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This was a young child who, a couple of weeks

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earlier, had been vaccinated as part of the

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normal pediatric vaccination schedule.

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Here we have a T1-weighted,

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T2-weighted, and STIR set of images.

0:19

What we see is marked enlargement of the

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cervical medullary junction to the cervical

0:25

spinal cord with abnormal signal intensity

0:28

extending even into the thoracic spine.

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We also note,

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incidentally, that the cerebellar tonsil appears

0:35

to extend through the foramen magnum

0:37

with a little bit of crowding.

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In a child with a cervical spinal cord expansile

0:44

lesion, we would first be in the neoplastic category.

0:50

In this case,

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the post-gadolinium enhanced scans would be

0:55

most useful. And here on the post-gad examination,

1:03

we note the absence of contrast enhancement

1:08

associated with this lesion.

1:14

No real areas on axial scanning of enhancement.

1:19

That would be decidedly uncommon for

1:22

a neoplasm of the spinal cord.

1:25

Over 90% of spinal cord neoplasms enhance.

1:30

We would have to say that this was a grade

1:32

one pilocytic astrocytoma and that,

1:37

in and of itself, would be somewhat unusual as well.

1:43

So now we go back to that clinical history.

1:46

The clinical history was that the

1:48

patient had prior vaccination.

1:51

Whenever we think about prior vaccination or

1:56

an antecedent viral illness, we have to raise

2:01

the possibility of acute disseminated encephalomyelitis (ADEM).

2:07

Acute disseminated encephalomyelitis,

2:10

far and away,

2:11

occurs in the brain more so than the spinal cord.

2:15

However, you can have multiple lesions both in the

2:19

brain and the spinal cord with ADEM,

2:21

or just as in the brain,

2:24

you can have isolated spinal cord ADEM.

2:28

ADEM may affect the optic nerves, and so it may

2:31

be in the differential diagnosis of neuromyelitis

2:36

optica spectrum disorder because it can cause

2:38

transverse myelitis, as well as optic neuritis.

2:44

However, the most common manifestation of ADEM

2:46

is deep gray matter as well as white matter disease

2:50

in the brain.

2:52

This ended up with a final diagnosis of spinal ADEM.

2:58

What is good for it being spinal ADEM.? Number one.

3:01

ADEM, far and away, occurs more commonly

3:03

in children than adults,

3:05

in part because of the multiple viral illnesses

3:08

and vaccinations they undergo and the

3:12

absence of contrast enhancement.

3:16

We would have to exclude a lot of viral

3:18

etiologies and infectious etiologies and

3:21

collagen vascular etiologies and autoimmune

3:25

disorders before coming to a

3:26

final diagnosis of ADEM,

3:29

but the timing with respect to

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the vaccination is perfect.