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Transverse Myelitis

Last Updated: July 21, 2020

Figure 1: Sagittal T2 (top row left), T1 (top row right), and T1 post-contrast (bottom row left) of the cervical spine with mild multilevel cord expansion, confluent T2 hyperintensity, and patchy enhancement extending over multiple levels. Axial T2 (bottom row right) also demonstrates hyperintense edema within the central cord.

Figure 2: Sagittal T1 (top row left) Sagittal T2 (top row right) Sagittal T1 post contrast (middle row left) axial T1 post contrast (middle row right), and axial T2 (bottom row). Mild multilevel cord expansion in the thoracic spine with confluent T2 hyperintensity and patchy contrast enhancement. Incomplete peripheral enhancement and T2 hyperintensity is also visible on axial imaging.

Clinical Features

  • Generally preceded by a viral like illness with rapid progression of neurological deficits in days
  • Most common symptoms include the following: sensory deficit with loss of pain and temperature sensation, band like dysesthesia at lesion level
  • Paraplegia or quadriplegia, back +/- radicular pain. Initially hypotonia and hyporeflexia followed by spasticity and hyperreflexia over time 
  • Any age, but peak at 10-19 years and 30-39 years. 
  • No gender predilection. 

Transverse Myelitis Consortium Working Group

  • Inclusion criteria
    • Development of sensory, motor, or autonomic dysfunction attributed to the spinal cord
    • Bilateral signs and symptoms
    • Clearly defined sensory level 
    • Cord inflammation confirmed by CSF pleocytosis, elevated IgG, or contrast enhancement 
    • Exclusion of extra-axial compressive cause
  • Exclusion Criteria
    • Radiation to the spine within the preceding 10 days 
    • Arterial distribution consistent with thrombosis of anterior spinal artery 
    • Cord arteriovenous malformation
    • Connective tissue disease including but not limited to such as sarcoid, lupus or Sjögren syndrome 
    • CNS infections such as syphilis, Lyme disease, HIV or other viral infections 
    • Brian MRI suggesting multiple sclerosis 
    • Clinical optic neuritis 


  • General 
    • Well circumscribed central cord lesion which greater than two vertebral segments in length +/- enhancement and involves at least 2/3 of the spinal cord on axial imaging 
  • Location
    • Most common in the thoracic spine 
    • 10% in the cervical cord 


  • CT 
    • Usually normal
    • Variable enlargement of the spinal cord, often not visible 
    • Variable contrast enhancement
  • MRI 
    • T1: 
      • Smooth cord expansion in acute phases
      • Mildly low signal intensity edema
    • T1 + contrast 
      • Variable enhancement: none, diffuse, patchy, or peripheral 
      • No enhancement in up to 40-50% of cases 
    • T2Wi
      • Hyperintense cord expansion
      • Central dot sign: Gray matter surrounded by edema 
    • STIR
      • Hyperintense cord expansion 


Contributor: Cortney Sostarich, MD

DOI: https://doi.org/10.18791/nsatlas.v1.04.04.04


  1. Transverse Myelitis Consortium Working Group*. "Proposed diagnostic criteria and nosology of acute transverse myelitis." Neurology 59.4 (2002): 499-505.
  2. West, Timothy W., Christopher Hess, and Bruce AC Cree. "Acute transverse myelitis: demyelinating, inflammatory, and infectious myelopathies." Seminars in neurology. Vol. 32. No. 02. Thieme Medical Publishers, 2012.
  3. Goh, Christine, Patricia M. Desmond, and Pramit M. Phal. "MRI in transverse myelitis." Journal of Magnetic Resonance Imaging 40.6 (2014): 1267-1279

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