From the Guidelines
No, compressive myelomalacia typically does not enhance on imaging studies. Compressive myelomalacia refers to softening and degeneration of the spinal cord due to prolonged compression. On MRI, it usually appears as a non-enhancing area of increased T2 signal intensity within the spinal cord. The lack of enhancement is due to the nature of the condition - it represents damaged, necrotic tissue rather than active inflammation or increased vascularity. In rare cases, there may be some mild peripheral enhancement at the edges of a myelomalacic area, but this is not a typical feature. If significant enhancement is seen, it should raise suspicion for other diagnoses such as intramedullary tumors, infection, or inflammatory conditions. For accurate diagnosis, MRI with and without contrast is the imaging modality of choice, as stated in the ACR Appropriateness Criteria® Myelopathy: 2021 update 1. T2-weighted and STIR sequences are particularly useful for identifying the hyperintense signal changes of myelomalacia. Diffusion-weighted imaging may also be helpful in some cases to differentiate myelomalacia from acute ischemia, as noted in the same criteria 1. Understanding this imaging characteristic is crucial for correct diagnosis and management of spinal cord compression and its sequelae.
Some key points to consider in the diagnosis of compressive myelomalacia include:
- The use of MRI without and with IV contrast to evaluate the spinal cord and surrounding structures 1
- The appearance of myelomalacia on T2-weighted and STIR sequences as a hyperintense signal change within the spinal cord
- The potential for mild peripheral enhancement at the edges of a myelomalacic area, but not significant enhancement
- The importance of considering alternative diagnoses, such as intramedullary tumors, infection, or inflammatory conditions, if significant enhancement is seen
- The role of diffusion-weighted imaging in differentiating myelomalacia from acute ischemia, as noted in the ACR Appropriateness Criteria® Myelopathy: 2021 update 1.
Overall, the diagnosis and management of compressive myelomalacia require a thorough understanding of the imaging characteristics of this condition, as well as the potential for alternative diagnoses. By using MRI with and without contrast, and considering the appearance of myelomalacia on T2-weighted and STIR sequences, clinicians can make an accurate diagnosis and develop an effective treatment plan.
From the Research
Compressive Myelomalacia
- Compressive myelomalacia is a condition where the spinal cord is compressed, leading to signal changes on magnetic resonance imaging (MRI) 2, 3, 4, 5, 6
- The condition can be caused by various factors, including trauma, malignancy, or demyelinating disease, but can also be idiopathic 2
MRI Findings
- MRI findings of compressive myelomalacia include long-segmental intramedullary T2-high signal intensity (HSI) extending more than 2 vertebral segments, cord swelling, and cord compression in midline location 2
- The signal changes can be fusiform in shape, with diffuse distribution occupying more than two-thirds of the cross-sectional dimension of the cord in axial image 2
- Contrast enhancement patterns, such as focal and peripheral enhancement, can also be observed 2, 3
Clinical Outcome
- The clinical outcome of compressive myelomalacia can vary, with some patients showing improvement after treatment, while others may experience progressive neurological decline 3, 4, 5
- The presence of intramedullary signal intensity and contrast enhancement on MRI can be associated with poor prognosis and worse surgical outcomes 3
- Early stage myelomalacia may be reversible, depending on the severity of the initial spinal cord injury, while late stage myelomalacia is often characterized by central cystic degeneration, syrinx formation, and atrophy 4
Location of Cord Compression
- The location of cervical cord compression can be related to the location of myelomalacia, with lesions often appearing distal to the pressure on the spinal cord or starting at the level of pressure and extending to an area distal to the pressure 6
- In some cases, the lesion with increased signal intensity on T2WI can be located proximal to the pressure on the spinal cord, but this is less common 6