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  • August 17, 2019

    Francesca Bagnato M.D.Ph.D Assistant Professor of Clinical Neurology

    TN Valley Health Care System Nashville Campus & Vanderbilt University Medical Center

    Imaging Spinal Cord Hidden Pathology

    Paralyzed Veterans of America Healthcare Summit 2019

    Orlando FL

  • DISCLOSURES Dr. Bagnato’s Research Lab is funded by the National MS Society (PP-1801- 29686 and RG-1901-33190) and the National Institutes of Health (1R01- NS109114-01).

    Dr. Bagnato acted a PI for Novartis Pharmaceuticals sponsored phase-IV study (Novartis VUMC64211).

    Dr. Bagnato received honorary compensations for speaking bureau from EMD Serono.

  • LEARNING OBJECTIVES Objective #1: To summarize anatomy and mechanisms of spinal cord disease outside lesions;

    Objective #2: To recognize the challenges associated with spinal cord imaging;

    Objective #3: To describe how imaging can untangle non-lesional “hidden” spinal cord pathology.

  • SPINAL CORD ANATOMY (1) 33 vertebral bones

    https://scireproject.com/community/topic/spinal‐cord‐anatomy/

    https://nba.uth.tmc.edu/neuroanatomy/L4/Lab04p01_index.html

  • SPINAL CORD ANATOMY (2)

    https://www.orthobullets.com/spine/2008/incomplete‐spinal‐cord‐injuries

  • SPINAL CORD PATHOLOGY

    The neuropathology of (various) diseases in the spinal cord may be divided in two broad categories:

    primary pathology spinal cord lesions

    secondary pathology  manifesting as retrograde and anterograde degeneration of the axon and its cell body.

  • SPINAL CORD PATHOLOGY

    The neuropathology of (various) diseases in the spinal cord may be divided in two broad categories:

    primary pathology spinal cord lesions, and

    secondary pathology  manifesting as retrograde and anterograde degeneration of the axon and its cell body.

  • PRIMARY PATHOLOGY

    Polio Multiple Sclerosis ALS

    http://medicalhealthguides.blogspot.com

  • ASA occlusion 3ry Syphilis Syringomyelia Vitamin B12  deficiency

    http://medicalhealthguides.blogspot.com

    PRIMARY PATHOLOGY

  • From Freund et al. Lancet Neurology 2019

    PRIMARY PATHOLOGY

  • Our virtues and our failings are inseparable, like force and matter. When they separate, man is no more…Nikole Tesla

    Interstellar space 10^-10 Tesla 10^-6 Gauss

    Earth's magnetic field 0.00005 Tesla 0.5 Gauss

    Small bar magnet 0.01 Tesla 100 Gauss

    Within a sunspot 0.15 Tesla 1500 Gauss

    Big electromagnet 1.5 Tesla 15,000 Gauss

    Strong lab magnet 10 Tesla 100,000 Gauss

    Surface of neutron star 100,000,000 Tesla 10^12 Gauss

    Magstar 100,000,000,000 Tesla 10^15 Gauss

    1 Tesla = 65,000 magnetic field lines per square inch 7 Tesla = 70,000 times the earth’s magnetic field

  • CHALLENGES IN SPINAL CORD IMAGING

    1. SMALL

    2. CLOSE TO MOVING ORGANS

    3. CLOSE TO STRCTURES WIT DIFFERENT CONTRAST

  • VISUALIZING LESIONS USING MRI

    Conventional MRI plays a crucial role in the diagnostic workup of spinal cord pathology as it shows intrinsic lesions and extrinsic compression of the spinal cord.

    Conventional MRI includes T2-weighted sequences, STIR (short-TI Inversion Recovery) and T1-weighted sequences obtained after the injection of the contrast agent Gadolinium.

  • Freund et al. Lancet neurology 2019

    Modified rom Freund et al. Lancet Neurology  2019

  • Neurosarcoidosis: Radiological Manifestations (5) FIGURE 4.

    NEUROSARCOIDOSIS

  • MULTIPLE SCLEROSIS AND NMO

    From Moccia et al. Ther. Adv Neurol. Disord. 2019

  • STIR ARTIFACTS

    http://mriquestions.com/gibbs‐artifact.html

  • SPINAL CORD PATHOLOGY

    The neuropathology of (various) diseases in the spinal cord may be divided in two broad categories:

    primary pathology spinal cord lesions, and

    secondary pathology  manifesting as retrograde and anterograde degeneration of the axon and its cell body.

  • From Freund et al. Lancet Neurology 2019

    Spinal Cord Hidden Pathology

    Degeneration

    Distal to the injury (Wallerian)

    Dying back or retrograde

  • PRIMARY PATHOLOGY

    Polio Multiple Sclerosis ALS

    http://medicalhealthguides.blogspot.com

  • Imaging Spinal Cord Hidden Pathology

  • Spinal Cord Atrophy (1) Spinal cord atrophy is generally measured as the cross-sectional area at the cervical level.

    Moccia et al. Ther. Adv Neurol. Disord. 2019

  • Spinal Cord Atrophy Measurements

    Weeda et al. Neuroimage Clin 2019

    axial slices starting from the most superior point of C1 and ending at a position 30 mm more inferior.

  • Winston Ann Neurol 2014

  • Winston Ann Neurol 2014

  • From Freund et al. Lancet Neurology 2019

    Spinal Cord Hidden Pathology

    Magnetization transfer imaging SWI Diffusion Tensor Imaging

  • MTI is a quantitative technique that measures the magnetization exchange between freely mobile protons and those associated with macromolecules such as myelin or axonal membranes MT ratio or MTR

    Magnetization Transfer Imaging (MTI)

    http://mriquestions.com/magnetization‐ transfer1.html

  • Magnetization Transfer Imaging (MTI)

    http://mriquestions.com/magnetization‐ transfer1.html

    MTR ~0.4

  • Magnetization Transfer Imaging (MTI)

    http://mriquestions.com/magnetization‐ transfer1.html

    MTR ~0.4

    MTR ~0.2

  • Magnetization Transfer Imaging (MTI)

    From Martin et al. PLOS‐one 2018

  • From Oh J et al. Neurology 2015

  • Diffusion Tensor Imaging (MTI)

    https://mrgranato.wordpress.com/2018/09/28/osmosis-diffusion- homework-article-sept-28/

  • Diffusion Tensor Imaging (DTI)

    http://mriquestions.com/magnetization‐ transfer1.html

  • Diffusion Tensor Imaging (DTI)

    http://mriquestions.com/magnetization‐ transfer1.html

    Radial diffusivity

    Axial Diffusivity

    Diagonal Diffusivity

    (R+A+D)/3 Mean Diffusivity

  • Diffusion Tensor Imaging (DTI)

    http://mriquestions.com/magnetization‐ transfer1.html

  • Diffusion Tensor Imaging (DTI)

    http://mriquestions.com/magnetization‐ transfer1.html

    Water if more free to move in diseased tissue!

  • Diffusion Tensor Imaging (DTI)

    From Oh J et al. Neurology 2013

  • DTI in Radiologically Isolated Syndrome

    From Oh J et al. Neurology 2013

  • DTI in ALS

    From Valsasina J et al. JNNP 2007

  • DTI in ALS

    From Valsasina J et al. JNNP 2007

  • DTI in Experimental Trauma

    From Wang‐Leandro J Trans Med 2018

  • SUMMARY #1: Both focal as well as diffuse and hidden spinal cord disease may affect patients with both traumatic and neurodegenerative conditions.

    Objective #2: Spinal cord MRI is feasible, advancing but challenging due to distinct anatomical features of the spinal cord.

    Objective #3: Advanced quantitative MRI techniques can uncover otherwise hidden spinal cord pathology and can deliver biomarkers of neurodegeneration to be used as proof of concept clinical trials on neuroprotection and repair.

  • Thank You for your kind attention

  • If you would like to receive continuing education credit for this activity, please

    visit: https://pva.cds.pesgce.com

    How to Claim CE Credit