Immediate Neuroimaging for Upper Motor Neuron Lesions

Initial Diagnostic Approach

A positive Babinski sign in a 12-year-old is pathological and requires urgent MRI of the brain and spinal cord to identify the underlying upper motor neuron lesion, according to the American College of Radiology, which designates MRI as the preferred imaging modality when a positive Babinski sign is detected, with CT as an alternative only if MRI is contraindicated 1

Recent trauma or infection history may indicate spinal cord injury or transverse myelitis 1
Progressive weakness, sensory changes, or bowel/bladder dysfunction suggests thoracic myelopathy or cord compression 1
Headaches, vision changes, or vomiting raises concern for increased intracranial pressure 2
Cognitive changes or behavioral alterations may indicate intracranial pathology 1
Fever or systemic illness could suggest infectious or inflammatory etiology 2

Hyperreflexia and spasticity in the lower extremities confirms upper motor neuron involvement 1
Sensory level on the trunk indicates spinal cord lesion at that dermatomal level 1
Cranial nerve abnormalities suggests brainstem or intracranial pathology 2
Papilledema on fundoscopy indicates elevated intracranial pressure requiring urgent intervention 2

Spinal cord tumors or compression, such as thoracic myelopathy, is a key consideration in a 12-year-old 1
Demyelinating disease, such as multiple sclerosis or acute disseminated encephalomyelitis, should be evaluated for demyelination 2
Cerebral mass lesions or stroke, though less common in this age group, should be considered 1
Genetic disorders, such as 22q11.2 deletion syndrome-related conditions, may be relevant 1
Infectious/inflammatory myelitis requires lumbar puncture if imaging shows cord inflammation 2

MRI brain with and without contrast AND MRI complete spine with and without contrast should be obtained urgently, as recommended by the American College of Radiology, to identify spinal cord pathology and other conditions 1
Contrast enhancement helps identify inflammatory, infectious, or neoplastic processes 2

Immediate neurology or neurosurgery consultation is warranted if signs of elevated intracranial pressure are present, such as papilledema, altered mental status, or severe headache 2
Progressive neurological deficits are occurring 1
Imaging reveals cord compression requiring surgical decompression 1
Multiple cranial neuropathies or other neurologic changes are present 2