Purpose or Case Report: A 16-year-old boy was transferred to our institution after experiencing a week of worsening numbness and weakness in his left lower extremity. Initially diagnosed with sciatica at an outside facility, he was treated with steroids. However, as his symptoms progressed, including difficulties with bowel movements, he returned for further evaluation.

Outside MRI studies of the lumbar spine and brain revealed hyperintensities and enhancement at T11-T12, raising concerns for transverse myelitis. Subsequent MRI of the cervical and thoracic spine and brain demonstrated extensive T2-weighted cord edema extending from C7 to the conus medullaris, along with a long segment of intramedullary hemorrhage, most pronounced from T8-T9. The differential diagnosis based on these findings included long-segment transverse myelitis complicated by cord hemorrhage or an intramedullary neoplasm, such as ependymoma or astrocytoma.

Comprehensive laboratory testing, including serologic and cerebrospinal fluid studies, ruled out infectious, autoimmune, metabolic, and demyelinating causes. Given the presence of intramedullary hemorrhage, a vascular etiology, such as an arteriovenous shunt, was considered; however, a diagnostic spinal angiogram showed no evidence of an aneurysm or vascular malformation.
Multi-specialty conferences involving radiology, infectious diseases, rheumatology, neuroimmunology, and neurosurgery were conducted, but no consensus was reached regarding the underlying etiology of the lesions. Ultimately, the patient was treated empirically for transverse myelitis with steroids, intravenous immunoglobulin (IVIG), and plasmapheresis.

Hemorrhagic transverse myelitis can result from a variety of etiologies, including infectious, neoplastic, demyelinating, vascular, autoimmune, and idiopathic factors. Key MRI sequences for evaluation include T2-weighted and post-contrast images, which are essential for assessing spinal cord edema, inflammation, and hemorrhagic changes. Additionally, gradient echo (GRE) sequences are vital for detecting subtle blood products, as blood degradation products display greater hypointensity and blooming on GRE images compared to T2-weighted images. By understanding this rare condition and its potential underlying causes, radiologists can play a crucial role in guiding clinical teams toward accurate diagnosis and timely management of patients with hemorrhagic transverse myelitis.
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