Case #85: The man with progressive limb weakness
This 60+ year old man presents with progressive limb weakness and numbness over the last 1 year.
Here are 2 of his MRI scans:
Questions:
1. What is the difference between the 1st and 2nd scan?
2. Identify the pathology.
Mon, 130709 @ 0700
Categories: Patient of the Week, Xray of the Week
kopi susu . good one!
how about fat , grey, white matter?. Not sure how to differentiate btw T1,T2 slides.
1. Picture one is T2; Picture two is T1 weighted on MRI. Fluid appears hyperintense in T2 weighted MRI. Easy way to remember is “kopi susu”; Both are fluids, but T1 = kopi (coffee – black); T2 = susu (milk – white).
2. Pathology: There is loss of cervical lordosis in this patient seen on both MRI. There is also a space occupying lesion (height: 3cm X thickness: 0.5cm) located behind the C3, 4, 5 vertebrae causing spinal canal stenosis, which is suggestive of a continuous lesion from the herniated nucleus pulposus. The most likely diagnosis would be herniation of the nucleosus pulposus causing compression of the pyramidal tract fibers traveling downwards leading to progressive limb weakness (Usually more on 1 side due to the presence of posterior longitudinal ligament) & numbness for the past 1 year. However, my differential diagnosis would include cervical spinal epidural abscess & Pott’s disease.
1. I think the MRI are differ in the sense that first MRI is T2 enchanced (as evidenced by bright fluid and bright fat tissues). the second MRI is T1 enchanced as evidenced by darken fluid (CSF) and bright fat tissues.
2. There were a hypodense lesion seen at C5 level prolapsed into spinal canal and compressed on spinal cord.
My diagnosis would be spinal stenosis secondary to prolapse intervertebral disk/herniated nucleous pulposus.
(Nevertheless, isnt that HNP fits more to younger age group, Dr Jimbo?)
On second thought, I think it’s the other way.
First MRI = T2 weighted
Second MRI – T1 weighted
1. Both MRI should be taken on the same day, the difference is in the proton density (T1 and T2), I think the first MRI is T1 weighted and the second MRI is T2 weighted.
2. Hypodense space occupying lesion at the C5-6 level compressing on the spinal cord.