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M R I - Division

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Complaint : 36Y, Male bilateral lower limb weakness, tingling & parasthesia from 6 months. No H/O Trauma.

Investigation:

          MRI Mid cervical spine, T2 Wt. Images of Axial sections.


FINDINGS
:

MRI :  Abnormal T2 hyper intensity confined to dorsal columns with an inverted 'V' configuration or inverted rabbit ears


DIAGNOSIS:  Vitamin B12 deficiency / sub acute combined degeneration of the cord.

DISCUSSION

   T2 hyper intense confined to dorsal columns highly suggestive of Vitamin B12 deficiency.

   Confirmation with laboratory data decreased plasma B12 levels.

Differential Diagnosis :  

    Spinal cord infarction

  • Hyperacute presentation, motor > sensory symptoms
  • Predominantly ventral cord or central gray matter signal changes

   Spinal cord contusion

  • Cord swelling, T2 hyperintensity +/- hemorrhage
  • Associated fracture, soft tissue injury
  • History, clinical findings enable diagnosis

  Inflammatory demyelination

  • Multiple sclerosis or acute disseminated encephalomyelitis (ADEM)
  • Lesions more focal, patchy than B12 deficiency, do not show specificity for lateral or dorsal columns
  • Characteristic clinical presentation

   Infectious myelitis

  • HIV vacuolar myelopathy, Varicella-Zoster/Herpes, Lyme disease
  • Imaging findings may be identical to B12 deficiency
  • Clinical, laboratory findings help distinguish

   Acute transverse myelitis

  • Acute (non-traumatic) presentation => diffuse multisegmental cord hyperintensity, swelling
  • Idiopathic or known etiology; clinical and laboratory findings may help distinguish cause
  • Increased CSF protein, pleocytosis, +/- oligoclonal bands (28%)

Special features to remember

  • Spinal cord symptoms appear first with motor  (spastic paraparesis, gait unsteadiness) .
  • and sensory (paraesthesias, absent reflexes, loss of joint position sense and vibration sense).
  • Treatment arrests degenerative process but does not restore destroyed neural fibers.
  • Imaging changes may not completely resolve.
  • Avoid N2O anesthesia in vulnerable patients.
  • Common in strict Vegetarians

 

REFERENCE : Ross, Brant-Zawadzki.Moore,  Diagnostic Imaging, Spine 1st edition, 2004.

SUBMITTED BY:  Academic division, 'MA' Advanced Diagnostic & Research Centre, Guntur, AP. INDIA.

                              DR. M.ADINARAYANA RAO. MD.

                              DR. G.GOWRI SEKHAR . DNB.,DMRD.

                              DR. D. PRASAD REDDY. DMRD.

                              

 


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