Evaluation by MRI of paraparesis and tetraparesis of undiagnosed aetiology

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Abstract
The clinical, neuroradiological, electrophysiological and CSF findings of seven patients with slowly progressive paraparesis or tetraparesis are presented. In all patients, the results of the tests performed, including evoked potentials, CT scanning, oligoclonal bands in the CSF and myelography, were normal or inconclusive and did not lead to the correct diagnosis of the aetiology. In contrast, magnetic resonance imaging (MRI) provided the diagnosis of the causative process: multiple sclerosis in four cases, meningioma of the craniocervical junction or upper thoracic spinal cord in two cases, and upper cervical cord low-grade astrocytoma in one case. The patients with tumour could be treated effectively. Without MRI, however, the correct diagnosis would have been delayed. T2-weighted spin-echo scans provided maximal sensitivity for the detection of MS plaques, although they lacked specificity for a special disease. Several morphological criteria during MRI were helpful in differentiating Binswanger's disease, leucodystrophy and adrenoleucodystrophy from MS. It is concluded that at present MRI is the only non-invasive test with which to screen reliably the craniocervical junction and the upper cervical level, both of which are diagnostically difficult regions. The case histories also demonstrate that MRI is essential in all patients where a full clinical evaluation of the suspected spinal segment is not possible. “Pure spinal MS” is a misleading diagnosis and should not be accepted without confirmation by MRI. MRI has to be performed early enough to permit timely treatment of spinal and brain-stem disorders.