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РАДИОЛОГИЧЕСКАЯ БИБЛИОТЕКА

05.08.2011 МРТ позвоночника. Арахноидит.

 Высокий юноша 1991 г.р. жалуется на боли в спине, ограничение движений (трудно и больно сгибаться). Около двух лет назад была тяжелая черепно-мозговая травма с переломом затылочной кости, субарахноидальным коровоизлиянием. Было внутрижелудочковое кровоизлияние, окклюзионная гидроцефалия. Выполнялась вентикулостомия (видимо, по Торкильдсену). После травмы при МРТ головного мозга была выявлена мешотчатая аневризма позвоночной артерии. В НИИПК им.Мешалкина (Новосибирск) ее тромбировали. В ходе всего этого неоднократно выполнялись люмбальные пункции. Перед настоящим исследованием осмотра невролога не было. Ходит обычно, высокий, худой.

 

Пришел он на МРТ поясничного отдела позвоночника. Вот что мы увидели:

Это был аксиал на уровне L4-5, остальные на верхнепоясничном-нижнегрудном:

Далее я убедилась, что процесс не заканчивается на 1 позвонок выше,

 получила от папы добро на весь позвоночник и мы пошли дальше:

Далее ввели контраст:

 

  

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Adhesive Arachnoiditis

Adhesive Arachnoiditis

 

page 384: The potential factors inciting chronic sterile spinal arachnoiditis are much debated but include the surgical procedure itself, the presence of intra-dural blood following surgery, diagnostic lumbar puncture, treated perioperative spinal infection, the previous use of myelographic contrast media (especially older oil-based preparations), and prior intraspinal injection of anesthetic, anti-inflammatory, or chemotherapeutic agents (e.g., steroids, methotrexate). Chronically persistent lumbosacral signs and symptoms in 6%–16% of postsurgical patients have been attributed to sterile arachnoiditis. The three MRI patterns described in adhesive arachnoiditis include: scattered groups of matted or “clumped” nerve roots; an “empty” thecal sac caused by adhesion of the nerve roots to its walls; and an intrathecal soft tissue “mass” with a broad dural base, representing a large group of mat- ted roots, which may obstruct the CSF pathways (Fig. 15.12) (Shafaie et al. 1997). These changes may be focal or diffuse. Contrast enhancement of the thickened meningeal scarring and underly- ing intrathecal roots may or may not be observed (Jinkins 1993).

Magnetic Resonance Imaging

As previously stated, MRI is the study of choice for the diagnostic evaluation of arachnoiditis.[1, 2, 3, 4] T1-weighted MRI scans, as demonstrated in the images below, may reveal an indistinct or absent cord outline due to the increase in the signal intensity of the surrounding CSF. This may be the result of an elevation in CSF protein content, the presence of inflammatory exudate, or the formation of adhesions along the surface of the spinal cord.

T1-weighted nonenhanced sagittal MRI of the lumbar

T1-weighted nonenhanced sagittal MRI of the lumbar spine reveals indistinct, poorly defined nerve roots of the cauda equina in tuberculous arachnoiditis and meningitis.

T1-weighted sagittal nonenhanced MRI of the cervic

T1-weighted sagittal nonenhanced MRI of the cervical spine shows abnormally increased signal intensity in the subarachnoid space, which is isointense relative to the spinal cord, in a patient with tuberculous arachnoiditis.

T1-weighted sagittal nonenhanced MRI of the lumbar

T1-weighted sagittal nonenhanced MRI of the lumbar spine shows signal intensity throughout the subarachnoid space that is diffusely increased, compared with that of the spinal cord (arrow), in tuberculous arachnoiditis.

T2-weighted MRI scans may demonstrate CSF loculation and obliteration of the subarachnoid space or irregularly thickened, clumped nerve roots (as in the first 2 images below), which occasionally may be misinterpreted as a tethered cord or a thickened filum terminale. With more severe arachnoiditis, progression of nerve root clumping and leptomeningeal adhesions may lead to angular defects in the dural sac. Peripheral adherence of the nerve roots to the walls of the thecal sac produces the so-called featureless, or empty, sac, as seen in the third image below.

Sagittal T2-weighted MRI of the lumbar spine after

Sagittal T2-weighted MRI of the lumbar spine after laminectomy for arachnoiditis shows thickened, clumped nerve roots.

Axial T2-weighted MRI of the lumbar spine in arach

Axial T2-weighted MRI of the lumbar spine in arachnoiditis shows that the nerve roots do not float freely in the thecal sac; instead, they adhere to one another.

Axial T2-weighted MRI of the lumbar spine obtained

Axial T2-weighted MRI of the lumbar spine obtained at the level of laminectomy for arachnoiditis. Peripheral adherence of the nerve roots to the dural sac causes the empty-sac appearance.

Contrast enhancement is an inconstant finding. When it does occur, enhancement may be the result of a vascular network within the fibrous stroma that develops in the subarachnoid space. Three patterns of enhancement have been described:

  • The most common pattern of enhancement (seen in the image below) is a smooth, linear layer of enhancement outlining the surface of the cord and nerve roots.
  • T1-weighted sagittal fat-suppressed contrast-enhan
  • T1-weighted sagittal fat-suppressed contrast-enhanced MRI of the lumbar spine in tuberculous arachnoiditis and meningitis shows thin, linear leptomeningeal enhancement of the conus medullaris and cauda equina.
  • The second-most common pattern is a nodular pattern (seen in the image below) with discrete foci of enhancement seen along the surface of the cord and nerve roots.
  • T1-weighted sagittal MRI of the cervical spine in
  • T1-weighted sagittal MRI of the cervical spine in tuberculous arachnoiditis shows nodular pockets of enhancement in the subarachnoid space after the administration of contrast material.
  • The least common pattern consists of diffuse intradural enhancement that completely fills the subarachnoid space (as demonstrated in the images below).
  • T1-weighted sagittal nonenhanced MRI of the lumbar
  • T1-weighted sagittal nonenhanced MRI of the lumbar spine shows signal intensity throughout the subarachnoid space that is diffusely increased, compared with that of the spinal cord (arrow), in tuberculous arachnoiditis.
  • T1-weighted sagittal contrast-enhanced MRI of a lu
  • T1-weighted sagittal contrast-enhanced MRI of a lumbar-spine tuberculous arachnoiditis reveals diffuse enhancement that fills the entire subarachnoid space. Tuberculosis (TB) bacilli were isolated from the CSF.

No pattern of enhancement has been found to be characteristic of any specific infectious agent or pathologic process. In general, benign arachnoiditis enhances less avidly than does carcinomatous meningitis; however, MRI findings alone cannot be used to differentiate infection from neoplasm.[5]

MRI after the administration of intrathecal gadopentate dimeglumine (Gd-DTPA) has been described as a safe, effective technique to diagnose or exclude the diagnosis of arachnoiditis.[6, 7, 8]

In one report, arachnoiditis could not be excluded on routine postoperative intravenous-enhanced MRI in a patient with progressive paraparesis and sphincter incontinence. Arachnoiditis was differentiated from postoperative changes with intrathecal-enhanced MRI. Doses ranging from 0.8 to 2 ml of gadolinium mixed with 3 to 5 ml of the patients' CSF under sterile conditions have been injected into the subarachnoid space. MRI was performed utilizing T1-weighted, fat-suppressed sequences in 2-3 orthogonal planes.

Purported advantages of gadolinium-enhanced intrathecal MR imaging include an absence of ionizing radiation, the capability of direct multiplanar imaging, an absence of bony artifact, and high spatial and contrast resolution. It should be noted that although a cooperative multicenter study of 95 patients failed to demonstrate behavioral changes, neurologic alteration, or seizure activity with intrathecal gadolinium, the administration of intrathecal gadolinium is not approved for use by the FDA and has been used off-label.

Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.

With MRI findings, the degree of confidence is high. Sarcoidosis and spinal anesthesia may cause false results.

 
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А может ли грыжа диска, до

А может ли грыжа диска, до 10мм (с деформирующим спондилезом в этом сегменте и патологическим переломом тела позвонка ) осложняться арахноидитом? В статье Марио я этой причины не увидела. Может , мои фантазии?  

 

 
 

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