Longitudinally extensive transverse myelitis (LETM) typically involving more than 3 vertebral body levels, offers a challenging differential diagnosis, including entities such as Neuromyelitis Optica Spectrum disorder (NMOSD), neurosarcoidosis, malignancy, metabolic disorders, infectious etiologies, vascular causes such as arteriovenous fistula, post radiation therapy, etc [1]. It is not infrequent to find in the clinical scenario of inflammatory myelopathies, the therapeutic challenge of whether a patient should go on immunosuppressive or immunomodulatory therapy targeting NMOSD versus other entities including granulomatous diseases, from which sarcoidosis appears to be an important key player in the landscape of clinical diagnosis and therapeutic decisions [2]. The clinical presentation of the spinal cord syndrome in neurosarcoidosis may be the one of a transverse myelitis, or of a central spinal cord syndrome which predominantly involves the upper limbs classically following a “cape sensory” distribution with weakness of the upper extremities [3].

  Enhanced MRI of the spine may show besides features of LETM, linear dorsal subpial and central canal spinal cord enhancement giving the characteristic picture of a Trident. This imaging finding is characteristic for spinal cord sarcoidosis [4] (Figure 1). Frequently CT chest may show enlarged hilar or mediastinal lymphadenopathy. Biopsy of the adenopathy is required to confirm the diagnosis of sarcoidosis. Histopathology frequently shows presence of epithelioid histiocytes characteristic for the granulomatous inflammation. The granulomas typically have minimal amount of focal necrosis [5].

References

1. Kitley J., et al. “The differential diagnosis of longitudinally extensive transverse myelitis”. Multiple Sclerosis 18 (2012): 271-285.
2. Jacob A and Weinshenker B. “An approach to the diagnosis of acute transverse myelitis”. Seminars in Neurology 28 (2008): 105-120.
3. Schadler P., et al. “Central Cord syndrome: a review of epidemiology, treatment and prognostic factors”. JSM Neurosurgery and Spine 4 (2016): 1075.
4. Zalewski N., et al. “Central canal enhancement and the trident sign in spinal cord sarcoidosis”. Neurology 87 (2016): 743-744.
5. Rosen Y. “Pathology of sarcoidosis”. Seminars in Respiratory and Critical Care Medicine 28 (2007): 36-52.

Citation

Citation: Herbert Alejandro Manosalva Alzate. “The Trident Sign in Inflammatory Myelopathy: A Useful Imaging Tip for the Diagnosis of Neurosarcoidosis". Relationship Between Both Values”.Acta Scientific Neurology 3.2 (2020): 01-02.

Copyright

Copyright: © 2020 Herbert Alejandro Manosalva Alzate. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.