A 38-year-old Woman With Progressive Leg Weakness and Numbness After a Ski Vacation

Rohit Bakshi, MD


December 04, 2001

Case Presentation

A 38-year-old woman presented with a 1-week history of progressive bilateral leg weakness, numbness below the chest, and urinary retention. Neurologic examination revealed mild to moderate weakness and hyperreflexia of the arms and legs bilaterally, a discrete sensory deficit at C7, and diminished rectal tone. MRI of the cervical spine with and without contrast was performed (Figure 1), including gadolinium postcontrast sagittal T1-weighted, sagittal T2-weighted, axial noncontrast T1-weighted, and axial T2-weighted images.

MRI of the cervical spine with and without contrast, including gadolinium postcontrast sagittal T1-weighted (left), sagittal T2-weighted (middle), axial noncontrast T1-weighted (upper right), and axial T2-weighted (lower right) images.

What is true about the lesion?

  1. It is an intramedullary lesion.

  2. It is extramedullary, intradural.

  3. It is extramedullary, extradural.

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Which is true of the lesion as shown by the axial T2-weighted image (arrow)?

  1. It is located in posterior column white matter.

  2. It is located in central cord gray and white matter.

  3. It is located in lateral column white matter.

  4. It contains a syringomyelia cavity.

  5. It involves less than half of cord diameter.

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The enhancement pattern is:

  1. Consistent with an ependymoma

  2. Consistent with metastatic disease

  3. Nonenhancing

  4. Moderate, heterogeneous enhancement

  5. Ring enhancement

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You obtain additional history from the patient and the spouse. The patient works in a high-stress profession. She has lost 30 pounds in the past 6 months but has been dieting. She experiences fatigue almost daily but does not sleep well at night. The patient had an upper respiratory infection during a skiing vacation 3 weeks earlier. Family history is positive for cancer in 2 first-degree relatives at an early age.

Which of the following is a next reasonable step?

  1. Perform CT-guided biopsy of the lesion

  2. Perform MRI-guided biopsy of the lesion

  3. Perform a spinal tap for CSF analysis

  4. Give empiric radiotherapy

  5. Begin anticoagulation

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