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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6009_Библиотеки_им_академика_М_И_Перельмана.pdf
Paraspinal Abscess
KEY FACTS
TERMINOLOGY
• Paraspinal phlegmon surrounding peripherally enhancing
fluid collections
IMAGING
• Prevertebral/paravertebral space
• Multiple or multiloculated collections along muscle plane
• NECT
○ Amorphous low-density intramuscular collection
○ Calcified psoas abscesses characteristic of tuberculous
paraspinal abscess (PA)
○ Endplate destruction
• MR
Infection and Inflammatory Disorders
○ Iso- to hypointense on T1WI
○ Hyperintense fluid collection and surrounding muscle on
T2WI and STIR
○ Diffuse enhancement: Phlegmon
○ Peripherally enhancing fluid collection(s): Abscess
(Left) Axial graphic through
the lumbar disc space
demonstrates an extensive
abscess infiltrating bilateral
psoas muscles and the
epidural space. Abnormal
retroperitoneal lymph nodes
are also present. (Right) Axial
NECT depicts bilateral
calcified paraspinal masses ſt
in a patient with tuberculosis
spondylodiscitis. The anterior
aspect of the vertebral body
adjacent to the subchondral
plate is affected with spread
to adjacent discs. Abscesses
may descend down the sheath
of the psoas and are typically
calcified.
TOP DIFFERENTIAL DIAGNOSES
• Neoplasm, primary or metastatic
• Retroperitoneal hematoma
• Extramedullary hematopoiesis
PATHOLOGY
• Most common pathogens
○ Staphylococcus aureus
○ Mycobacterium tuberculosis
○ Escherichia coli
CLINICAL ISSUES
• Fever (50%) at presentation
• Back pain and tenderness
• ↑ ESR, ↑ WBC
DIAGNOSTIC CHECKLIST
• Peripherally enhancing collection in paravertebral soft
tissue with associated spondylitis characteristic of PA
250
(Left) Sagittal contrastenhanced CT shows a large
anterior paravertebral abscess
ſt with narrowing of the
airway from adjacent disc
space infection. Also note the
large ventral epidural abscess
with cord compression .
(Right) Axial T1WI C+ MR
shows a peripherally
enhancing collection ſt in the
left neural foramen operative
site in this patient presenting
with fever following resection
a schwannoma.
Epidural Abscess
KEY FACTS
Infection and Inflammatory Disorders
TERMINOLOGY
• Spinal epidural abscess
• Extradural spinal infection with abscess formation
IMAGING
• Lower thoracic and lumbar > upper thoracic and cervical
• CT
○ Enhancing epidural mass narrowing central canal
• MR
○ T1WI: Iso- to hypointense to cord
○ T2WI/STIR: Hyperintense
○ T1WI C+: Homogeneously or heterogeneously
enhancing phlegmon
○ Peripherally enhancing necrotic abscess
• Fat saturation: STIR, T2WI FS, T1WI C+ FS
○ Increases lesion conspicuity by suppressing signal from
epidural fat and vertebral marrow
• Signal alteration in spinal cord secondary to compression,
ischemia, or direct infection
• Persistent epidural enhancement without mass effect on
follow-up MR imaging
○ Probable sterile granulation tissue or fibrosis
○ Correlate with ESR and CRP for disease activity
TOP DIFFERENTIAL DIAGNOSES
• Extradural metastasis
○ Often contiguous with vertebral lesion
• Epidural hematoma
○ ± mild peripheral enhancement
PATHOLOGY
• Staphylococcus aureus most common cause; Mycobacterium
tuberculosis next most frequent
CLINICAL ISSUES
• Fever, acute or subacute spinal pain and tenderness
• Radiculopathy, paraparesis/paralysis, paresthesia, loss of
bladder and bowel control
(Left) Sagittal graphic through
the lumbar spine
demonstrates vertebral
osteomyelitis with an
intervertebral abscess
extending ventrally and
dorsally and narrowing the
central canal. (Right) Sagittal
T1WI C+ MR in an intravenous
drug abuser shows a large
ventral epidural abscess
collection ſt with peripheral
enhancement causing severe
mass effect upon the cervical
cord. There is relative
preservation of the C5-6
endplates with no disc
enhancement.
(Left) Sagittal T1 C+ MR shows
abnormal circumferential
epidural thickening and
enhancement in this patient
with meningitis complicated
by epidural phlegmon ſt and
abscess . (Right) Sagittal
STIR MR shows a large ventral
epidural abscess ſt as T2
hyperintensity with severe
mass effect upon the cord.
Involvement of the posterior
C5-6 disc is seen as linear
hyperintensity st. There is
cord hyperintensity in this
patient , who was
quadriparetic.
251
Abscess, Spinal Cord
KEY FACTS
TERMINOLOGY
• Infection of spinal cord with necrosis
• Very rare, typically associated with dermal sinus in children
IMAGING
• Irregular ring-enhancing mass within cord with appropriate
clinical history of inflammation/infection
• Increased T2WI signal from abscess core and surrounding
edema; cord expansion
• Capsule may show low signal as in brain abscess
• May show positive diffusion (reduced apparent diffusion
coefficient) similar to brain abscess
TOP DIFFERENTIAL DIAGNOSES
Infection and Inflammatory Disorders
• Hypervascular cord primary neoplasms
• Metastasis
• Acute transverse/viral myelitis
• Acute multiple sclerosis
• Cavernous malformation
(Left) Sagittal graphic shows
an irregular abscess cavity in
the cervical cord with cord
expansion and edema. (Right)
Sagittal T2WI MR shows high
signal intensity centrally with
a dark rim, which is often seen
in inflammatory lesions and
extensive edema, tracking
rostrally into the medulla and
caudally into the thoracic
spinal cord. This appearance is
not specific for abscess and
primary or secondary cord
neoplasm would have to be
considered as well.
PATHOLOGY
• 2 major etiologies
○ Adult intramedullary abscess either hematogenous
seeding from cardiopulmonary source or idiopathic
○ Children often have congenital cause allowing direct
extension of infection
– Dermal sinus tract or spinal dysraphism
CLINICAL ISSUES
• Often presents with signs/symptoms of structural cord
lesion rather than infection
• Mixed neurologic deficits including fever, pain, motor
deficit, sensory disturbance, and sphincter dysfunction
• Mortality of 8% in antibiotic era (1977-1997)
DIAGNOSTIC CHECKLIST
• Brain MR to exclude concomitant brain abscess
• Serial WBC count, ESR, enhanced MR important for
postoperative follow-up, detection of recurrence
252
(Left) Sagittal T2WI MR in a
patient with streptococcal
endocarditis shows diffuse
cord expansion with a ringshaped area of low T2 signal
(abscess capsule) within the
cord from C4 to C5-6 ſt.
(Right) Sagittal T1WI C+ MR in
a patient with streptococcal
endocarditis demonstrates the
abscess capsule region shows
ring enhancement .
Acute Transverse Myelopathy
KEY FACTS
Infection and Inflammatory Disorders
TERMINOLOGY
• Noncompressive myelopathy
• Etiologies include inflammatory causes [acute transverse
myelitis (ATM)] + vascular disease + radiation +
paraneoplastic + idiopathic (unknown)
○ ATM is broad generic term encompassing
heterogeneous group of disorders causing cord
dysfunction
– Is more specific term for cord dysfunction that is
inflammatory in etiology
– Inflammation defined by CSF findings and MR
enhancement
IMAGING
• Hyperintense lesion on T2WI with mild cord expansion
±enhancement
• Longitudinally extensive T2 signal abnormality =
neuromyelitis optica, acute disseminated
encephalomyelitis, viral infection
TOP DIFFERENTIAL DIAGNOSES
• Inflammatory etiologies
○ Acquired demyelinating
– Multiple sclerosis
– Neuromyelitis optica
– Acute disseminated encephalomyelitis
○ Parainfectious
○ Systemic autoimmune
○ Paraneoplastic (antineuronal immune disorder
associated with cancer)
• Noninflammatory mimics
○ Radiation
○ Metabolic
○ Tumor and cysts
○ Vascular
– Cord infarction
– Dural fistula (type I AVF)
• Idiopathic ATM
(Left) Sagittal T2WI MR shows
longitudinally extensive T2
hyperintensity throughout the
cervical cord and lower
medulla. Differential
diagnoses include
neuromyelitis optica, acute
disseminated
encephalomyelitis, and
parainfectious and systemic
autoimmune disorders. (Right)
Sagittal T2 FS MR in this
patient with multiple bone
metastases and prior radiation
therapy shows diffuse
increased signal in the cord.
Primary considerations would
be radiation myelopathy vs.
paraneoplastic myelopathy.
(Left) Sagittal T2 TSE MR in
this patient with lung cancer
shows a focal mass at the C3
level ſt with adjacent cord
edema from a focal cord
parenchymal metastasis.
(Right) Sagittal T1 C+ MR
shows enhancement of focal
cord metastasis ſt in this
patient with lung carcinoma
and worsening myelopathy.
253
Multiple Sclerosis
KEY FACTS
TERMINOLOGY
• Primary demyelinating disease of CNS with multiple lesions
disseminated over time and space
○ Concomitant intracranial lesions in periventricular,
subcallosal, brain stem, or cerebellar white matter
IMAGING
• Isolated spinal cord disease (10-20%)
• Cervical segment is most commonly affected
○ Dorsolateral aspect of cord
○ < 1/2 of cross-sectional area of spinal cord
○ < 2 vertebral segments in length
• Sagittal and axial T1WI & T2WI sequences with gadolinium
Infection and Inflammatory Disorders
○ Lesions typically oval, peripheral, and asymmetric
○ Discrete vs. vague hyperintense lesions
○ Enhancement lasts 1-2 months but does not reflect
disease progression
(Left) Sagittal graphic depicts
multiple demyelinating
plaques within the cervical
spinal cord. (Right) Sagittal
T2WI MR of the cervical spinal
cord demonstrates multiple T2
hyperintense foci ſt, some
well defined and others ill
defined. The multiplicity of
lesions & lack of edema or
significant cord expansion is
typical for demyelinating
disease.
TOP DIFFERENTIAL DIAGNOSES
• Intramedullary neoplasm
• Idiopathic transverse myelitis
• Neuromyelitis optica
PATHOLOGY
• Autoimmune, inflammatory process focused on CNS myelin
CLINICAL ISSUES
• Peak onset: 20-40 years
• Relapsing-remitting: Distinct periods of new or worsening
symptoms alternating with complete or partial recovery
• Secondary progressive: From relapsing-remitting multiple
sclerosis, worsening deficits
• Primary progressive: Steady progression of symptoms
• Progressive relapsing: Includes distinct periods of
exacerbation but without recovery
254
(Left) Sagittal T1WI C+ MR
shows multiple enhancing
demyelinating lesions within
the cervical spinal cord.
Enhancement varies from
focal st to ill defined . The
enhancement pattern changes
with evolution of
inflammation. (Right) T1WI C+
MR (sagittal on top, axial on
bottom) images illustrate an
incomplete rim-enhancing
lesion ſt in the dorsal cervical
cord at the C3-4 level. A 2nd
small enhancing focus is noted
in the ventral cord at the C6
level st.
Neuromyelitis Optica
KEY FACTS
Infection and Inflammatory Disorders
TERMINOLOGY
• Synonyms: Devic disease, optic-spinal multiple sclerosis
• Autoimmune inflammatory disorder involving myelin of
neurons of optic nerves and spinal cord with limited brain
parenchymal involvement
IMAGING
• Longitudinally extensive (> 3 vertebral segments) T2
hyperintensity within cord + enhancement of optic nerves
(85% of cases)
• T2 abnormality tends to involve entire cross section of cord,
unlike more focal involvement of multiple sclerosis
TOP DIFFERENTIAL DIAGNOSES
• Inflammatory etiologies
○ Multiple sclerosis
○ Acute disseminated encephalomyelitis (ADEM)
○ Parainfectious myelitis (viral, bacterial)
• Systemic autoimmune disease
• Noninflammatory mimics
○ Dural fistula
○ Tumor
• Idiopathic acute transverse myelitis
PATHOLOGY
• Autoimmune disease targeting water channel proteins
(aquaporin-4)
CLINICAL ISSUES
• Revised diagnostic criteria (2006)
○ Optic neuritis, myelitis, and at least 2 of 3 supportive
criteria
– Contiguous cord lesion 3 or more segments in length,
initial brain MR nondiagnostic for multiple sclerosis, or
neuromyelitis optica (NMO)-IgG seropositivity
DIAGNOSTIC CHECKLIST
• Simultaneous optic neuritis and myelitis → NMO cannot be
distinguished from ADEM at 1st attack
(Left) Sagittal T2WI MR shows
a long segment of cord
enlargement with T2
hyperintensity ſt. (Right)
Sagittal T1WI C+ MR shows
cord enlargement and illdefined enhancement ſt.
Neuromyelitis optica (NMO) is
an autoimmune disease
possibly targeting the
aquaporin-4 transmembrane
water channel. The
vasculocentric distribution of
NMO-IgG antigen correlates
with the sites of
immunoglobulin and
complement deposition seen
in spinal cord lesions of
patients with NMO.
(Left) Axial T1WI C+ FS MR
reveals intense enhancement
and mild enlargement of the
intracanalicular and
prechiasmatic segments of the
right optic nerve ſt. (Right)
Coronal T1WI C+ FS MR
reveals intense enhancement
and mild enlargement of the
intracanalicular and
prechiasmatic segments of the
right optic nerve ſt. This is the
classic appearance of Devic
disease involving the optic
nerves and spinal cord with no
brain parenchymal
abnormalities.
255
ADEM
KEY FACTS
TERMINOLOGY
• Para-/postinfectious immune-mediated inflammatory
disorder of white matter
○ Antibodies to pathogens exhibit cross immunoreactivity
with myelin basic protein
IMAGING
• Multifocal white matter lesions with relatively little mass
effect or vasogenic edema
○ Flame-shaped lesions with slight cord swelling
○ Dorsal white matter more voluminous
○ May see gray matter involvement
Infection and Inflammatory Disorders
○ Variable enhancement depending on stage of disease
○ May see nerve enhancement
• Brain almost always involved
TOP DIFFERENTIAL DIAGNOSES
• Inflammatory etiologies
○ Acquired demyelinating
(Left) Sagittal T1WI C+ MR
shows linear enhancement
along the dorsal surface of the
midcervical cord ſt. Acutely,
there is perivenous edema,
demyelination, and infiltration
with macrophages and
lymphocytes with relative
axonal sparing. The late
course of the disease is
characterized by perivascular
gliosis. (Right) Axial T2WI MR
depicts a hyperintense focus in
the right hemicord ſt with
minimal cord enlargement.
ADEM is a postinfectious
disease mediated by
autoreactive cells or
molecules.
– Multiple sclerosis
– Neuromyelitis optica
○ Parainfectious myelitis
○ Systemic autoimmune (vasculitis)
• Noninflammatory mimics
○ Vascular malformation
○ Infarction, spinal cord
○ Tumor and cysts
• Idiopathic acute transverse myelitis
CLINICAL ISSUES
• Typically monophasic illness lasting 2-4 weeks
○ Encephalopathy, paresis
• Typically in childhood or young adult
DIAGNOSTIC CHECKLIST
• Rescanning if initially negative
○ Typically delay between clinical onset and appearance of
imaging findings
256
(Left) Sagittal T2 MR in this
patient with postvaccination
ADEM shows diffuse lower
cervical and thoracic cord
expansion and T2
hyperintensity ſt. (Right)
Axial FLAIR MR shows focal
demyelination involving right
posterior temporal white
matter in this patient with
postvaccination
demyelination.
Sarcoidosis
KEY FACTS
Infection and Inflammatory Disorders
TERMINOLOGY
• Neurosarcoidosis
• Noncaseating granulomatous disease
IMAGING
• Intramedullary
○ Fusiform cord enlargement
○ Enhancing intramedullary masses
○ Focal or diffuse T2-hyperintense lesions
• Intradural extramedullary
○ Leptomeningeal enhancement
○ Dural masses
• Extradural
○ CT/radiographs: Sclerotic or mixed lytic and sclerotic
lesions
• Combination of leptomeningeal and peripheral
intramedullary mass-like enhancement suggestive of spinal
sarcoidosis
TOP DIFFERENTIAL DIAGNOSES
• Intramedullary neoplasm
• Idiopathic transverse myelitis
• Lymphoma
• Intradural metastases
• Multiple sclerosis
CLINICAL ISSUES
• Clinical CNS involvement in patients with sarcoidosis (5%)
○ Spinal intramedullary sarcoidosis (< 1%)
• Lower extremity weakness, paresthesia
• Bladder and bowel dysfunction
• Protean imaging manifestations
○ Mimicking multiple spinal pathologies
○ Typically, systemic disease present; rarely, intramedullary
sarcoid as initial presentation
• Treatment: Intravenous ± oral corticosteroids
○ Immunosuppressive therapy
(Left) Graphic depicts multiple
intramedullary sarcoid
granulomas in brainstem &
upper cervical cord. The
intramedullary, intradural
extramedullary, & extradural
regions can be involved. Rare
findings, such as calcifications
& cyst formation, have also
been described. (Right)
Sagittal T1WI C+ MR
demonstrates diffuse linear
leptomeningeal enhancement
ſt with areas of nodularity
. There is intracranial
involvement with sarcoidosis
st. Bulky leptomeningeal
disease is unusual with
neurosarcoidosis.
(Left) Axial T2WI MR (top)
shows intramedullary
hyperintensity ſt. Axial T2WI
MR (bottom) reveals irregular
leptomeningeal enhancement
along the cord st. (Right)
Sagittal T1WI C+ MR exhibits
multiple enhancing
subarachnoid nodules
interspersed among the cauda
equina ſt. Intradural
extramedullary lesions are
usually represented by
leptomeningeal sarcoidosis
infiltration, present in up to
60% of spinal cord lesions.
257
Grisel Syndrome
KEY FACTS
TERMINOLOGY
• Atlantoaxial rotary subluxation accompanying respiratory
infection or otolaryngologic surgery
IMAGING
• Fixed, rotated head occurring in child soon after upper
respiratory infection or otolaryngologic surgery
• Difficult to obtain adequate films 2° to head position
• Open-mouth odontoid: Asymmetric C1 lateral masses
○ Anteriorly rotated side wider and closer to odontoid
○ Opposite side smaller and farther from odontoid
• Lateral view: ± widened atlantodental interval
• Dynamic CT: Should include occiput C1-C2
Infection and Inflammatory Disorders
○ Initial scan: Maintain position of comfort
○ 2nd scan: Rotate head to contralateral side
○ Interpretation: C1-C2 relationship fixed or C1 unable to
rotate past neutral to contralateral side
• MR may replace CT to eliminate radiation dose
(Left) Lateral radiograph
shows typical retropharyngeal
effusion due to strep
pharyngitis ſt. Grisel
syndrome may occur with any
stage of infection, from
effusion to extensive abscess.
(Right) Axial CECT shows
retropharyngeal space abscess
ſt due to left palatine
tonsillitis . Although the C1C2 articulation is not affected,
one can appreciate how easily
inflammatory changes can
track to that articulation.
TOP DIFFERENTIAL DIAGNOSES
• Torticollis
○ Resolves within few days to weeks
• Septic C1-C2 joint
PATHOLOGY
• Multiple theories: Common theme tracking of
inflammatory mediators from upper airway
CLINICAL ISSUES
• Pain, head tilt, restricted neck movement
• Cock-robin position: Head rotated and tilted to 1 side with
chin lifted to opposite side
• Associated with otitis media, pharyngitis, retropharyngeal
abscess, upper respiratory infection, otolaryngologic
surgery
• 68% < 12 years old; 90% < 21 years old
• Leads to permanently fixed deformity if left untreated
• Reduction and immobilization are key
258
(Left) Sagittal STIR MR in a
florid case of craniovertebral
junction bacterial infection
shows marked increased signal
involving prevertebral space
ſt, odontoid, and loss of
anterior C1 arch margin. This
is to be contrasted with the
less aggressive appearance of
Grisel syndrome. (Right) Axial
T1 C+ MR shows infection
involving the craniovertebral
junction with multiple small
abscesses within the posterior
nasopharyngeal tissue ſt.
Note the close anatomic
relationship, which would
allow for C1-C2 joint
involvement.
IgG4-Related Disease/Hypertrophic Pachymeningitis
KEY FACTS
Infection and Inflammatory Disorders
TERMINOLOGY
• Idiopathic hypertrophic pachymeningitis
• IgG4-related hypertrophic pachymeningitis (IgG4-RHP)
• Multiorgan immune-mediated condition, which mimics
multiple malignant, infectious, and inflammatory disorders
○ Chronic progressive diffuse inflammatory fibrosis of dura
of brain or spine
IMAGING
• Linear low-signal mass involving dura with variable mass
effect upon cord
• Low-signal linear mass effacing CSF and cord
• Peripheral enhancement related to peripheral zone of
active inflammation vs. chronic central fibrosis
TOP DIFFERENTIAL DIAGNOSES
• Meningioma
• Lymphoma
• Tuberculosis
• Sarcoidosis
• Dural metastases
• Venous engorgement (CSF leak)
PATHOLOGY
• Autoreactive IgG4 antibodies observed in IgG4-related
disease
○ No evidence they are directly pathogenic
• Central pathology features
○ Lymphoplasmacytic infiltration
○ Obliterative phlebitis
○ Storiform fibrosis
○ Mild to moderate tissue eosinophilia
CLINICAL ISSUES
• Spinal presentation as mass with myelopathy or
radiculopathy
• Histopathology remains cornerstone of diagnosis
(Left) Sagittal T2WI MR shows
extensive low signal intensity
thickening of the dura
involving the posterior fossa
and extending to involve the
upper cervical dura to the C4
level ſt. There is severe cord
compression with loss of
normal CSF signal from the
C1-3 level. (Right) Sagittal
T1WI C+ MR shows diffuse
enhancement of dural
thickening of the posterior
fossa and upper cervical dura.
Note the variable
enhancement with areas that
homogeneously enhance ſt
and other areas with more
peripheral enhancement .
(Left) Axial T1WI C+ MR shows
diffuse enhancement of the
markedly thickened dura
circumferentially surrounding
the cord ſt. (Right) Sagittal
T2WI MR shows extensive
linear low signal ſt involving
the dura throughout both the
ventral and dorsal aspects of
the lumbar spine. This patient
has undergone dural biopsy
.
259