CVJ Soft Tissue Abnormality



CVJ Soft Tissue Abnormality


Jeffrey S. Ross, MD



DIFFERENTIAL DIAGNOSIS


Common



  • Rheumatoid Arthritis


  • Retro-Odontoid Pseudotumor


  • Osteomyelitis, C1-C2


  • Extramedullary Tumor



    • Metastases


    • Lymphoma


    • Plasmacytoma


    • Nasopharyngeal Carcinoma


    • Neurofibromatosis Type 1


    • Schwannoma


    • Paraganglioma


    • Chordoma


    • Chondrosarcoma


    • Meningioma


  • Intramedullary Mass



    • Syringomyelia


    • Chiari 1 Malformation


    • Chiari 2 Malformation


    • Glioma, Brainstem


    • Hemangioblastoma, Spinal Cord


Less Common



  • Carotid Pseudoaneurysm/Dissection


  • Synovial Cyst


Rare but Important



  • Neurenteric Cyst


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Do intralesion calcifications represent arc-whorl intralesional calcifications (chondrosarcoma) or fragmented destroyed bone (chordoma, metastasis)?


  • Does patient have known primary neoplasm (metastasis), myeloma (plasmacytoma), or a nasopharyngeal mass (nasopharyngeal carcinoma)?


Helpful Clues for Common Diagnoses



  • Rheumatoid Arthritis



    • Thickened & inflamed synovium called pannus


    • Never involves spine without hands &/or feet involvement


    • Odontoid erosions, ligamentous laxity


    • C1-C2 instability in 33% of all RA patients


    • Neutral, flexion, and extension lateral radiographs performed for evaluation



      • High correlation to neurologic symptoms with distance 9 mm or more between C1-2


  • Retro-Odontoid Pseudotumor



    • Increased soft tissue dorsal to odontoid secondary to C1-2 osteoarthritis



      • Low signal mass on T1 & T2 (fibrotic)


      • May cause cervicomedullary junction compression


    • Usually seen with altered biomechanics of lower cervical spine ⇒ surgical/congenital fusion


    • Mimics appearance of RA


    • Multiple other levels of degenerative disc disease


  • Osteomyelitis, C1-C2



    • Infection starts as septic arthritis of C1-2


    • Risk factors include diabetes, drug abuse, endocarditis, immunocompromise


    • Soft tissue mass and bone destruction at C1-2 level



      • Staph aureus most common organism in USA


      • Mycobacterium tuberculosis most common worldwide


    • MR shows low T1 signal mass centered at C1-2 with variable involvement of odontoid and lateral masses at C2


    • May show enlarged atlanto-dental interval


    • Epidural mass with thecal sac/cord compression


    • Grisel syndrome: Inflammatory, nontraumatic subluxation of C1-C2 following peripharyngeal infection


  • Extramedullary Tumor



    • Metastases



      • Multiple lesions, bone destruction, systemic primary


    • Lymphoma



      • Large pharyngeal mucosal space mass with associated cervical adenopathy > 50% of time


      • NHL 5x as common as Hodgkin disease in head & neck


    • Nasopharyngeal Carcinoma



      • Mass centered in lateral pharyngeal recess of NP with deep extension & cervical adenopathy


      • Nodal metastases present in 90% of cases at presentation



      • Multi-planar images show invasion of clivus, sphenoid bone & sinus, C1 & C2 bodies


    • Neurofibromatosis Type 1



      • Plexiform neurofibroma ⇒ diffuse enlargement of major nerve trunks/branches → bulky rope-like (“bag of worms”) nerve expansion with adjacent tissue distortion


      • Look for kyphoscoliosis ± multiple nerve root tumors, plexiform neurofibroma, dural ectasia/lateral meningocele


    • Schwannoma



      • Hypoglossal or upper cervical roots as site of origin


      • Hypoglossal neuropathy results in tongue denervation


      • Dumbbell with uniform enhancement


      • Larger lesions may show central cystic formation


    • Paraganglioma



      • Multiple black dots (“pepper”) in tumor substance indicating high velocity flow voids from feeding arterial branches


      • Jugular foramen or vagal varieties may present with upper cervical/skull base level mass


    • Chordoma



      • Mass is hyperintense to discs on T2WI, with multiple septa


      • Destructive, lytic lesion


      • May extend into disc, involve 2 or more adjacent vertebrae


    • Chondrosarcoma



      • Lytic mass with or without chondroid matrix, cortical disruption, and extension into soft tissues


      • Chondroid matrix mineralization of “rings and arcs” (characteristic)


    • Meningioma

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Aug 7, 2016 | Posted by in NEUROLOGY | Comments Off on CVJ Soft Tissue Abnormality

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