Findings
Sagittal T2 image(1) shows volume loss and T2 hyperintensity involving the mid-cervical spinal cord. Sagittal T1 image(2) shows prominent posterior epidural fat that is seen posterior to the upper cervical spinal canal. Flexion sagittal T2 image(3) shows enlargement of the posterior epidural space of the cervicodorsal spine with prominent flow voids and they cause compression of the mid-cervical spinal cord. The craniovertebral junction is normal in the sagittal T2(1) and coronal STIR(4) images.
Diagnosis
Hirayama disease.
Summary
In young male patients with bilateral upper limb weakness, Hirayama disease should be strongly suspected. Even if the spinal cord is normal in signal intensity in the neutral images, flexion MRI should be done. Soft pointer to Hirayama disease is prominence of the posterior epidural fat in the neutral images that reaches up to the upper cervical spine(at and above C4 level) where generally it is not visualized – as seen in image 2 in this case.
Further reads
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