Evaluation of magnetic resonance imaging for the differentiation of inflammatory, neoplastic, and vascular intradural spinal cord diseases in the dog.

Magnetic resonance imaging (MRI) is a common test for dogs with suspected intradural spinal cord lesions, however studies on diagnostic performance for this test are lacking. Objectives of this multi-institutional, retrospective, case-control study were to estimate sensitivity and specificity of MRI for (1) distinguishing between histopathologically confirmed intradural spinal cord disease versus degenerative myelopathy in dogs, (2) categorizing intradural spinal cord diseases as neoplastic, inflammatory, or vascular; and (3) determining tumor type within the etiologic category of neoplasia. Additional aims were to (1) determine whether knowledge of clinical data affects sensitivity and specificity of MRI diagnoses; and (2) report interrater agreement for MRI classification of intradural spinal lesions. Cases were recruited from participating hospital databases over a 7-year period. Three reviewers independently evaluated each MRI study prior to and after provision of clinical information. A total of 87 cases were sampled (17 degenerative myelopathy, 53 neoplasia, nine inflammatory, and eight vascular). Magnetic resonance imaging had excellent (>97.6%) sensitivity for diagnosis of intradural spinal cord lesions but specificity varied before and after provision of clinical data (68.6% vs. 82.4%, P = 0.023). Magnetic resonance imaging had good sensitivity (86.8%) and moderate specificity (64.7-72.5%) for diagnosing neoplasia. Sensitivity was lower for classifying inflammatory lesions but improved with provision of clinical data (48.1% vs. 81.5%, P = 0.015). Magnetic resonance imaging was insensitive for diagnosing vascular lesions (25.0%). Interrater agreement was very good for correctly diagnosing dogs with intradural lesions (ĸ = 0.882-0.833), and good (ĸ = 0.726-0.671) for diagnosing dogs with neoplasia.

Suspected primary hematomyelia in 3 dogs.

Primary hematomyelia refers to hemorrhage occurring within the spinal cord without an identifiable etiology. Clinical signs, magnetic resonance imaging characteristics, and histopathological findings are described. Diagnosis was made through histological analysis and rule-outs for underlying factors. Following removal of the hematoma, neurologic deficits improved, although some residual deficits persisted.

Hématomyélie primaire suspectée chez 3 chiens. L'hématomyélie primaire fait référence à l'hémorragie qui se produit dans la moelle épinière sans une étiologie identifiable. Les signes cliniques, les caractéristiques de l'imagerie par résonance magnétique et les résultats de l'histopathologie sont décrits. Le diagnostic a été posé à l'aide d'une analyse histologique et de l'élimination des facteurs sous-jacents. Après l'enlèvement de l'hématome, le déficit neurologique s'est amélioré, même si des déficits résiduels ont persisté.(Traduit par Isabelle Vallières).

Spontaneous intramedullary hematoma initially mimicking myocardial infarction.

Spontaneous intramedullary hematoma (IMH) is a rare condition. The initial clinical manifestations are variable. Early symptoms of high thoracic IMH include thoracocervical pain that can be mistaken for emergent cardiopulmonary conditions such as myocardial infarction, pulmonary embolus, and aortic dissection. We report on a 34-year-old man who presented initially with chest pain and radiating pain in both shoulders. He was initially misdiagnosed as having a myocardial infarction and treated with heparin. Two hours after admission, correct diagnosis of IMH was based on the repeated neurologic examination and spine magnetic resonance imaging study. The patient underwent emergency surgical decompression and hematoma removal.We draw the misdiagnosis to the attention of the emergency physicians because early recognition of spontaneous IMH is very important for early surgical decompression to improve the prognosis.

Warfarin-associated hematomyelia.

A 71-year-old woman on warfarin (2.5 mg daily) developed severe low back pain with reduced touch sensation and weakness of the lower limbs that progressed to complete paralysis within 28 to 30 hours. Imaging revealed bleeding at the D4 through D11 level, however the patient refused emergency laminectomy. No recovery was observed and the patient was discharged to a rehabilitation facility. Only few other cases of hematomyelia linked to anticoagulant therapy have been reported. Early diagnosis, appropriate management and immediate intervention are needed to prevent irreversible neurological sequelae. The elusive clinical features at presentation may cause an important diagnostic delay.

Spinal dural arteriovenous shunt presenting with intramedullary hemorrhage: case report.

The authors report on a 49-year-old man with a thoracic spinal dural arteriovenous shunt (dAVS) in which rupture of a varix caused intramedullary hemorrhage. In the literature, patients with a thoracic dAVS predominantly present with congestive myelopathy; however, the patient featured in this report presented without increased deep tendon reflexes or muscle weakness, but instead with intermittent stabbing chest pain and paresthesia. Magnetic resonance images and angiograms demonstrated tortuous enlargement and the formation of a varix-like structure of the draining veins, features compatible with those of high-flow angiopathy. Recognition of this phenomenon is important in thoracic dAVS because intramedullary hemorrhage dramatically degrades outcome. A high index of clinical suspicion can prevent a similar case of thoracic dAVS from progressing to intramedullary hemorrhage.

A case of posterior spinal artery syndrome in the cervical cord: a review of the clinicoradiological literature.

We describe a patient with posterior spinal artery (PSA) syndrome due to vertebral artery (VA) dissection. A 63-year-old woman developed neck pain, bilateral shoulder and arm numbness, and paraparesis after prolonged neck extension during a dental procedure. Neurological examination revealed sensory deficits in the legs, paraparesis, cerebellar ataxia, urinary retention and constipation. Magnetic resonance imaging disclosed T2-hyperintense lesions in the posterolateral C4-C7 cord with partial enhancement. T1-hyperintensity and stenosis were found in the right VA at C3-C5. These clinicoradiological findings suggested bilateral PSA syndrome and unilateral VA dissection. This is the fourth report of VA dissection-induced PSA syndrome.

Rotational angiography for diagnosis and surgical planning in the management of spinal vascular lesions.

OBJECT: The management of spinal vascular malformations has undergone significant evolution with the advent of advanced endovascular and angiographic technology. Three-dimensional rotational spinal angiography is an advanced tool that allows the surgeon to gain a better appreciation of the anatomy of these spinal vascular lesions and their relation to surrounding structures. This article describes the use of rotational angiography and 3D reconstructions in the diagnosis and management of spinal vascular malformations. METHODS: The authors present representative cases involving surgical treatment planning for spinal vascular malformations with focus on the utility and technique of rotational spinal angiography. They report the use of rotational spinal angiography for a heterogeneous collection of vascular pathological conditions. RESULTS: Eight patients underwent rotational spinal angiography in addition to digital subtraction angiography (DSA) for the diagnosis and characterization of various spinal vascular lesions. Postprocessed images were used to characterize the lesion in relation to surrounding bone and to enhance the surgeon's ability to precisely localize and obliterate the abnormality. The reconstructions provided superior anatomical detail compared with traditional DSA. No associated complications from the rotational angiography were noted, and there was no statistically significant difference in the amount of radiation exposure to patients undergoing rotational angiography relative to traditional angiography. CONCLUSIONS: The use of rotational spinal angiography provides a rapid and powerful diagnostic tool, superior to conventional DSA in the diagnosis and preoperative planning of a variety of spinal vascular pathology. A more detailed understanding of the anatomy of such lesions provided by this technique may improve the safety of the surgical approach.

Cervical hematomyelia after traditional Chinese massage: a case report.

Hematomyelia is rare, and usually related to major trauma. Non-traumatic causes are much rarer and include underlying vascular malformations and cord tumors. We present the case of a previously well 44-year-old woman who developed severe acute neck pain and right-sided motor deficit after a session of traditional Chinese massage that entailed minimal neck manipulation. Emergent MRI confirmed hematomyelia of the right cervical hemicord, notably without associated bony or ligamentous injury. Follow-up spinal angiography and MRIs revealed no underlying vascular malformation or tumor. We highlight this case as there has been no reported case of hematomyelia occurring after mild trauma, although two cases of idiopathic hematomyelia have been reported. Though exceedingly rare, hematomyelia should be considered in the list of differential diagnoses in any case of neck pain and motor deficit after seemingly trivial injury.

Complex arteriovenous fistulas at C1 causing hematomyelia through aneurysmal rupture of a feeder from the anterior spinal artery.

A 64-year-old woman presented with left occipital headache and right dissociated sensory loss due to hematomyelia on the left ventral side of C1 caused by rupture of an aneurysm on one of the feeders extending from the anterior spinal artery to complex epidural or dural and intradural arteriovenous fistulas (AVFs). Branches from the left occipital and ascending pharyngeal arteries and those from the left C2 radicular, left posterior spinal and anterior spinal arteries formed these multiple shunts, linking with a common venous drain flowing into the right petrosal vein. Surgical interception of all the shunts was achieved, making it unnecessary to directly treat the aneurysm in the spinal cord. The feeders, aneurysm and AVFs were not visualized on postoperative angiography, and the patient returned to a normal working life.

Hemorragia intramedular (Hematomielia)no traumática: revisión / Non traumatic intramedullary hemorrhage (hematomyelia): a review

La hemorragia intramedular (hematomielia) no traumática es el sangrado producido en el interior del tejido medular en ausencia de trauma, su primera descripción clínica aparece reportada por Tellegen en 1850, se le considera la más infrecuente de las hemorragias intraespinales y rara si la comparamos con la frecuencia en que ocurren las hemorragias intracerebrales. La incidencia es alta en los varones (relación hombre-mujer 1,5:1) y muy relacionada con la entidad patológica condicionante. Esta obedece a múltiples causas: malformaciones arteriovenosas, cavernomas, tumores, cuagulopatias, inflamatoria, etc. La disfunción aguda del cordón espinal junto a las imágenes por resonancia magnética son elementos decisivos para el diagnóstico. El tratamiento aun sujeto de controversias, médico o quirúrgico (precoz o tardío), dependerá de la etiología del sangrado y del estatus neurológico en el momento del diagnóstico, hallándose los resultados más favorables en aquellos pacientes a los cuales se les realizó un pronto diagnóstico seguidos de una cirugía temprana.

Non traumatic intramedular hemorrhage (hematomyelia) is the blood found in the medullar tissues in absence of trauma, its first clinical description was reported by Tellegen in 1850.Is considered to be the most infrequent of intraespinales hemorrhage. The incidence is high in men and is related with conditionate pathological entity. Its do to multiples causes: Arteriovenos malformation, cavernomas, tumors, coagulopathies, inflammations, etc. The acute dysfunction of the spinal cord and magnetic resonance imaging are decisive in the diagnosis. The treatment though subject to controversies, medical or surgery (early or late), will depend on the bleeding etiology and the neurological status in the moment of the diagnosis, finding the most favorable result in those patients that were diagnosed earlier following an early surgery.

Intramedullary spinal cord hemorrhage (hematomyelia).

Intramedullary spinal cord hemorrhage (hematomyelia) is an uncommon cause of myelopathy and can present in an acute, subacute, stepwise, or chronic fashion. Spinal vascular malformations such as intramedullary cavernomas and intradural arteriovenous malformations are the most common cause of atraumatic intramedullary spinal cord hemorrhage based on the existing literature. Additional considerations include warfarin or heparin anticoagulation, hereditary or acquired bleeding disorders, primary spinal cord tumors, spinal cord metastases, Gowers' intrasyringal hemorrhage, or a delayed complication of spinal radiation. Prompt diagnosis of hematomyelia first requires recognition of a myelopathy syndrome (transverse, central, anterior, posterior, or hemi-cord) often accompanied by sudden, severe back or neck pain and sometimes radicular pain. MRI with and without gadolinium is the preferred imaging modality. There are no clinical trials to guide the management of acute intramedullary spinal cord hemorrhage, and subsequent treatment is usually directed toward the underlying cause.

Acute paraplegia due to spinal arteriovenous fistula in two patients with hereditary hemorrhagic telangiectasia.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterized by recurrent epistaxis, cutaneous telangiectasia, and visceral arteriovenous malformations (AVM). Of these, spinal AVM is a rare manifestation that concerns mainly children. In this report, we describe two cases of spinal AVM revealed by acute paraparesis due to subarachnoid hemorrhage in children with HHT and reviewed the literature on spinal arteriovenous malformations in HHT. In most of the cases reported, the clinical presentation was acute in the pediatric population and insidious during adulthood. The prognosis of spinal AVM mainly depends on the presence or not of medullar signs and symptoms and on the delay before treatment. In conclusion, any child with a family history of HHT should be considered at risk for spinal AVM in order to improve management of such complications and to decrease the risk of neurological sequellae.

Magnetic resonance imaging of acute intramedullary myelopathy: radiological differential diagnosis for the on-call radiologist.

Spinal cord disease is often viewed as having a poor outcome. Although in certain conditions this is true, non-traumatic myelopathy encompasses a vast array of diseases some of which are exquisitely responsive to treatment. Accurate diagnosis becomes important as damage is often progressive and long-term disability and morbidity is related to the degree of neurological impairment when the diagnosis is reached. Out-of-hours magnetic resonance imaging (MRI) is generally requested and performed to ascertain whether there is spinal cord compression; however, there are other causes of a cord syndrome, which are more subtle. This review aims to provide a summary of the imaging features of non-traumatic intramedullary spinal cord emergencies, many of which may appear radiologically similar.

Imaging in spinal vascular disease.

Spinal vascular diseases are rare and constitute only 1% to 2% of all vascular neurologic pathologies. In this article, the following vascular pathologies of the spine are described: spinal arterial infarcts, spinal cavernomas, and arteriovenous malformations (including perimedullary fistulae and glomerular arterivenous malformations), and spinal dural arteriovenous fistulae. This article gives an overview about their imaging features on MRI, MR angiography, and digital subtraction angiography. Clinical differential diagnoses, the neurologic symptomatology, and the potential therapeutic approaches of these diseases, which might vary depending on the underlying pathologic condition, are given.