Intramedullary Lesions, Multiple

Lubdha M. Shah, MD

DIFFERENTIAL DIAGNOSIS

Common

Less Common

Rare but Important

ESSENTIAL INFORMATION

Key Differential Diagnosis Issues

Lesions in other locations such as osseous, supratentorial, & systemic can help with differential considerations

Helpful Clues for Common Diagnoses

Multiple Sclerosis, Spinal Cord
- 2/3 of cord lesions in cervical cord & < 2 vertebral segments in length
- Dorsolateral aspect of cord involving gray & white matter
- Enhancement lasts 1-2 months
Metastases, Spinal Cord
- Typically < 1.5 cm with extensive edema
- Brain mets in 20%
ADEM, Spinal Cord
- Multifocal flame-shaped white matter lesions
  - Variable enhancement, depending on the stage
- Little mass effect or edema
- Supratentorial involvement is typical

Helpful Clues for Less Common Diagnoses

Hemangioblastoma, Spinal Cord
- 75% sporadic; 25% VHL-associated
Ependymoma, Cellular, Spinal Cord
- Many grow centrifugally & usually cause symmetric expansion of cord
  - May help to differentiate from astrocytomas: More infiltrating, causing asymmetric, lumpy cord expansion
Cavernous Malformation, Spinal Cord
- Multiple lesions in approximately 15-33% of spontaneous cases
  - Familial form is autosomal dominant with variable expression & more commonly has multiple lesions, occurring in as many as 73%

Helpful Clues for Rare Diagnoses

Sarcoidosis
- Invariable presence of systemic disease
- Intramedullary lesions in cervical & thoracic cord
Cysticercosis
- 5% of neurocysticercosis cases, involving subarachnoid space most commonly
  - Thoracic cord predilection related to higher percentage blood flow