Table 2

Characteristics of each differential

DifferentialAdditional MRI sagittalMRI axialCSFOtherConfirmatory
InfarctionDoes not enhance with contrast; ’pencil-like' lesionTract specific: most commonly anterior; associated vertebral body infarct 4%–35%Normal (may be abnormal with underlying spinal disease)Onset typically sudden; pain at level of lesion (59%–70%)Spinal angiogram
HaemorrhageMRI changes vary with time due to ageing of bloodIntra/extramedullary mass; low central signal with border of increased signalXanthochromia possible*Commonly associated with underlying vascular malformationMRI
NMOSDConus involvement may suggest MOG-Ab; T1 hypointense and T2 hyperintenseCentral grey matter involvement; bright spotty lesion on T2Oligoclonal bands uncommon (10%); IgG index rarely raised (8%)*Optic neuritis; brainstem symptomsAquaporin-4 or MOG antibody testing
MSPosterolateral lesions (<half the axial area)Oligoclonal bands >95% MS and 70% clinically isolated syndrome*Abnormal visual evoked potentials (30%)Diagnostic criteria
Atypical MS (long-standing or primary progressive)Diffuse cord involvement may be a feature found in primary progressive MS.Oligoclonal bands >95% MS and 70% clinically isolated syndrome*Abnormal visual evoked potentials (>50%)Diagnostic criteria
AutoimmuneCentral grey matter/complete transverse myelitis*Systemic features; may be associated with aquaporin-4 antibodiesDiagnostic criteria (aquaporin-4 antibody testing)
ADEMVariable location; commonly diffuse lesions*Altered mental statusDifficult to confirm
(MOG antibody testing)
ParaneoplasticMRI may be normal.Central grey matter/tract specific; symmetrical*Diagnosis of malignancyAntineuronal antibody testing
SarcoidVariable enhancement; minimal cord enlargementVariable: dorsal cord subpial GAD enhancement may help differentiate from NMOSDOligoclonal bands uncommon;
CSF ACE (not sensitive)*
Lung/eyes/skin involvementBiopsy
VascularInfarctionDo not enhance with contrast; ’pencil-like' lesionTract specific: most commonly anterior; associated vertebral body infarct 4%–35%Normal (may be abnormal if underlying cause present)Onset typically sudden; pain at level of lesion (59%–70%)Spinal angiogram
MalformationConus involved in >80% of cases; dilated perimedullary vessels enhanced on T1 and seen as flow voids on T2Oedema seen as centromedullary T2 hyperintensity; vessels (flow voids) on dorsumOligoclonal bands (27%)*Typically patients fluctuate with exercise.Spinal angiogram
MetabolicContrast enhancement is rare.Symmetric T2 hyperintensity dorsal tracts*Variable cytopenias; typically anaemiaB12/copper levels/genetic testing
Acute infectionViralPredominantly central grey matter*Prodromal illnessDifficult to confirm
TuberculosisWhite matter nodules or target lesionsMarked pleocytosis and raised proteinConstitutional symptoms; lung/lymph nodesPCR
ParasiticEccentric nodular pattern*Systemic features of infectionAntibody testing
Chronic infectionSyphilisDorsal T2 hyperintensity (may mimic metabolic)Only abnormal half the time (depends on previous treatment)*History of sexually transmitted infectionAntibody testing
HTLV-1T2 hyperintensity (early) and then cord atrophyLateral columns commonly but can affect central and anterior cord*Uveitis, arthropathy, alveolitis, myositisWHO diagnostic guidelines
HIVDorsal T2 hyperintensity (may mimic metabolic)Neither sensitive nor specific in this case*Constitutional symptomsConfirmatory HIV testing
NeoplasticAstrocytomaHeterogeneous or no enhancement; irregular marginsEccentric location; may be exophytic and appear extramedullaryCytology may be more useful than in cerebral malignancy*Neurofibromatosis IBiopsy
EpendymomaRostral and caudal cysts; homogenous enhancement
(75%); clear borders
Variable but more commonly central than other malignanciesCytology may be more useful than in cerebral malignancy*Biopsy
MetastaticEccentric locationCytology may be more useful than in cerebral malignancy*MRI and biopsy (primary or spinal cord)
  • *CSF may show variable pleocytosis or mildly raised protein, not specific, may be dependent on sample timing.

  • ADEM, acute disseminated encephalomyelitis; CSF, cerebrospinal fluid; GAD, glutamate decarboxylase; HTLV-1, human T cell lymphotropic virus type 1; MOG-Ab, myelin oligodendrocyte glycoprotein antibody; MS, multiple sclerosis; NMOSD, neuromyelitis optica spectrum disorder.