PMC5529383_01
Magnetic resonance imaging (MRI) of the spinal cord during course of illness. MRI showed a longitudinally extensive transverse myelitis (LETM) of the cervical and thoracic spinal cord. In the beginning, the abnormal T2-weighted intramedullary signal hyperintensity appeared filigree, extended over more than seven vertebral segments and was most prominent in the anterior gray substance. (A) Few days later, MRI revealed cervicothoracic cord swelling a large-scale injury of the cord. During the course of illness, LETM expanded transversally (C) and craniocaudally (B,D) into the brain stem [(E,F), arrowhead]. (C,G) Demonstrate edematous changes in the cervical spinal cord and medulla in axial images (arrow). White box shows area of higher magnification. Brain MRI was unremarkable (H,I).
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F1
Magnetic resonance imaging (MRI) of the spine ruled out compression but revealed T2-weighted intramedullary signal hyperintensity extending over more than seven vertebral segments (Figure 1) without contrast enhancement in the T1-weighted sequences.
Course of illness with timeline of therapy and craniocaudal extension of LETM in MRI. The arrows show a succession of clinical deterioration and complications in the first 2 weeks of illness. The gray bars represent time and duration of the used treatments. The dashed gray lines mark the continuation of drug administration. The black bars illustrate the ongoing craniocaudal extension of T2 signal hyperintensity. LE, lower extremity; MRI, magnetic resonance imaging; LETM, longitudinally extensive transverse myelitis.
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F2
After treatment with high-dose IV methylprednisolone (sequential treatment regimen is shown in Figure 2), a follow-up lumbar puncture showed normal cell counts with persistent elevation of protein, lactate, and albumin.
Multiple hemorrhagic lesions in upper and lower spinal cord. Heterogeneous appearance of spinal cord with high and low signal intensity in T1 (A), low signal in T2 (B), and contrast enhancement in T1 with gadolinium (C) indicates intramedullary hemorrhage in sagittal images (arrowhead). Representative axial images confirm hemorrhages with hypointense signal abnormalities in T2 medic [(D,E), white arrow]. T2 medic (multi-echo data image combination) is a heavily T2* weighted 2D spoiled gradient echo multi-echo sequence, which is also used to detect hemorrhagic lesions. (F) Demonstrates a 1.5 cm x 0.8 cm large hypointense lesion without contrast enhancement in the dorsal spinal canal at the L1 level likely representing a blood clot in sagittal (arrowhead) and axial view (arrow). White boxes display areas of higher magnification.
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F3
MRI on day 13 revealed further ascending T2 lesion with involvement of the medulla oblongata and hemorrhages in the upper and lower spinal cord (Figures 3A-F).