Diagnostic value of bright spotty lesions on MRI after a first episode of acute myelopathy

Background and purposeTo determine the diagnostic value of bright spotty lesions (BSLs) for aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder (NMOSD^AQP4+), the predictive value of axial-BSLs for AQP4-IgG seropositivity, and the radio-clinical differences in NMOSD^AQP4+ patients with and without axial-BSLs.Materials and methodsRetrospective study that included patients aged ≥ 16 years, with a first acute spinal cord syndrome between 2005 and 2018 and abnormal spinal cord MRI with axial and sagittal T2 sequences. Patients with MRI findings consistent with compressive myelopathy were excluded. All spinal cord MRI were retrospectively evaluated for the presence of BSLs by 2 radiologists blinded to the diagnosis of acute myelopathy.ResultsA total of 82 patients were included; 15 aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder patients (NMOSD^AQP4+), and 67 other patients, considered as the other causes of myelopathy (OM) group. The specificity of axial-BSLs for NMOSD^AQP4+ patients was 94.0% (95% CI [85.6 to 97.7]). The sensitivity was 40.0% (95% CI [19.8 to 64.3]). In the multivariable analysis, the only MRI characteristic associated with AQP4-IgG positivity was the presence of axial-BSLs (OR: 9.2, 95% CI [1.2 to 72.9]; P = 0.022). In NMOSD^AQP4+ patients, the median of cord expansion ratio was higher with axial-BSL (1.2, IQR [1.1–1.3]) than without axial-BSL (1.1, IQR [1.0–1.2]; P = 0.046).ConclusionAfter a first acute spinal cord syndrome, the presence of axial-BSLs on spinal cord MRI seems very specific for NMOSD^AQP4+ and seems to be a predictor radiological marker of AQP4-IgG positivity.     

Central nervous system and muscle involvement in dengue patients: A study from a tertiary care center

BackgroundNeurological involvement in dengue virus (DENV) infection is being increasingly reported. There is paucity of studies evaluating the relative frequency of central nervous system (CNS) and muscle involvement in dengue.ObjectivesTo evaluate the frequency and prognosis of neurological and muscle involvement in dengue, and correlate these with dengue subtypes.Study designConsecutive dengue patients were included, and their clinical features, laboratory investigations and cerebrospinal fluid (CSF) findings were recorded. Cranial MRI was done in unconscious patients and electromyography and nerve conduction study in patients with flaccid weakness. Patients were categorized into encephalopathy, encephalitis, immune mediated and dengue associated muscle dysfunction (DAMD). Outcome at 1 month and its predictors were evaluated.Results116 patients aged 5–70 years were included; 82 had dengue fever (DF), 18 had dengue hemorrhagic fever (DHF), and 16 had dengue shock syndrome (DSS). Neurological manifestations were present in 92 (79%); encephalopathy in 17 (15%), encephalitis in 22 (19%), transverse myelitis in 1 (1%) and DAMD in 52 (45%) patients. Central nervous system (CNS) involvement was commoner in DHF/DSS compared to DF (44% vs 26%). 10 patients with CNS involvement died versus 1 with DAMD. The patients in the CNS group had more frequent hypotension, renal dysfunction and respiratory failure compared to the DAMD group, and had worse outcome. DENV2 and DENV3 were the commonest serotypes, but serotypes did not differ between CNS and DAMD groups.ConclusionsDAMD is commoner than CNS involvement in dengue. CNS involvement however, is associated with more serious illness and predicts poorer outcome.     

Acute ascending necrotizing myelitis in Okinawa caused by herpes simplex virus type 2

Summary A case of rapidly progressing ascending myelitis was necropsied. Necrosis was present throughout the whole length of the spinal cord and involved both the grey and white matter randomly. The perivascular lymphocytic infiltration in the spinal cord in the present case was more pronounced than that in the previously reported two cases of necrotizing myelopathy associated with malignancy. Using immunoperoxidase staining the presence of herpes simplex virus type 2 (HSV 2) antigen was demonstrated. Electron microscopic examinations revealed large numbers of HSV particles in the spinal cord. HSV 2 may be a common aetiological agent of necrotizing myelopathy and myelitis in Okinawa, an HSV 2 endemic area. In the present case, the necrosis was mainly found in the spinal cord but was also observed, to a very limited extent, in the brain.     

Epidural hematoma mimicking transverse myelitis in a patient with primary antiphospholipid syndrome

Antiphospholipid syndrome (APS) is an autoimmune disease, and its most critical pathologic process is thrombosis, which may explain most of the clinical features. Acute management of thrombosis involves immediate anticoagulation. Acute proximal venous thrombosis can be managed with thrombolytic therapy to reduce the long-term complications of the postthrombotic syndrome (pain, swelling, skin discoloration, or ulceration) and perform recanalization of occluded vessels. However, thrombolytic therapies are associated with high risks of bleeding. To our knowledge, this is the first report of epidural hematoma mimicking transverse myelitis after catheter-directed thrombolysis in a patient with primary APS. A 42-year-old male was admitted with sudden onset pain and swelling on left lower extremity. Venography demonstrated multiple thrombi on superficial femoral vein, common femoral vein, common iliac vein, and external iliac vein. Laboratory tests indicated the presence of IgM anticardiolipin antibody. He was diagnosed with primary APS with multiple venous thrombi. He was treated with urokinase (200,000/h) as thrombolytic therapy. After 1 day, he complained both leg weakness and urinary dysfunction. T1- and T2-weighted magnetic resonance images of spine showed about 8 cm-sized mass, suggesting hematoma on the posterior epidural space at thoracolumbar area. Despite the successful evacuation of hematoma, neurologic symptoms persisted and he is now receiving aspirin, warfarin, and physical therapy.     

多发性硬化型脊髓炎MRI研究进展

脊髓炎是一种脊髓炎性病变导致运动、感觉及自主神经功能障碍的综合征,常常给患者带来不同程度的残疾,其主要包括疾病相关性脊髓炎和特发性横贯性脊髓炎。临床中对多发性硬化(multiple sclerosis,MS)型脊髓炎的诊断存在一定的困难,但随着神经高级影像学的快速发展,MRI已成为MS型脊髓炎诊断的重要手段。现就MS型脊髓炎MRI研究进展进行综述。     

鞘内注射异烟肼联合地塞米松治疗结核性脊膜脊髓炎的价值

目的:探讨鞘内注射异烟肼联合地塞米松治疗结核性脊膜脊髓炎的临床价值.方法:选择结核性脊膜脊髓炎患者80例,分为两组,各40例,对照组实施异烟肼1200mg/d、链霉素600mg/d、利福平1g/d肌内注射,地塞米松10mg/d静脉注射,观察组则将异烟肼与地塞米松改为鞘内注射,连续治疗8周为1疗程,对所有患者随访20周,比较治疗前后两组脑脊液常规与生化结果,统计两组脑脊液细胞、蛋白、氯化物及糖恢复正常时间及治疗期间发生的不良反应.结果:治疗后两组,脊液中糖、蛋白、氯化物水平及细胞总数均显著低于治疗前(P＜0.05),观察组脊液中糖、蛋白、氯化物水平及细胞总数均低于对照组(P＜0.05),观察组脑脊液细胞、蛋白、氯化物及糖恢复正常时间均显著快于对照组(P＜0.05),观察组发生腰疼、背痛,低颅压性头痛及肝功能损伤的比例显著低于对照组(P＜0.05).结论:鞘内给予异烟肼联合地塞米松能有效提高脑脊液内药物浓度,提高药物治疗效果,缩短化疗时间,减少全身用药的不良反应.     

Acute autoimmune transverse myelitis following COVID-19 vaccination: A case report

Rationale:Transverse myelitis is an infectious or noninfectious inflammatory spinal cord syndrome. We report a rare case of transverse myelitis following vaccination against COVID-19.Patient concerns:A 70-year-old male presented with progressive sensorimotor dysfunction of the bilateral lower limbs 7 days after receiving the mRNA-1273 vaccine against COVID-19. Spinal magnetic resonance imaging revealed intramedullary lesions with gadolinium enhancement on the Th1/2 and Th5/6 vertebral levels. Cerebrospinal fluid (CSF) testing showed a mildly increased level of total protein and positive oligoclonal bands (OCB).Diagnosis:The patient was diagnosed with acute transverse myelitis.Intervention:The patient received 5 days of intravenous methylprednisolone pulse (1000 mg/day) followed by oral prednisolone (30 mg/day with gradual tapering).Outcomes:The patient fully recovered from muscle weakness of the lower limbs. He was discharged from our hospital and able to independently walk without unsteadiness.Lesson:This is a rare case of transverse myelitis following COVID-19 vaccination. Positive OCB in CSF in the present case highlights the possibility of autoimmune processes, including polyclonal activation of B lymphocytes, following vaccination.     

Cervical myelitis presenting as occipital neuralgia

Aim: Occipital neuralgia is a common form of headache that is characterized by paroxysmal severe lancinating pain in the occipital nerve distribution.

Methods: The exact pathophysiology is still not fully understood and occipital neuralgia often develops spontaneously. There are no specific guidelines for evaluation of patients with occipital neuralgia.

Result: Cervical spine, spinal cord and posterior neck muscle lesions can induce occipital neuralgia. Brain and spine imaging may be necessary in some cases, according to the nature of the headache or response to treatment.

Discussion: We report a case of cervical myelitis presenting as occipital neuralgia.