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A 58-year-old man with a basilar tip aneurysm is referred by a neurosurgeon. He has a 4-year history of progressive spastic paraparesis. He has recently had urge incontinence of urine. He also has numbness in the right toes more than the left, and pain in the thighs and back. There have been some gradual fluctuations, but no clear, discrete episodes of deterioration. He has had no disturbances of vision, eye movement, or motor control of the upper extremities. He was referred when surgical clipping of the aneurysm 3 months ago failed to help his symptoms. Which of the following is the most appropriate next diagnostic test?
A. Cerebral angiography
B. Spinal angiography
C MRI of the spinal cord
D Spinal cord biopsy
E. VER
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The correct answer is C..; MRI of the spinal cord.
This patient has a gradually progressive myelopathy. The differential diagnosis is broad, but MS is high on the list. A subset of patients with MS consists of middle-aged men with a progressive form of the disease. An MRI of the spinal cord could show MS plaques in the cord or other abnormalities intrinsic to the spinal cord parenchyma, and could also exclude compressive lesions. Vascular malformations of the spinal cord can also be seen in this way, although sometimes spinal angiography is required for definitive diagnosis.
Cerebral angiography would not be helpful, except to evaluate for residual aneurysm, which is unlikely to be related to this patient's problem. Spinal cord biopsy is unwarranted in this case unless a specific indication is provided on neuroimaging. Visual evoked responses may be abnormal in MS, even without clinical evidence of disease, but would not account for the patient’s spastic paraparesis.
