Nontraumatic Spinal Cord Compression: MRI Primer for Emergency Department Radiologists

Laur, Olga; Nandu, Hari; Titelbaum, David S.; Nuñez, Diego; Khurana, Bharti

doi:10.1148/rg.2019190024

Cited by 33 publications

(22 citation statements)

References 40 publications

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“…The presence of COVID-19 infection can lead us astray, and we can miss the urgent diagnosis requiring medullar magnetic resonance imaging studies and surgical decompression. 5 Finally, the diagnosis might be acute myelopathy associated with COVID-19 infection 6 ; however, this must remain a diagnosis of elimination, in particular, because no specific treatment is available. Thus, with or without COVID-19 infection, patient with acute paraplegia must very quickly undergo computed tomography and, if the findings are negative, medullar magnetic resonance imaging.…”

Section: Acute Paraplegia With or Without Coronavirus Disease 2019 Infection: Decision-making Algorithmmentioning

confidence: 99%

“…3,4 This diffuse endothelial damage is followed by an increase in the circulating endothelial cells and a type III hypersensitive reaction. 4,5 The severity of COVID-19 includes a progressively higher production of cytokines, inducing, among other complications, a hypercoagulative state. In particular, IL-6 correlates with an augmented megakaryocytopoiesis, proven by histologic study of bone marrow and lungs with a high number of denuded megakaryocytes.…”

Section: Covid-19 Thromboembolic Complications: Deepening Immunoinflammatory Featuresmentioning

confidence: 99%

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Acute paraplegia with or without coronavirus disease 2019 infection: Decision-making algorithm

Naudin

Lermusiaux

Long

et al. 2021

Journal of Vascular Surgery

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In the context of the coronavirus disease 2019 (COVID-19) pandemic, a recent report by Naudin et al 1 sought to explain arterial thrombosis as a presentation of COVID-19 infection. Their patient was admitted with acute monoparesis and sensory loss of the left lower limb as a consequence of aortoiliac thrombosis and limb ischemia during COVID-19 infection. 1 However, we want to emphasize that, in addition to limb ischemia, spinal cord ischemia should be considered in patients with acute limb paresis and COVID-19 infection. We read very interesting article from Naudin et al while we were finishing a case series including very similar cases about two male patients with paraparesis and COVID-19 infection. The first patient was admitted with sudden paraplegia, urinary retention, and a pain and temperature sensory level of T6, with intact proprioceptive senses. His cremasteric and bulbocavernosus reflexes were absent. Dorsalis pedis pulses were present. A full spinal cord magnetic resonance imaging was normal. The next day, signs of limb ischemia were developed. Color Doppler ultrasound examination and computed tomography angiography revealed an infrarenal abdominal aorta thrombosis, with extension to both common iliac arteries.The second patient, with known multiple sclerosis, was admitted with urinary incontinence and acute paraparesis. In addition, he had diminished deep tendon reflexes of the lower limbs and hypoesthesia in the right leg. Distal pulses in the lower extremities were present. The next day, he developed signs of limb ischemia. Color Doppler ultrasound examination and computed tomography angiography revealed complete thrombosis of the infrarenal abdominal aorta with extension to both common iliac arteries.The results of COVID-19 tests were positive for both patients. It is plausible that the paraparesis in both patients was a sign of spinal cord ischemia as a consequence of aortic thrombosis in the context of COVID-19 infection. Spinal cord ischemia is a rare disease with a prevalence of 1.2% of all strokes. 2 In patients with COVID-19, who are more vulnerable to thromboembolic events, 3 such rare conditions may occur more frequently. Therefore, in patients with any acute neurologic deficit, different ischemic disorders, including spinal cord ischemia, as a consequence of thrombotic complication of COVID-19 should be considered and evaluated.

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Section: Acute Paraplegia With or Without Coronavirus Disease 2019 Infection: Decision-making Algorithmmentioning

confidence: 99%

Section: Covid-19 Thromboembolic Complications: Deepening Immunoinflammatory Featuresmentioning

confidence: 99%

Acute paraplegia with or without coronavirus disease 2019 infection: Decision-making algorithm

Naudin

Lermusiaux

Long

et al. 2021

Journal of Vascular Surgery

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“…Laur и соавт. [23] показали, что при проведении МРТ-исследования компрессия может быть локализована в эпидуральном, интрадуральном экстрамедуллярном или интрамедуллярном анатомических пространствах (рисунок 4). Чтобы различить эпидуральное поражение от интрадурального, необходима программа визуализации с подавлением жира, где степень компрессии спинного мозга и наличие интрамедуллярного T2-гиперинтенсивного сигнала указывают на наличие острого отека спинного мозга и являются критическими данными для последующей неотложной хирургической декомпрессии [23].…”

Section: трудности диагностикиunclassified

Epidural compression in infants less than 6 months of life with neuroblastoma: experience of Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology

Горохова

Качанов

Меришавян

et al. 2020

Voprosy gematologii/onkologii i immunopatologii v pediatrii

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Neuroblastoma (NB) can manifest through neurological symptoms caused by tumor extension into the spinal canal and the resulting epidural compression (EC). Clinical symptoms and management in patients with epidural compression depend on its level and duration, the severity of spinal cord compression, the patient's age and other factors. One of the biggest challenges is the diagnosis and treatment of EC in infants in the first months of life. Our retrospective analysis included 13 patients with NB complicated by spinal cord EC who had been diagnosed at the age of 0–6 months and treated at the D. Rogachev NMRCPHOI over the period from 01.01.2012 to 01.12.2018 (82 months). The study was approved by the Independent Ethics Committee and the Scientific Council of the D. Rogachev NMRCPHOI of the Ministry of Healthcare of the Russian Federation. The diagnosis of NB was based on the international diagnostic criteria. The tumors were staged in accordance with the INSS classification. The patients were stratified into risk groups and treated according to the modified NB-2004 protocol of the German Oncology Group. All the patients underwent diagnostic testing for neurogenic tumors as well as contrast-enhanced magnetic resonance imaging of the spinal cord with the assessment of the level of tumor invasion and the degree of spinal cord compression. The children were evaluated by a neurologist at admission and at follow-up visits. The median age at diagnosis of NB was 3.9 (0.5–6) months. At disease onset, 53.8% of patients had neurological symptoms, with motor deficiencies being the most common ones. In this group of patients, the median time from first neurological symptoms to diagnosis of NB was 1.56 months. Neurological symptoms at disease onset were not present or diagnosed at local healthcare facilities in 46.2% of infants. Extra-organic retroperitoneal primary tumors were found in 61.6% of patients; 30.7% of primary tumors were located in the posterior mediastinum, and 7.7% of primary tumors – in the lesser pelvis. No patients had MYCN-amplified tumors; in 1 case the MYCN gene status was evaluated as Gain; neither 1p nor 11q deletions were detected. The distribution of patients by INSS stages was as follows: stage 2 – 15.3%, stage 3 – 46.1%, stage 4 – 23.3% and stage 4S – 15.3%. The majority of patients (77.7%) were stratified into an observation group, the remaining patients (23.3%) were allocated to a medium risk group in accordance with the NB-2004 protocol. The level of tumor invasion into the spinal cord canal varied. Tumor invasion at the level of the cervicothoracic spine was observed in 15.4% of patients, at the level of the thoracic spine – in 15.4%, at the level of the thoracolumbar spine – in 46.2%, at the level of the lumbar spine – in 15.4%, and at the level of the sacral spine – in 7.7%. Neurosurgical intervention (laminotomy) was performed in 4 cases (30.7%). In one patient, laminotomy was the only treatment option (chemotherapy was not given). In two patients, neurosurgery was performed because of the deterioration of neurological symptoms caused by the start of the first polychemotherapy (PCHT) cycle. Chemotherapy was carried out in 92.3% patients. The patients from the observation group received 1–3 PCHT cycles (the median number of cycles was 2). Only one patient from the observation group did not receive PCHT. This patient underwent 2 surgeries. Currently, 10/13 (77%) patients are alive, 3/13 (33%) patients are dead (2/3 patients died of therapy-related infectious complications, and 1/3 – of acute heart failure in the early postoperative period). The median follow-up was 37.3 months. According to the assessment of late effects, neurological disorders were found in all the analyzed patients (n = 9), and orthopedic disorders were found in 66.6% (6/9) patients. The results of our analysis illustrate both the difficulty of diagnosis and management of EC in patients with NB and the need¬ for uniform testing and treatment standards with established follow-up and rehabilitation strategies for this group of patients.

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“…Up to 20% of these patients develop complications including spinal cord compression, which can lead to permanent neurological dysfunction if treatment is delayed. With the development of more effective systemic therapy (such as targeted and immunotherapy), the survival of patients with metastatic cancer has increased, and consequently, the incidence of spinal metastases is expected to rise ( 1 – 3 ).…”

Section: Introductionmentioning

confidence: 99%

Deep Learning Model for Classifying Metastatic Epidural Spinal Cord Compression on MRI

et al. 2022

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BackgroundMetastatic epidural spinal cord compression (MESCC) is a devastating complication of advanced cancer. A deep learning (DL) model for automated MESCC classification on MRI could aid earlier diagnosis and referral.PurposeTo develop a DL model for automated classification of MESCC on MRI.Materials and MethodsPatients with known MESCC diagnosed on MRI between September 2007 and September 2017 were eligible. MRI studies with instrumentation, suboptimal image quality, and non-thoracic regions were excluded. Axial T2-weighted images were utilized. The internal dataset split was 82% and 18% for training/validation and test sets, respectively. External testing was also performed. Internal training/validation data were labeled using the Bilsky MESCC classification by a musculoskeletal radiologist (10-year experience) and a neuroradiologist (5-year experience). These labels were used to train a DL model utilizing a prototypical convolutional neural network. Internal and external test sets were labeled by the musculoskeletal radiologist as the reference standard. For assessment of DL model performance and interobserver variability, test sets were labeled independently by the neuroradiologist (5-year experience), a spine surgeon (5-year experience), and a radiation oncologist (11-year experience). Inter-rater agreement (Gwet’s kappa) and sensitivity/specificity were calculated.ResultsOverall, 215 MRI spine studies were analyzed [164 patients, mean age = 62 ± 12(SD)] with 177 (82%) for training/validation and 38 (18%) for internal testing. For internal testing, the DL model and specialists all showed almost perfect agreement (kappas = 0.92–0.98, p < 0.001) for dichotomous Bilsky classification (low versus high grade) compared to the reference standard. Similar performance was seen for external testing on a set of 32 MRI spines with the DL model and specialists all showing almost perfect agreement (kappas = 0.94–0.95, p < 0.001) compared to the reference standard.ConclusionA DL model showed comparable agreement to a subspecialist radiologist and clinical specialists for the classification of malignant epidural spinal cord compression and could optimize earlier diagnosis and surgical referral.

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Nontraumatic Spinal Cord Compression: MRI Primer for Emergency Department Radiologists

Cited by 33 publications

References 40 publications

Acute paraplegia with or without coronavirus disease 2019 infection: Decision-making algorithm

Acute paraplegia with or without coronavirus disease 2019 infection: Decision-making algorithm

Epidural compression in infants less than 6 months of life with neuroblastoma: experience of Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology

Deep Learning Model for Classifying Metastatic Epidural Spinal Cord Compression on MRI

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