Short case....Acute postinfectious transverse myelitis

1. Short case publication... version 2.7| Edited by professor Yasser Metwally | November 2008
Short case
Edited by
Professor Yasser Metwally
Professor of neurology
Ain Shams university school of medicine
Cairo, Egypt
Visit my web site at:
http://yassermetwally.com
A 33 years old patient presented clinically with paraplegia associated with a mid-dorsal sensory level of acute onset and a
regressive course. Clinical manifestations were bilateral and symmetrical. An antecedent upper respiratory infection was
present 2 weeks before the neurological disease.
DIAGNOSIS: ACUTE POSTINFECTIOUS TRANSVERSE MYELITIS

2. Figure 1. A centrally located multisegmental (3 to 8 spinal segments) MRI T2 hyperintensity that occupies more
than two thirds of the cross-sectional area of the cord is characteristic of transverse myelitis. The MRI T2
hyperintensity commonly shows a slow regression with clinical improvement. The central spinal cord MRI T2
hyperintensity represents evenly distributed central cord edema. MRI T1 Hypointensity might be present in the
same spinal segments that show T2 hyperintensity although to a lesser extent. The MRI T2 hyperintensity is central,
bilateral, more or less symmetrical and multisegmental. Notice the MRI T2 central isointensity, or dot (within and in
the core of the MRI T2 hyperintensity) which is believed to represent central gray matter squeezed by the uniform,
evenly distributed edematous changes of the cord. (central dot sign).
Figure 2. Postpontrast MRI T1 study. Notice contrast enhancement that is peripheral to and maximal at or
near the segmental MRI T2 hyperintensity. In idiopathic transverse myelitis enhancement is peripheral to the
centrally located area of high T2 signal intensity rather than in the very same area. The prevalence of cord
enhancement is significantly higher in patients with cord expansion.

3. Figure 3. MRI T2 study showing a centrally located multisegmental (3 to 8 spinal
segments) MRI T2 hyperintensity that occupies more than two thirds of the
cross-sectional area of the cord is characteristic of transverse myelitis. The MRI
T2 hyperintensity commonly shows a slow regression with clinical improvement.
The central spinal cord MRI T2 hyperintensity represents evenly distributed
central cord edema.
Table 1. The MRI picture characteristic of idiopathic transverse myelitis
A centrally located multisegmental (3 to 8 spinal segments) MRI T2 hyperintensity that occupies more than two thirds
of the cross-sectional area of the cord is characteristic of transverse myelitis. The MRI T2 hyperintensity commonly
shows a slow regression with clinical improvement. The central spinal cord MRI T2 hyperintensity represents evenly
distributed central cord edema. MRI T1 Hypointensity might be present in the same spinal segments that show T2
hyperintensity although to a lesser extent. The MRI T2 hyperintensity is central, bilateral, more or less symmetrical and
multisegmental.
MRI T2 central isointensity, or dot (within and in the core of the MRI T2 hyperintensity) might be present and is
believed to represent central gray matter squeezed by the uniform, evenly distributed edematous changes of the cord.
(central dot sign). It might not be of any clinical significance.
Contrast enhancement is commonly focal or peripheral and maximal at or near the segmental MRI T2 hyperintensity. In
idiopathic transverse myelitis enhancement is peripheral to the centrally located area of high T2 signal intensity rather
than in the very same area. The prevalence of cord enhancement is significantly higher in patients with cord expansion.
Spinal cord expansion might or might not be present and when present is usually multisegmental and better appreciated
on the sagittal MRI T1 images. Spinal cord expansion tapers smoothly to the normal cord, and is of lesser extent than
the high T2 signal abnormality.
Multiple sclerosis plaques (and subsequent T2 hyperintensity) are located peripherally, are less than 2 vertebral
segments in length, and occupies less than half the cross-sectional area of the cord. In contrast to transverse myelitis,
enhancement in MS occurs in the same location of high-signal-intensity lesions seen on T2-weighted images.
References
1. Metwally, MYM: Textbook of neurimaging, A CD-ROM publication, (Metwally, MYM editor) WEB-CD agency for
electronic publishing, version 9.4a October 2008

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