Thread by @RafidMustafa

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Inspired by phenomenal #neurotwitter educators @caseyalbin, @zach_london, @LyellJ.. I figured it's finally time to join the #tweetorial game.

Let's begin with a case:

A patient presents to your clinic with new paraparesis and this imaging finding.

What do you do do next?

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▶️IV corticosteroids?
▶️IVIG?
▶️Plasma Exchange?
▶️...?

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Here's the thing-
Misdiagnosis of myelopathies is common
Many patients, especially those with hyperacute or progressive myelopathies, are incorrectly labeled as having "transverse myelitis" which can lead to iatrogenic morbidity from inappropriate investigations or treatments.

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In 2018, @nzalewski2 published this piece in @GreenJournal showing the majority of patients referred to Mayo Clinic with suspected "idiopathic transverse myelitis" ultimately had an alternate specific diagnosis (over 1/3 of which were nonfinflammatory!)
n.neurology.org/content/90/2/e…

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Our colleagues @HopkinsMedicine (Drs. Barreras Cortes, Pardo-Villamizar, and team) published similar findings in @GreenJournal that same year, highlighting the importance of clinical history, imaging, and CSF characteristics in myelopathy diagnosis.
n.neurology.org/content/90/1/e…

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So where does that leave us in how we approach myelopathy?

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Huge credit to my mentor @EoinFlanagan14 in shaping how I approach myelopathies...
I learned from him how critical the clinical history is, particularly the time from symptom onset to maximal neurologic deficit.
We can break this time to nadir into three categories:

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▶️Hyperacute (<12 hours)
▶️Acute/subacute (1-21 days)
▶️Chronic/progressive (progression beyond 21 days)

This approach helps us narrow our differential

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Hyperacute

Think vascular (e.g., spinal cord infarction).

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Acute/subacute

Think inflammatory or infectious.

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Chronic/progressive

Think alternative causes like spondylosis, dural arteriovenous fistula, sarcoidosis, nutritional, or neoplastic.

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Back to our case...

What do we do next?
What is the alternate, specific diagnosis?

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Well if you're interested, join me over the coming weeks to see how we can use concepts we learned today as well as some fun signs (see below) to narrow down a number of myelopathy diagnoses...

Thanks all!
Extremely excited to more officially join the #MedTwitter community!