Intramedullary Lesion, Solid Enhancement



Intramedullary Lesion, Solid Enhancement


Lubdha M. Shah, MD



DIFFERENTIAL DIAGNOSIS


Common



  • Ependymoma, Cellular, Spinal Cord


  • Ependymoma, Myxopapillary, Spinal Cord


  • Astrocytoma, Spinal Cord


  • Multiple Sclerosis, Spinal Cord


Less Common



  • Hemangioblastoma, Spinal Cord


  • ADEM, Spinal Cord


  • Cavernous Malformation, Spinal Cord


  • Neuromyelitis Optica


  • Type I DAVF


Rare but Important



  • Lymphoma


  • Metastases, Spinal Cord


  • Infarction, Spinal Cord


  • Type II AVM


  • Ganglioglioma


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Look for multiple lesions, supratentorial lesions, & osseous lesions in metastases, multiple sclerosis, ADEM, & hemangioblastoma


  • Internal hemorrhagic products with heterogeneous T1/T2 signal can be seen with certain lesions, such as cavernous malformation, ependymoma, & paraganglioma


Helpful Clues for Common Diagnoses



  • Ependymoma, Cellular, Spinal Cord



    • Well-circumscribed, intensely enhancing intramedullary mass causes fusiform cord enlargement



      • Hemosiderin at cranial or caudal margin “cap sign” in 20-64% of cases


      • Polar or intratumoral cysts in 50-90%


    • Associated syrinx & surrounding edema


  • Ependymoma, Myxopapillary, Spinal Cord



    • Intensely enhancing glioma arising from ependymal cells of filum terminale, conus, cauda equina



      • May be T1 hyperintense due to mucin accumulation


      • T2 hyperintense lesion; hypointense at margin due to hemosiderin


    • May have bony canal expansion


    • Usually spans 2-3 vertebral segments


  • Astrocytoma, Spinal Cord



    • Intramedullary enhancing, infiltrating mass that expands the cord



      • Cervical > thoracic


      • Usually < 4 segments


      • Multisegmental or holocord, more common with pilocystic astrocytoma


    • May be associated with cyst/syrinx


  • Multiple Sclerosis, Spinal Cord



    • 10-20% cases have isolated spinal cord involvement


    • Cervical cord is most commonly affected


    • Dorsolateral aspect of cord


    • Enhancement during the acute or subacute state can be homogeneous, nodular, or ring enhancing


Helpful Clues for Less Common Diagnoses



  • Hemangioblastoma, Spinal Cord



    • Subpial intramedullary mass on dorsal aspect of cord shows intense, homogeneous enhancement



      • ± Syrinx in > 50%


      • Lesions ≥ 2.5 cm show serpentine flow voids


    • Extensive, long segment edema


    • Hemorrhage is common


  • ADEM, Spinal Cord



    • Multifocal spinal cord white matter lesions with little mass effect or vasogenic edema


    • Brain typically also involved


    • Enhancement depends on stage



      • ± Nerve enhancement


  • Cavernous Malformation, Spinal Cord



    • Mottled/speckled pattern due to varying stages of blood products: “Popcorn” appearance


    • Hemosiderin ring


    • ± Minimal enhancement


    • No edema unless recent hemorrhage


  • Neuromyelitis Optica



    • Idiopathic demyelinating syndrome involving the optic nerves and spinal cord


    • Lesions extending over 3 or more vertebral segments on spinal cord MR


    • Distinct from “typical” MS is > 50 cells/mm3 in CSF (often polymorphonuclear) & absent oligoclonal bands


    • Normal initial brain MR



    • NMO-IgG seropositivity


    • Associated with several systemic diseases including collagen vascular diseases, autoantibody syndromes, infections, & toxin exposures


  • Type I DAVF



    • Cord central T2 hyperintensity + prominent intradural vessels on cord surface


    • May show diffuse (usually faint) cord enhancement


    • Distal thoracic cord/conus most common location


Helpful Clues for Rare Diagnoses

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Aug 7, 2016 | Posted by in NEUROLOGY | Comments Off on Intramedullary Lesion, Solid Enhancement

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