Category: Neuroradiology, Region: Spinal canal / Myelon, Plane: Other
A 21-years-old man was brought to the Emergency Room with history of acute onset of tetraplegia after falling asleep and having spent the night on the chair with his elbows on his knees and his head in his hands. He reported having smoked heroin and cannabis the night before. In his previous history it was mentioned surgical correction of Tetralogy of Fallot at the age of 13 months. Physical examination revealed flaccid paralysis with complete motor deficit below the spinal level of C6 to the right and below C7 to the left. Tactile hypoesthesia was present from C6 to D4 level, with complete tactile anesthesia below D4, involving the perineum, and no pain response below C6 bilaterally. The tendon reflexes in the lower limbs, the right triceps reflex and the bulb-cavernous reflex were absent, with reduced axial tone. A complete blood panel revealed neutrophilic leukocytosis (11 x 103 / mm3), increase in CPK (2777 mU / ml) and in myoglobin (349.8 ng / ml). The tox-screen confirmed the consumption of opioids and cannabinoids. Therefore we performed CT of the brain and spine with negative outcome for blood extravasation, focal parenchymal lesions, hydrocephalus and trauma of the column. On the other hand, the MRI of the spine showed an extended and altered signal of the spinal cord from C2 to D7, more evident between C4-C7, where all the quadrants were interested and the spinal cord was swollen sectorially. The lesion was hyperintense on T2 weighted images [FIGURE 1-2] and hypointense in T1, with contrast enhancement and associated alteration of the paraspinous tissue [FIGURE 3-4-5-6 ]. Angiography of medullary vessels didn’t show AVM, neither fistulas or dissection. The CSF analysis revealed a slight protidorrachia (67mg/dl) and serology analysis has a negative outcome for ANCA and ANA. Then we set an empirical therapy with acyclovir (750mg x 3), ceftriaxone (2 g die), methylprednisolone (500mg die) and ASA (100mg die). Due to the acute onset of respiratory distress, the patient was transferred to the ICU where he was sedated, intubated and connected to the ventilator. In the following days there was a steady improvement of the sensibility up to total recovery, although motor deficits still occurred. After the weaning from mechanical ventilation, the patient was transferred to the "Spinal Unit" for a 5 months rehabilitation program, to let the complete motor function recovery. The MRI confirmed a reduction of medullary areas related to altered signal and to the bulge of the spinal cord [FIGURE 7-8]. Today the patient presents only a urination problem, solved by intermittent catheterizations. The final diagnosis was transverse myelitis of undefined diagnosis, probably due to the use of opioids and cannabinoids. FIGURE 1-2: STIR sagittal (1) and FSE axial (2) T2-weighted images show an hyperintense vast area within spinal cord between C4-C7, a spinal cord swelling and an hyperintense signal of contiguous paraspinous tissues. FIGURE 3-4-5-6: sagittal (3) and axial C5 (4), C6 (5) and C7 (6) T1-weighted images, after contrast medium administration, show contrast enhancement of the spinal cord and of the contiguous paraspinous tissues. FIGURE 7-8: follow up STIR sagittal (7) and FSE axial (8) T2-weighted images reveal a reduction in spinal cord hyperintensity and swelling with restitutio ad integrum of paraspinous tissue.