Objective:

To characterize the timing and patterns of gadolinium enhancement in spinal cord stroke (SCS) on magnetic resonance imaging (MRI).

Background:

Gadolinium-enhancing lesions on spinal cord MRI are often associated with inflammatory etiologies (i.e., myelitis), but vascular myelopathies like SCS can also exhibit gadolinium enhancement. The timing and location in SCS remain unclear.

Design/Methods:

Spinal cord MRIs from patients diagnosed with SCS between October 2010 and March 2024 at a specialized myelopathy center were analyzed. MRIs were categorized into four stages based on the time from symptom onset to acquisition: acute (< 48 hours), early (2 to 10 days), subacute (11 to 30 days), and late (more than 30 days).  One MRI per stage was reviewed for each patient when available. Lesion location on T2-weighted images and gadolinium enhancement patterns on T1-weighted sequences were assessed.

Results:

MRIs from 170 patients were evaluated. Most were female (n=96, 57%) and white (n=123, 73%). A total of 312 MRIs with T1-weighted gadolinium-enhanced sequences were included. Of these, 89 (29%) showed lesion enhancement, 65 (21%) showed root enhancement, and 16 (5%) meningeal enhancement. Lesion enhancement was found in 13 of 78 studies (17%) performed within 48 hours (acute), 33 of 74 studies (44%) between 2 and 10 days (early), 25 of 38 studies (66%) between 11 and 30 (subacute), and 18 of 122 studies (15%) after 30 days (late). Of 56 patients without acute-stage enhancement, 25 (45%) showed enhancement in follow-up MRIs, most commonly in the subacute stage.

Conclusions:

Nearly one-third of patients with SCS showed gadolinium enhancement during the course of their ischemic injury, most commonly in the subacute stage. Clinicians should be aware that gadolinium enhancement should not interpreted as exclusive to inflammatory myelopathies, as acute vascular myelopathies may also show this finding.