuroradiology board review. This lecture is geared towards the ABR core exam for residents, but it would be useful for review for the ABR certifying exam or certificate of added qualification (CAQ) exam for neuroradiology.

More description and the answer (spoiler!) are seen below the video.

This case shows an aggressive lesion of the upper thoracic spine in a relatively young patient. It appears to be centered in the posterior elements of the upper thoracic spine. There is central osseous matrix formation as well as a surrounding soft tissue mass with adjacent bone destruction. This is causing significant narrowing of the spinal canal.

The diagnosis is: osteosarcoma

In this case, you know you are dealing with an aggressive mass because of the soft tissue component and bone destruction. The differential includes primary bone lesions, metastatic disease, and lymphoma, but because of the new bone formation (osteoid matrix), it suggests osteosarcoma.

Board Review Cases – Spine

This playlist is a collection of only the spine imaging board review cases on this site.

These cases are geared towards preparation for the radiology resident ABR core exam, although similar material is used for the ABR certifying exam general and neuroradiology sections as well as neuroradiology CAQ. The format of this playlist is case-based. Each case consists of a series of images followed by 1 or 2 questions. The first question is usually to name the diagnosis, while the second is a multiple choice question to test deeper understanding of the specific condition. Try to get the diagnosis before you see the second questions.

 

Board Review 2 – Case 12

Neuroradiology board review. This lecture is geared towards the ABR core exam for residents, but it would be useful for review for the ABR certifying exam or certificate of added qualification (CAQ) exam for neuroradiology.

More description and the answer (spoiler!) are seen below the video.

This case shows multiple images throughout the body, with initial emphasis on the lumbar spine, where there is destruction of a lumbar vertebral body and surrounding abscess and inflammatory changes of the adjacent disc. There is relative sparing of the lumbar discs.

There is also disease elsewhere in the body, including an osseous lesion in a left-sided rib, ground glass and tree-in-bud nodules in the lungs, and nodular enhancing lesions in the brain. This makes you think about some sort of systemic process.

The diagnosis is: spinal tuberculosis

Spinal tuberculosis is a serious disease which can cause a discitis-osteomyelitis. The classic teaching, although it may not be true, is that the disease will spare the intervertebral discs. Other things to consider in the differential are metastatic disease and other infections.