Differential | Additional MRI sagittal | MRI axial | CSF | Other | Confirmatory | |
Infarction | Does not enhance with contrast; ’pencil-like' lesion | Tract 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 | |
Haemorrhage | MRI changes vary with time due to ageing of blood | Intra/extramedullary mass; low central signal with border of increased signal | Xanthochromia possible* | Commonly associated with underlying vascular malformation | MRI | |
NMOSD | Conus involvement may suggest MOG-Ab; T1 hypointense and T2 hyperintense | Central grey matter involvement; bright spotty lesion on T2 | Oligoclonal bands uncommon (10%); IgG index rarely raised (8%)* | Optic neuritis; brainstem symptoms | Aquaporin-4 or MOG antibody testing | |
MS | Posterolateral 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 | ||
Autoimmune | Central grey matter/complete transverse myelitis | * | Systemic features; may be associated with aquaporin-4 antibodies | Diagnostic criteria (aquaporin-4 antibody testing) | ||
ADEM | Variable location; commonly diffuse lesions | * | Altered mental status | Difficult to confirm (MOG antibody testing) | ||
Paraneoplastic | MRI may be normal. | Central grey matter/tract specific; symmetrical | * | Diagnosis of malignancy | Antineuronal antibody testing | |
Sarcoid | Variable enhancement; minimal cord enlargement | Variable: dorsal cord subpial GAD enhancement may help differentiate from NMOSD | Oligoclonal bands uncommon; CSF ACE (not sensitive)* | Lung/eyes/skin involvement | Biopsy | |
Vascular | Infarction | Do not enhance with contrast; ’pencil-like' lesion | Tract 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 |
Malformation | Conus involved in >80% of cases; dilated perimedullary vessels enhanced on T1 and seen as flow voids on T2 | Oedema seen as centromedullary T2 hyperintensity; vessels (flow voids) on dorsum | Oligoclonal bands (27%)* | Typically patients fluctuate with exercise. | Spinal angiogram | |
Metabolic | Contrast enhancement is rare. | Symmetric T2 hyperintensity dorsal tracts | * | Variable cytopenias; typically anaemia | B12/copper levels/genetic testing | |
Acute infection | Viral | Predominantly central grey matter | * | Prodromal illness | Difficult to confirm | |
Tuberculosis | White matter nodules or target lesions | Marked pleocytosis and raised protein | Constitutional symptoms; lung/lymph nodes | PCR | ||
Parasitic | Eccentric nodular pattern | * | Systemic features of infection | Antibody testing | ||
Chronic infection | Syphilis | Dorsal T2 hyperintensity (may mimic metabolic) | Only abnormal half the time (depends on previous treatment)* | History of sexually transmitted infection | Antibody testing | |
HTLV-1 | T2 hyperintensity (early) and then cord atrophy | Lateral columns commonly but can affect central and anterior cord | * | Uveitis, arthropathy, alveolitis, myositis | WHO diagnostic guidelines | |
HIV | Dorsal T2 hyperintensity (may mimic metabolic) | Neither sensitive nor specific in this case* | Constitutional symptoms | Confirmatory HIV testing | ||
Neoplastic | Astrocytoma | Heterogeneous or no enhancement; irregular margins | Eccentric location; may be exophytic and appear extramedullary | Cytology may be more useful than in cerebral malignancy* | Neurofibromatosis I | Biopsy |
Ependymoma | Rostral and caudal cysts; homogenous enhancement (75%); clear borders | Variable but more commonly central than other malignancies | Cytology may be more useful than in cerebral malignancy* | Biopsy | ||
Metastatic | Eccentric location | Cytology 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.