Semin Neurol 2008; 28(1): 105-120
DOI: 10.1055/s-2007-1019132
© Thieme Medical Publishers

An Approach to the Diagnosis of Acute Transverse Myelitis

Anu Jacob1 , Brian G. Weinshenker2
  • 1Division of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, United Kingdom
  • 2Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota
Further Information

Publication History

Publication Date:
07 February 2008 (online)

ABSTRACT

The differential diagnosis of acute inflammatory transverse myelitis (ATM) is broad. Therefore, physicians must be aware of the many potential etiologies for acute myelopathy, and should pursue an ordered, efficient, and cost-effective approach to the diagnosis based on the patient's clinical history, examination, and magnetic resonance imaging (MRI) findings. Clinical, immunological, and radiological findings of noncompressive myelopathies are reviewed, as are how these findings can be used to distinguish between demyelinating, infectious, other inflammatory, vascular, neoplastic, and paraneoplastic etiologies. We also review predictors of further episodes of ATM in patients with demyelinating disorders. We discuss the diagnostic clues and pitfalls of the not uncommon clinical scenario of a presumed “myelopathy with normal MRI.” Finally, we suggest an algorithm for the diagnosis and management of acute myelopathies.

REFERENCES

  • 1 Pou Serradell A, Roquer Gonzalez J, Perich Alsina X. Acute posterior cord lesions in multiple sclerosis: an MRI study of the clinical course in 20 cases.  Rev Neurol (Paris). 2000;  156(12) 1126-1135
  • 2 Brex P A, Ciccarelli O, O'Riordan J I et al.. A longitudinal study of abnormalities on MRI and disability from multiple sclerosis.  N Engl J Med. 2002;  346(3) 158-164
  • 3 Miller D, Barkhof F, Montalban X, Thompson A, Filippi M. Clinically isolated syndromes suggestive of multiple sclerosis, part I: natural history, pathogenesis, diagnosis, and prognosis.  Lancet Neurol. 2005;  4(5) 281-288
  • 4 Fisniku L K, Brex P, Dan A R et al.. 20-year MRI and clinical follow-up of patients with clinically isolated syndromes suggestive of MS.  Neurology. 2007;  68(suppl 1) A331
  • 5 Lennon V A, Wingerchuk D M, Kryzer T J et al.. A serum autoantibody marker of neuromyelitis optica: distinction from multiple sclerosis.  Lancet. 2004;  364(9451) 2106-2112
  • 6 Weinshenker B G, Wingerchuk D M, Vukusic S et al.. Neuromyelitis optica IgG predicts relapse after longitudinally extensive transverse myelitis.  Ann Neurol. 2006;  59(3) 566-569
  • 7 Pittock S J, Weinshenker B G, Lucchinetti C F et al.. Neuromyelitis optica brain lesions localized at sites of high aquaporin 4 expression.  Arch Neurol. 2006;  63(7) 964-968
  • 8 Wingerchuk D M. Postinfectious encephalomyelitis.  Curr Neurol Neurosci Rep. 2003;  3(3) 256-264
  • 9 Das R N, Jaykumar J. Acute transverse myelitis following typhoid vaccination.  Ulster Med J. 2007;  76(1) 39-40
  • 10 Cizman M, Pokorn M, Osredkar D. Re: transverse myelitis after measles and rubella vaccination.  J Paediatr Child Health. 2005;  41(8) 460
  • 11 Fonseca L F, Noce T R, Teixeira M L, Teixeira Jr A L, Lana-Peixoto M A. Early-onset acute transverse myelitis following hepatitis B vaccination and respiratory infection: case report.  Arq Neuropsiquiatr. 2003;  61(2A) 265-268
  • 12 Booss J, Davis L E. Smallpox and smallpox vaccination: neurological implications.  Neurology. 2003;  60(8) 1241-1245
  • 13 Larner A J, Farmer S F. Myelopathy following influenza vaccination in inflammatory CNS disorder treated with chronic immunosuppression.  Eur J Neurol. 2000;  7(6) 731-733
  • 14 Ahasan H A, Chowdhury M A, Azhar M A, Rafiqueuddin A K. Neuroparalytic complications after anti-rabies vaccine (inactivated nervous tissue vaccine).  Trop Doct. 1995;  25(2) 94
  • 15 Kaplin A I, Krishnan C, Deshpande D M, Pardo C A, Kerr D A. Diagnosis and management of acute myelopathies.  Neurologist. 2005;  11(1) 2-18
  • 16 Krishnan C, Kerr D A. Idiopathic transverse myelitis.  Arch Neurol. 2005;  62(6) 1011-1013
  • 17 Transverse Myelitis Consortium Working Group . Proposed diagnostic criteria and nosology of acute transverse myelitis.  Neurology. 2002;  59(4) 499-505
  • 18 Hummers L K, Krishnan C, Casciola-Rosen L et al.. Recurrent transverse myelitis associates with anti-Ro (SSA) autoantibodies.  Neurology. 2004;  62(1) 147-149
  • 19 Frohman E M, Havrdova E, Lublin F et al.. Most patients with multiple sclerosis or a clinically isolated demyelinating syndrome should be treated at the time of diagnosis.  Arch Neurol. 2006;  63(4) 614-619
  • 20 Pittock S J, Weinshenker B G, Noseworthy J H et al.. Not every patient with multiple sclerosis should be treated at time of diagnosis.  Arch Neurol. 2006;  63(4) 611-614
  • 21 Villar L M, Masjuan J, Sadaba M C et al.. Early differential diagnosis of multiple sclerosis using a new oligoclonal band test.  Arch Neurol. 2005;  62(4) 574-577
  • 22 Soderstrom M, Ya-Ping J, Hillert J, Link H. Optic neuritis: prognosis for multiple sclerosis from MRI, CSF, and HLA findings.  Neurology. 1998;  50(3) 708-714
  • 23 Kincaid O, Lipton H L. Viral myelitis: an update.  Curr Neurol Neurosci Rep. 2006;  6(6) 469-474
  • 24 Calgüneri M, Onat A M, Ozturk M A et al.. Transverse myelitis in a patient with Behcet's disease: favorable outcome with a combination of interferon-alpha.  Clin Rheumatol. 2005;  24(1) 64-66
  • 25 Moskau S, Urbach H, Hartmann A, Schmidt S. Multifocal myelitis in Behçet's disease.  Neurology. 2003;  60(3) 517
  • 26 Theodoridou A, Settas L. Demyelination in rheumatic diseases.  J Neurol Neurosurg Psychiatry. 2006;  77(3) 290-295
  • 27 Cheshire W P, Santos C C, Massey E W, Howard Jr J F. Spinal cord infarction: etiology and outcome.  Neurology. 1996;  47(2) 321-330
  • 28 Jacob A, Das K, Boggild M, Buxton N. Inflammation or neoplasm? Another side to the story.  Clin Neurol Neurosurg. 2006;  108(8) 811-812
  • 29 Wang P Y, Shen W C, Jan J S. MR imaging in radiation myelopathy.  AJNR Am J Neuroradiol. 1992;  13(4) 1049-1055 discussion 1056-1048
  • 30 Pittock S J, Kryzer T J, Lennon V A. Paraneoplastic antibodies coexist and predict cancer, not neurological syndrome.  Ann Neurol. 2004;  56(5) 715-719
  • 31 Keegan M, Pittock S, Lennon V. Autoimmune myelopathy associated with CRMP-5 IgG.  Mult Scler. 2006;  12(suppl 1) S24
  • 32 Pittock S J, Lucchinetti C F, Lennon V A. Anti-neuronal nuclear autoantibody type 2: paraneoplastic accompaniments.  Ann Neurol. 2003;  53(5) 580-587
  • 33 Pittock S J, Lucchinetti C F, Parisi J E et al.. Amphiphysin autoimmunity: paraneoplastic accompaniments.  Ann Neurol. 2005;  58(1) 96-107
  • 34 Pittock S J, Yoshikawa H, Ahlskog J E et al.. Glutamic acid decarboxylase autoimmunity with brainstem, extrapyramidal, and spinal cord dysfunction.  Mayo Clin Proc. 2006;  81(9) 1207-1214
  • 35 Wingerchuk D M, Lennon V A, Pittock S J, Lucchinetti C F, Weinshenker B G. Revised diagnostic criteria for neuromyelitis optica.  Neurology. 2006;  66(10) 1485-1489
  • 36 Majid A, Galetta S L, Sweeney C J et al.. Epstein-Barr virus myeloradiculitis and encephalomyeloradiculitis.  Brain. 2002;  125(Pt 1) 159-165
  • 37 Aktipi K M, Ravaglia S, Ceroni M et al.. Severe recurrent myelitis in patients with hepatitis C virus infection.  Neurology. 2007;  68(6) 468-469
  • 38 Tan E M, Cohen A S, Fries J F et al.. The 1982 revised criteria for the classification of systemic lupus erythematosus.  Arthritis Rheum. 1982;  25(11) 1271-1277
  • 39 Vitali C, Bombardieri S, Jonsson R et al.. Classification criteria for Sjogren's syndrome: a revised version of the European criteria proposed by the American-European Consensus Group.  Ann Rheum Dis. 2002;  61(6) 554-558
  • 40 Alarcon-Segovia VM Classification and Diagnostic Criteria for Mixed Connective Tissue Disease. Amsterdam; Excerpta Medica 1987
  • 41 Preliminary criteria for the classification of systemic sclerosis (scleroderma).  Subcommittee for scleroderma criteria of the American Rheumatism Association Diagnostic and Therapeutic Criteria Committee . Arthritis Rheum. 1980;  23(5) 581-590
  • 42 Criteria for diagnosis of Behçet's disease.  International Study Group for Behçet's Disease . Lancet. 1990;  335(8697) 1078-1080
  • 43 Weidauer S, Nichtweiss M, Lanfermann H, Zanella F E. Spinal cord infarction: MR imaging and clinical features in 16 cases.  Neuroradiology. 2002;  44(10) 851-857
  • 44 Masson C, Pruvo J P, Meder J F et al.. Spinal cord infarction: clinical and magnetic resonance imaging findings and short term outcome.  J Neurol Neurosurg Psychiatry. 2004;  75(10) 1431-1435
  • 45 Han J J, Massagli T L, Jaffe K M. Fibrocartilaginous embolism-an uncommon cause of spinal cord infarction: a case report and review of the literature.  Arch Phys Med Rehabil. 2004;  85(1) 153-157
  • 46 Suzuki F, Nakajima M, Matsuda M. Cervical cord compression caused by a pillow in a postlaminectomy patient undergoing magnetic resonance imaging: case report.  J Neurosurg. 1999;  90(suppl 1) 145-147
  • 47 Fujimoto Y, Oka S, Tanaka N et al.. Pathophysiology and treatment for cervical flexion myelopathy.  Eur Spine J. 2002;  11(3) 276-285

Brian G WeinshenkerM.D. F.R.C.P.(C.) 

Department of Neurology, Mayo Clinic College of Medicine

200 First Street SW, Rochester, MN 55905

Email: weinb@mayo.edu

    >