Abstract Details

Title Delayed Diagnosis of Fibrocartilaginous Embolism: Assessing the Vertebral Body on MRI

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P4 - Poster Session 4 (5:30 PM-6:30 PM)

Poster/Presentation
Number 3-008

Objective

Fibrocartilaginous embolism (FCE) is a well described phenomena that makes up 5.5% of spinal cord infarcts. It refers to the migration of fibrocartilaginous nucleus pulposus material from the vertebral body through nearby vasculature and embolizes into one of the spinal cord vessels. The embolic event may not follow the typical vascular distribution seen in a majority of spinal cord infarcts and could be frequently misdiagnosed on neuroimaging review.

Background A 43 year old healthy man presented as a transfer from an outside hospital after acute onset of bilateral lower extremity weakness and subsequent spasticity. Outside hospital MRI spine was initially interpreted as without cord signal abnormality, compression or enhancement. At our institution on review of the same imaging, we found a possible subtle cord T2 hyper-intensity in the left posterolateral cord at the T10-11 level concerning for demyelination, possibly transverse myelitis. The patient was initiated on high-dose corticosteroids however the patient did not show clinical improvement. Therefore, MRI spine was repeated one week later with dedicated Diffusion Weighted Imaging (DWI). There was not only a more definitive T2 hyperintense spinal cord lesion but also corresponding mild diffusion-restriction in the cord. Additionally, there was T11 vertebral body infarction which is a rare but diagnostic feature essential in distinguishing FCE from an inflammatory cord lesion.

Design/Methods N/A

Results N/A

Conclusions This case was originally misdiagnosed as idiopathic transverse myelitis but did not respond appropriately to management. The MRI finding of vertebral body infarction accompanying the spinal cord signal abnormality is a rare but highly specific finding for FCE proposed to be in the same arterial distribution. If found radiographically, vertebral body infarction can aid in timely proper diagnosis, avoidance of unnecessary testing such as cerebrospinal fluid analysis and excess therapeutic exposure such as high-dose corticosteroids.

Authors/Disclosures
Estevana Isaac, MD PRESENTER	Dr. Isaac has nothing to disclose.
Steven C. Swavely, MD (University of Pennsylvania Lancaster General Health)	No disclosure on file
Kiran Talekar	An immediate family member of Kiran Talekar has received personal compensation for serving as an employee of Verismo. An immediate family member of Kiran Talekar has received personal compensation for serving as an employee of GSK Pharmaceuticals. An immediate family member of Kiran Talekar has stock in GSK. The institution of Kiran Talekar has received research support from NIH. The institution of Kiran Talekar has received research support from Gates Foundation. An immediate family member of Kiran Talekar has received intellectual property interests from a discovery or technology relating to health care.
Joseph C. McCall, MD (Thomas Jefferson University)	No disclosure on file

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