Answer for CoW 25 Feb 2018
Tuberculous Spinal Arachnoiditis with Tuberculomas- brain.
Findings
SPINE Spinal cord expansion from D4 to lower border of L1 vertebra with clumped & thickened nerve roots showing enhancement on contrast. Multiple nodular T2 hypointense lesions noted in thecal sac extending from D7 upto filum terminale level, showing conglomerate rim enhancement with enhancement of adjacent meninges. BRAIN Multiple conglomerate rim enhancing lesions noted in prepontine, quadrigeminal cisterns,right ambient cistern causing mass effect over pons, midbrain & adjacent parenchyma with thick leptomeningeal enhancement.
Discussion
Spinal arachnoiditis refers to an inflammatory process of the leptomeninges that has various causes, including infections, intrathecal administration of chemical agents, subarachnoid hemorrhage, trauma, disk disease. Tuberculosis has been reported to be the most common infectious cause. Frequent involvement of nerve roots and the spinal cord differentiates tubercuar arachnoiditis from arachnoiditis of other causes. Although the disease may occur as a primary event, more than 50% of the cases are associated with meningitis or, occasionally tubercular spondylitis. Diagnosis of TB arachnoiditis is usually based on clinical features, association tubercular meningitis and CSF analysis. MRI Increased signal intensity of the CSF on T1WI & enhancement of the meninges ( signifying ongoing inflammation) are signs that may aid in early diagnosis of arachnoiditis before onset of adhesive process. This enhancement is smooth in contrast to the irregular, nodular pattern of enhancement in leptomeningeal carcinomatosis. Other signs: Enhancement of spinal cord and nerve roots. Presence of CSF loculations Subarachnoid nodular lesions
REFERENCES: Kumar A, Montanera W, Willinsky R. TerBrugge WG, Aggarwal S. MR features of tubercular arachnoiditis. J Coinput Assist Tomogr 1993: 17: 127-130 Jinkins JR. Gupta R, Chang KH, Radriguez-Carbajali. MR imaging of central nervous system tuberculosis. Radial Clin North Am 1995;33:771-786 Ross JS, Masaryk Ti. Modic MT. et al. MR imaging of lumbar arachnoiditis. AiR 1987; 149:1025-1032 Johnson CE, Sze G. Benign lumbar arachnoiditis: MR imaging with gadopentetate dimeglumine. AJNR 1990; 1 1:763-770 Fin GJ. Stevens JM. Postoperative arachnoiditis diagnosed by high resolution fast spin echo MRI of the lumbar spine. Neuroi-adiologv 1995:37:139-145
Findings
SPINE Spinal cord expansion from D4 to lower border of L1 vertebra with clumped & thickened nerve roots showing enhancement on contrast. Multiple nodular T2 hypointense lesions noted in thecal sac extending from D7 upto filum terminale level, showing conglomerate rim enhancement with enhancement of adjacent meninges. BRAIN Multiple conglomerate rim enhancing lesions noted in prepontine, quadrigeminal cisterns,right ambient cistern causing mass effect over pons, midbrain & adjacent parenchyma with thick leptomeningeal enhancement.
Discussion
Spinal arachnoiditis refers to an inflammatory process of the leptomeninges that has various causes, including infections, intrathecal administration of chemical agents, subarachnoid hemorrhage, trauma, disk disease. Tuberculosis has been reported to be the most common infectious cause. Frequent involvement of nerve roots and the spinal cord differentiates tubercuar arachnoiditis from arachnoiditis of other causes. Although the disease may occur as a primary event, more than 50% of the cases are associated with meningitis or, occasionally tubercular spondylitis. Diagnosis of TB arachnoiditis is usually based on clinical features, association tubercular meningitis and CSF analysis. MRI Increased signal intensity of the CSF on T1WI & enhancement of the meninges ( signifying ongoing inflammation) are signs that may aid in early diagnosis of arachnoiditis before onset of adhesive process. This enhancement is smooth in contrast to the irregular, nodular pattern of enhancement in leptomeningeal carcinomatosis. Other signs: Enhancement of spinal cord and nerve roots. Presence of CSF loculations Subarachnoid nodular lesions
REFERENCES: Kumar A, Montanera W, Willinsky R. TerBrugge WG, Aggarwal S. MR features of tubercular arachnoiditis. J Coinput Assist Tomogr 1993: 17: 127-130 Jinkins JR. Gupta R, Chang KH, Radriguez-Carbajali. MR imaging of central nervous system tuberculosis. Radial Clin North Am 1995;33:771-786 Ross JS, Masaryk Ti. Modic MT. et al. MR imaging of lumbar arachnoiditis. AiR 1987; 149:1025-1032 Johnson CE, Sze G. Benign lumbar arachnoiditis: MR imaging with gadopentetate dimeglumine. AJNR 1990; 1 1:763-770 Fin GJ. Stevens JM. Postoperative arachnoiditis diagnosed by high resolution fast spin echo MRI of the lumbar spine. Neuroi-adiologv 1995:37:139-145
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!