Unusual Cervical Spinal Cord Toxicity Associated with Intra-arterial Carboplatin, Intra-arterial or Intravenous Etoposide Phosphate, and Intravenous Cyclophosphamide in Conjunction with Osmotic Blood Brain–Barrier Disruption in the Vertebral Artery
David Fortina,
Leslie D. McAllistera,
Gary Nesbita,
Nancy D. Doolittlea,
Michael Minera,
E. Jerome Hansona and
Edward A. Neuwelt
,a
a From the Departments of Neurology (D.F., L.D.McA., N.D.D., E.A.N.) and Radiology (G.N.), Oregon Health Sciences University, Portland, OR; the Division of Neurosurgery, Ohio State University, Columbus, OH (M.M.); and Trinity Lutheran Hospital, Kansas City, MO (E.J.H.).
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FIG 1. Case 2: Cervical spine MR study obtained after onset of neck pain and left upper distal extremity dysesthesia, 3 days after vertebral disruption and chemotherapy.
A, Sagittal T2-weighted image depicts hyperintense cord signal extending from C2 to C5. The hyperintense signal is cone-shaped and centered at the C3 level. Cord enlargement is visible at C3–C4.
B, Axial fast spin-echo T2-weighted image at C3–C4 shows abnormal hyperintense signal occupying the left centrolateral portion of the cord, with a distribution involving primarily the gray matter bilaterally and the left posterolateral white matter (arrow).
C, Sagittal T2-weighted image 2 months after the onset of symptoms shows residual abnormal hyperintense signal in the posterior aspect of the cord at C3–C4. Cord enlargement is no longer noticeable.
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FIG 2. Case 3: Cervical spine MR imaging performed 2 months after onset of neck pain, left upper distal extremity dysesthesia and paresis in patient 3. Symptom onset occurred 4 days after a vertebral disruption and chemotherapy. The patient's initial MR study showed findings similar to those in figure 1 (case 2).
A, Sagittal contrast-enhanced T1-weighted image shows linear anterior cord enhancement extending from C4 to C7.
B, Axial T1-weighted contrast-enhanced image at C5–C6 shows an enhancing signal occupying the anterior central portion of the cord. The distribution of this signal is symmetrical and involves mostly the gray matter, seeming to spare the peripheral white matter. There was no significant enhancement on the initial study.
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FIG 3. Case 7: Cervical spine MR study obtained after onset of neck pain and dysesthesia and paresthesia in upper distal extremities, 3 days after vertebral disruption and chemotherapy.
A, Sagittal T2-weighted image displays extensive abnormal diffuse hyperintense signal extending from the medulla down to the C7 level. Also note mild cervical spinal cord enlargement.
B, Axial fast spin-echo T2-weighted image at C4–C5 depicts abnormal diffuse hyperintense signal involving the cord, sparing only the peripheral white matter.
C, Sagittal contrast-enhanced T1-weighted image shows an area of abnormal faint and diffuse enhancement at the level of C5, over a 2-cm longitudinal segment (arrow). Also note the increase in cord diameter with obliteration of the subarachnoid spaces at that level.
D, T2-weighted sagittal image obtained 1 month after the initial study shows hyperintense signal now limited to the C4 and C5 vertebral segments. Also note the decrease in cord enlargement, as evidenced by the clear delineation of the anterior and posterior subarachnoid spaces.
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