Copper Deficiency Myelopathy: Characteristic MRI Findings
Primary Imaging Pattern
The hallmark MRI finding in copper deficiency myelopathy is a hyperintense T2 signal abnormality in the dorsal (posterior) columns of the spinal cord, most characteristically appearing as an inverted "V" shape in the cervical and thoracic regions. 1, 2
Specific Radiographic Features
Signal Characteristics
- T2-weighted hyperintensity is the dominant finding, appearing as increased signal in the posterior columns 1, 3, 4
- The abnormality typically presents as a thin, longitudinally extensive lesion affecting the dorsal columns 3
- The classic inverted "V" configuration in axial images represents bilateral dorsal column involvement and is the most common radiographic pattern 1
Anatomic Distribution
- Cervical cord is most frequently affected, particularly C2-C6 segments 3, 4
- Thoracic cord involvement is also common, often showing symmetric dorsal midline hyperintensity 2
- The pattern is typically a long segment of symmetric dorsal spinal cord T2-hyperintensity extending across multiple vertebral levels 2
Advanced Imaging Findings
- Diffusion tensor imaging may reveal decreased fractional anisotropy (FA) corresponding to the T2 hyperintensity, which can normalize with copper supplementation 5
- Fat-suppressed T2 sequences (FS-Echo T2) enhance visualization of the posterior column lesions 3
Reversibility of Imaging Findings
- MRI abnormalities may be partially or completely reversible with copper supplementation and normalization of serum copper levels 5, 2
- Radiographic improvement typically precedes clinical neurological recovery, which may remain incomplete even when imaging normalizes 5
- Control imaging after treatment may show resolution of hyperintensity or only minimal residual signal abnormality 5
Critical Diagnostic Pitfall
This imaging pattern precisely mimics subacute combined degeneration from vitamin B12 deficiency, making laboratory confirmation essential before attributing findings to either etiology 1, 2. The clinical and radiographic pictures are virtually indistinguishable between these two metabolic myelopathies 2.
When to Suspect Copper Deficiency
Neuroradiologists and clinicians should consider copper deficiency myelopathy when encountering:
- Long-segment symmetric dorsal column T2 hyperintensity on spinal MRI 2
- Inverted "V" shaped signal abnormality in the posterior columns 1
- Clinical presentation of sensory ataxia, spasticity, or gait instability with concomitant cytopenia 1, 6
- History of gastric bypass surgery (36.2% of cases), excessive zinc consumption (19.9% of cases), or malabsorption syndromes 1, 7
Recommended Imaging Protocol
3T spine MRI with T2-weighted sequences provides optimal visualization of posterior column pathology 3. Fat-suppressed T2 sequences should be included to enhance detection of subtle cord signal abnormalities 3.