Utility of MRI Enhancement Pattern in Myelopathies With Longitudinally Extensive T2 Lesions

Rafid Mustafa; Theodore J Passe; Alfonso S Lopez-Chiriboga; Brian G Weinshenker; Karl N Krecke; Nicholas L Zalewski; Felix E Diehn; Elia Sechi; Jay Mandrekar; Timothy J Kaufmann; Padraig P Morris; Sean J Pittock; Michel Toledano; Giuseppe Lanzino; Allen J Aksamit; Neeraj Kumar; Claudia F Lucchinetti; Eoin P Flanagan

doi:10.1212/CPJ.0000000000001036

Utility of MRI Enhancement Pattern in Myelopathies With Longitudinally Extensive T2 Lesions

Neurol Clin Pract. 2021 Oct;11(5):e601-e611. doi: 10.1212/CPJ.0000000000001036.

Authors

Rafid Mustafa¹, Theodore J Passe¹, Alfonso S Lopez-Chiriboga¹, Brian G Weinshenker¹, Karl N Krecke¹, Nicholas L Zalewski¹, Felix E Diehn¹, Elia Sechi¹, Jay Mandrekar¹, Timothy J Kaufmann¹, Padraig P Morris¹, Sean J Pittock¹, Michel Toledano¹, Giuseppe Lanzino¹, Allen J Aksamit¹, Neeraj Kumar¹, Claudia F Lucchinetti¹, Eoin P Flanagan¹

Affiliation

¹ Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL.

Abstract

Objective: To determine whether MRI gadolinium enhancement patterns in myelopathies with longitudinally extensive T2 lesions can be reliably distinguished and assist in diagnosis.

Methods: We retrospectively identified 74 Mayo Clinic patients (January 1, 1996-December 31, 2019) fulfilling the following criteria: (1) clinical myelopathy; (2) MRI spine available; (3) longitudinally extensive T2 hyperintensity (≥3 vertebral segments); and (4) characteristic gadolinium enhancement pattern associated with a specific myelopathy etiology. Thirty-nine cases with alternative myelopathy etiologies, without previously described enhancement patterns, were included as controls. Two independent readers, educated on enhancement patterns, reviewed T2-weighted and postgadolinium T1-weighted images and selected the diagnosis based on this knowledge. These were compared with the true diagnoses, and agreement was measured with Kappa coefficient.

Results: Among all cases and controls (n = 113), there was excellent agreement for diagnosis using postgadolinium images (kappa, 0.76) but poor agreement with T2-weighted characteristics alone (kappa, 0.25). A correct diagnosis was more likely when assessing postgadolinium image characteristics than with T2-weighted images alone (rater 1: 100/113 [88%] vs 61/113 [54%] correct, p < 0.0001; rater 2: 95/113 [84%] vs 68/113 [60%] correct, p < 0.0001). Of the 74 with characteristic enhancement patterns, 55 (74%) were assigned an alternative incorrect or nonspecific diagnosis when originally evaluated in clinical practice, 12 (16%) received immunotherapy for noninflammatory myelopathies, and 2 (3%) underwent unnecessary spinal cord biopsy.

Conclusions: Misdiagnosis of myelopathies is common. The gadolinium enhancement patterns characteristic of specific diagnoses can be identified with excellent agreement between raters educated on this topic. This study highlights the potential diagnostic utility of enhancement patterns in myelopathies with longitudinally extensive T2 lesions.