Central canal enhancement and the trident sign in spinal cord sarcoidosis

We report an enhancement pattern in 9 patients with spinal cord sarcoidosis (SCS) with subacute onset (<4 weeks) myelitis as the initial manifestation of sarcoidosis. Presenting symptoms included numbness in 9, urinary complaints in 7, and weakness in 6. Examination revealed abnormal proprioception in 8, spastic quadriparesis/paraparesis in 6, and sensory level in 6. MRI showed central canal enhancement alone (11%) or in combination with dorsal-subpial enhancement1 (89%) (figure 1), often resembling a trident head on axial sequences (figure 2). Lung biopsies in 7 patients confirmed sarcoidosis; both patients without biopsies had hilar adenopathy. Central canal enhancement and the trident sign in subacute myelitis should raise suspicion for SCS.