Monitoring Approach for Transverse Myelitis

Initial Diagnostic Evaluation

The American College of Oncology recommends MRI of the spine with thin axial cuts through the region of suspected abnormality for diagnosis and as the baseline for future monitoring 1
Lumbar puncture should be performed to assess cell count, protein, glucose, oligoclonal bands, viral PCRs, cytology, and onconeural antibodies, as recommended by the Journal of Clinical Oncology 1
Blood tests should include B12, HIV, RPR, ANA, Ro/La, TSH, and aquaporin-4 IgG to rule out other causes, according to the Journal of Clinical Oncology 1

For severe cases (Grade 3-4), more frequent MRI monitoring is recommended (every 3-4 months) by the Nature Reviews Neurology 3
For moderate cases (Grade 2), MRI monitoring should be conducted every 6 months, as suggested by the Nature Reviews Neurology 3
For mild cases (Grade 1), annual MRI monitoring is appropriate if symptoms are stable, according to the Nature Reviews Neurology 3

T2-weighted and T2-FLAIR sequences are essential for detecting new or enlarging lesions, as recommended by the Nature Reviews Neurology and the Journal of Neurology, Neurosurgery and Psychiatry 3, 4
Gadolinium-enhanced T1-weighted sequences should be included to detect active inflammation, according to the Nature Reviews Neurology and the Journal of Neurology, Neurosurgery and Psychiatry 3, 4

Clinical assessments measuring disability and recording relapses should always be performed in parallel with MRI, as suggested by the Nature Reviews Neurology and the Journal of Neurology, Neurosurgery and Psychiatry 3, 5
Evaluation for urinary retention and constipation should be conducted at each follow-up visit, according to the Journal of Clinical Oncology 1

For transverse myelitis associated with immune checkpoint inhibitor therapy, permanently discontinue the therapy and conduct more frequent monitoring (every 3 months), as recommended by the Journal of Clinical Oncology 1
For patients at high risk of developing opportunistic infections who are on immunosuppressive therapy, brain MRI is recommended every 3-4 months, according to the Nature Reviews Neurology 3

First follow-up MRI should be performed 3-6 months after initial diagnosis, as suggested by the Nature Reviews Neurology 3
Subsequent MRIs should be performed every 6-12 months depending on clinical stability, according to the Nature Reviews Neurology 3
More frequent monitoring (every 3-4 months) is warranted for patients with progressive symptoms, immunosuppressive therapy, or high risk of complications, as recommended by the Nature Reviews Neurology and the Journal of Clinical Oncology 3, 1

Failing to distinguish between disease progression and treatment-related complications, as noted by the Nature Reviews Neurology and the Journal of Clinical Oncology 3, 1
Inconsistent MRI protocols between follow-up scans, making comparison difficult, according to the Nature Reviews Neurology 3
Overlooking clinical assessment in favor of imaging findings alone, as warned by the Nature Reviews Neurology and the Journal of Neurology, Neurosurgery and Psychiatry 3, 5