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CC BY 4.0 · Arq Neuropsiquiatr 2025; 83(04): s00451807720
DOI: 10.1055/s-0045-1807720
Neuroimaging

Pointing the trident in the right direction: recognizing spinal neurosarcoidosis through a specific MRI pattern

Alena Khalil 
1   Nova Southeastern University, Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale FL, United States.
,
Kevin J. Abrams 
2   Baptist Health South Florida, Department of Radiology, Division of Clinical Neuroradiology, Miami FL, United States.
,
Márcio Luís Duarte 
3   Universidade de Ribeirão Preto, Departamento de Radiologia, Guarujá SP, Brazil.
4   Diagnósticos da América S.A., São Paulo SP, Brazil.
,
Leonardo Furtado Freitas 
2   Baptist Health South Florida, Department of Radiology, Division of Clinical Neuroradiology, Miami FL, United States.
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We herein report the case of a 51-year-old male presenting with progressive neurological symptoms, including numbness, tingling below the umbilicus, urinary difficulty, constipation, and weakness. Following a recent coronavirus disease 2019 (COVID-19) vaccination, magnetic resonance imaging (MRI) ([Figure 1]) revealed longitudinally extensive transverse myelitis (LETM) with a trident-shaped pattern on axial sequences, a hallmark of spinal neurosarcoidosis.[1] [2] [3] Positron emission tomography-computed tomography ([Figure 2]) demonstrated multiple hypermetabolic hilar and mediastinal lymphadenopathies, further supporting this diagnosis, particularly given the possibility of false-positive aquaporin-4-immunoglobulin G (AQP4-IgG) enzyme-linked immunosorbent assay (ELISA) results.[4] Early recognition of the trident sign enabled the prompt initiation of corticosteroids and immunosuppressive therapy, highlighting the diagnostic utility of this specific MRI pattern in an appropriate clinical scenario, with primary spinal cord lymphoma as a differential diagnosis.[5]

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Figure 1 Magnetic resonance imaging of the thoracic spine in sagittal (A–D) and axial views (E–F). Evidence of longitudinally extensive transverse myelitis at the cervicothoracic junction is observed, associated with significant edema and spinal cord swelling (blue braces). Notably, a contrast-enhancing component (white asterisks) in the posterior column and central regions, extending toward the pial/subpial surface and central ependymal canal, demonstrates T2-weighted/ short tau inversion recovery (STIR) hyposignal and exhibits a “trident-shaped head” appearance on axial images. The dorsal enhancement likely results from granulomatous inflammation spreading via perivascular pathways and may be influenced by meningeal lymphatic drainage and increased vascular permeability, predisposing this region to inflammation.
Zoom
Figure 2 Positron emission tomography-computed tomography scan with fluorodeoxyglucose (FDG) in sagittal (A), coronal (B–C), and axial (D–E) views. No significant FDG uptake was observed in the cervicothoracic spinal cord lesion. However, multiple mediastinal, hilar, and precarinal lymphadenopathies demonstrated high radiotracer uptake, suggesting a granulomatous inflammatory process.

 

Conflict of Interest

The authors have no conflict of interest to declare.

Authors' Contributions

Conceptualization: AK; Methodology: MLD; Project administration: MLD, LFF; Supervision: LFF, KJA; Validation: LFF, KAJ; Writing – review & editing: LFF.


Data Availability Statement

The data used to support the findings of the present study are included within the article.


Editor-in-Chief: Ayrton Roberto Massaro.


Associate Editor: Luis Filipe de Souza Godoy.



Address for correspondence

Leonardo Furtado Freitas

Publication History

Received: 24 December 2024

Accepted: 13 February 2025

Article published online:
13 May 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/)

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Bibliographical Record
Alena Khalil, Kevin J. Abrams, Márcio Luís Duarte, Leonardo Furtado Freitas. Pointing the trident in the right direction: recognizing spinal neurosarcoidosis through a specific MRI pattern. Arq Neuropsiquiatr 2025; 83: s00451807720.
DOI: 10.1055/s-0045-1807720

  Permissions and Reprints
Zoom
Figure 1 Magnetic resonance imaging of the thoracic spine in sagittal (A–D) and axial views (E–F). Evidence of longitudinally extensive transverse myelitis at the cervicothoracic junction is observed, associated with significant edema and spinal cord swelling (blue braces). Notably, a contrast-enhancing component (white asterisks) in the posterior column and central regions, extending toward the pial/subpial surface and central ependymal canal, demonstrates T2-weighted/ short tau inversion recovery (STIR) hyposignal and exhibits a “trident-shaped head” appearance on axial images. The dorsal enhancement likely results from granulomatous inflammation spreading via perivascular pathways and may be influenced by meningeal lymphatic drainage and increased vascular permeability, predisposing this region to inflammation.
Zoom
Figure 2 Positron emission tomography-computed tomography scan with fluorodeoxyglucose (FDG) in sagittal (A), coronal (B–C), and axial (D–E) views. No significant FDG uptake was observed in the cervicothoracic spinal cord lesion. However, multiple mediastinal, hilar, and precarinal lymphadenopathies demonstrated high radiotracer uptake, suggesting a granulomatous inflammatory process.