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What’s the Diagnosis – Case 125

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What’s the Diagnosis – Case 125

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What’s the Diagnosis – Case 125

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Findings The spinal cord signal intensity is normal in 2008. In 2018 there is a marked degree of T2 hyperintensity of the spinal cord preferentially along the left side beginning at the C4-C5 disc space level and extending inferiorly along the entire course of C5 to the C5-C6 disc space level. On the axial T2 images is the corresponding abnormal high signal along the left side of the cord with a slight enlargement of the left side of the cord. There is severe central canal stenosis at C4-C5 and minimal to mild deformity of the cord. On the post contrast images, there is a prominent enhancement of the cord particularly at the C4-C5 disc space level but with an overall vague or hazy pattern. No rounded or mass like enhancement is present.

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Diagnosis: Venous Congestion/Ischemia and Cord Edema in Cervical Spondylosis In over ten years of putting together these cases this was one of the more fascinating and perplexing cases, I’ve had and required a great number of resources to get to the correct interpretation. In innumerable cervical spine mri’s severe central canal stenosis is present and in cases typically with moderate or severe compression of the cord we may see a mild to moderate amount of T2 hyperintensity of the cord. It is extremely uncommon to see this very slight degree of mass effect of the cord be associated with such a massive amount of T2 hyperintensity of the cord. On initial interpretation, given the enlargement of the left side of the cord a mass was favored over cervical spondylotic changes inducing the markedly abnormal cord. However, after contrast administration, there is no rounded or mass like focus of enhancement but rather this vague or hazy type enhancement. Histology has been obtained in other cases where again the diagnosis has been thought to be tumor and on biopsy only inflammatory changes and findings of edema of the cord were found. This has led to the belief that in some patients with severe central canal/spinal stenosis but with only slight deformity of the cord venous hypertension/congestion is precipitated that leads to venous ischemia, a break down of the blood cord barrier/hyperpermeability, and then marked edema within the spinal cord. Interestingly, as in this case the hazy, vague enhancement has been most commonly seen at the affected disc space level. In the cases reported in the literature, patients have responded very well to decompression and our patient is to have surgery next week.

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References Spinal cord swelling with abnormal gadolinium-enhancement mimicking intramedullary tumors in cervical spondylosis patients: Three case reports and review of the literature. Sasamori T, Hida K, Yano S, Takeshi A, Iwasaki Y. Asian J Neurosurg. 2010 Jul;5(2):1-9. Venous hypertensive myelopathy associated with cervical spondylosis. Okada S, Chang C, Chang G, Yue JJ. Spine J. 2016 Nov;16(11):e751-e754. doi: 10.1016/j.spinee.2016.06.003. Epub 2016 Jun 9. Swelling and enhancement of the cervical spinal cord: when is a tumour not a tumour? Nurboja B, Chaudhuri A, David KM, Casey AT, Choi D. Br J Neurosurg. 2012 Aug;26(4):450-5. doi: 10.3109/02688697.2011.633636. Epub 2011 Nov 22.

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Again, a very special thank you to multiple individuals for their assistance in the understanding of this case. • Christian Geanette, MD • John Tsiouris, MD and Ajay Gupta, MD from NYPH • Darius Melisaratos, MD

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HSS Radiology: What's the Diagnosis Case #125  

48-year-old man with long standing, intermittent upper extremity symptoms.

HSS Radiology: What's the Diagnosis Case #125  

48-year-old man with long standing, intermittent upper extremity symptoms.