Spinal intradural tumors

Spinal intradural tumors are uncommon lesions but may cause significant morbidity. In establishing the differential diagnosis for a spinal lesion, location, age, and the patient's clinical presentation are important. Magnetic resonance imaging plays a central role in the visualization of spinal tumors, easily allowing tumors to be classified as extradural, intradural extramedullary, or intramedullary which is very useful in tumor characterization. We describe intradural tumors; the majority is extramedullary, with nerve sheath tumors being the most frequent. Intramedullary tumors are uncommon spinal tumors. Ependymomas and astrocytomas comprise the majority of this group. Typical imaging features of both intradural extramedullary and intramedullary tumors are described.     

Imaging of tumors of the spine and spinal cord

Imaging of the spine and spinal cord has traditionally been accomplished with plain radiography, myelography, and CT. Recently, MR imaging has become the technique of choice in the assessment of lesions of the spine and spinal cord. MR imaging provides accurate localization of intramedullary, intradural extramedullary, and extradural tumors. Ependymomas and low-grade astrocytomas are the most common intramedullary tumors. MR imaging findings are distinguishable by the delineation and size of the lesion, and the signal intensity on T2-weighted images. Other less common tumors include malignant astrocytomas, hemangioblastomas, and intramedullary metastasis. Numerous foci of high-velocity signal loss are seen in the hemangioblastomas. Metastasis, meningiomas, and schwannomas are the most common intradural extramedullary tumors. Meningiomas are characterized by dural enhancement on postcontrast T1-weighted images. Schwannomas and neurofibromas often erode bony structures and appear to be dumbbell-shaped. Epidural metastasis accounts for the majority of extradural tumors. Primary malignant extradural tumors include lymphomas, chordomas, and so on. The most common primary benign extradural tumor is hemangioma, which often appears to be hyperintense on both T1-weighted and T2-weighted images. Intramedullary non-neoplastic lesions include demyelinating, vascular, and infectious diseases. Diffuse, peripheral, or speckled contrast enhancement, and lack of contrast enhancement may suggest non-neoplastic lesions.     

椎管内血管性病变的MRI诊断

目的 总结不同类型椎管内血管性病变的影像特点,以提高对该类疾病的诊断水平. 资料与方法 对33例经手术病理或DSA证实的椎管内血管性病变的影像及临床资料进行回顾性分析,其中海绵状血管瘤11例(髓内8例,髓外硬脊膜外3例),血管母细胞瘤4例(单发2例,多发2例),动静脉病变18例(动静脉瘘12 例,动静脉畸形6例).所有病例均行MR平扫和增强扫描. 结果 椎管内血管性病变好发年龄在40岁左右,临床多表现为渐进性的神经系统受损症状.海绵状血管瘤髓内较髓外相对多见,髓内病变颈段好发,病变多局限,病灶周围T2低信号环较具特征性,强化多不明显;硬脊膜外海绵状血管瘤少见,多发生在胸段,常为边界清楚梭型肿物,均匀明显强化.血管母细胞瘤较少见,可单发亦可多发,多发生在颈、胸段,当伴有较大范围脊髓空洞或囊变,并有明显强化结节时,诊断不难;动静脉病变最多见, MRI多能发现蜿蜒血管流空信号,较易诊断,但具体分型有赖于DSA或手术. 结论 椎管内不同类型的血管性病变具有相对特异的影像表现,MRI可较好地显示病变,并能准确定位,同时可以显示脊髓变性的程度和范围,有利于病变的诊治及判断预后.     

Neoplasms of the spinal cord and filum terminale: radiologic-pathologic correlation.

Intramedullary spinal cord neoplasms are rare, accounting for about 4%10% of all central nervous system tumors. Despite their rarity, these lesions are important to the radiologist because magnetic resonance (MR) imaging is the preoperative study of choice to narrow the differential diagnosis and guide surgical resection. On contrast materialenhanced MR images, intramedullary spinal tumors almost always manifest as expansion of the spinal cord and show enhancement. Syringohydromyelia and cystic lesions are frequently associated with intramedullary tumors. Nontumoral cysts tend to be located at the poles of the tumors and do not enhance on contrast-enhanced MR images, whereas cysts within the substance of the tumor are considered tumoral cysts and typically demonstrate peripheral enhancement. Spinal cord ependymomas are the most common type in adults, and cord astrocytomas are most common in children. Both entities constitute up to 70% of all intramedullary neoplasms. A central location within the spinal cord, presence of a cleavage plane, and intense homogeneous enhancement are imaging features that favor an ependymoma. Intramedullary astrocytomas are usually eccentrically located within the cord, are ill defined, and have patchy enhancement after intravenous contrast material administration. Even with these characteristics, it may not be possible to differentiate these two entities on the basis of imaging features alone. Cord hemangioblastomas are the third most common type of intramedullary spinal tumor. Gangliogliomas commonly extend over more than eight vertebral segments. Paragangliomas and primitive neuroectodermal tumors have an affinity for the filum terminale and cauda equina. Other spinal cord tumors include metastatic disease, which is characterized by prominent cord edema for the size of the enhancing portion, and primary lymphoma.     

0.6 T MR imaging of the cervical spine: multislice and multiecho techniques

During a 6 month period, 50 patients with signs and symptoms referable to the cervical spine were studied with a 0.6 T superconducting magnetic resonance (MR) imaging unit. The last 23 of these 50 patients were studied with combined multislice and multiecho techniques. In 38 of the 50 patients, abnormalities were demonstrated on MR images. Intramedullary lesions included syringomyelia (three cases), primary tumors (two), metastatic neoplasm (one), cord atrophy secondary to trauma (one), and multiple sclerosis (one). Intradural, extramedullary lesions included two neurofibromas and two Chiari malformations. The rest of the lesions were extradural: degenerative changes (10), spinal stenosis with cord compression (five), disk degeneration and/or herniation (five), postoperative changes (four), metastases to bone/epidural disease (three), and neurofibromatosis (one). Two patients had more than one abnormality. The MR findings were compared with available routine radiographs, computed tomographic (CT) scans with and without metrizamide, and myelograms. MR imaging was consistently better than routine CT scanning in the detection of lesions of the spinal cord and in directly imaging the effects on the spinal cord of extrinsic abnormalities such as spinal stenosis. Metrizamide-enhanced CT scanning detected all cases of syringomyelia, but it involved an invasive procedure. Myelography alone was slightly less sensitive and considerably less specific than MR in detecting intramedullary lesions and in distinguishing cord neoplasms from syringomyelia. Multislice, multiecho techniques with up to 240 msec echo times (TEs) were particularly helpful in the detection and characterization of extradural processes.(ABSTRACT TRUNCATED AT 250 WORDS)     

MR imaging of intraspinal tumors—Capability in histological differentiation and compartmentalization of extramedullary tumors

Summary Magnetic resonance (MR) images of 29 consecutive patients with intraspinal neoplasms (9 intramedullary tumors, 20 extramedullary tumors) were reviewed to evaluated the utility of MR imaging in distinguishing the intraspinal compartmental localisation and signal characteristics of each lesion. Compartment and histology of all neoplasms were surgically proven. MR correctly assigned one of three compartments to all lesions, 9 intramedullary, 14 intradural extramedullary (6 schwannomas, 3 neurofibromas, 5 meningiomas), and 6 extradural (3 schwannomas, 1 meningioma, 1 cavernous hemangioma, 1 metastatic renal cell carcinoma). All intramedullary tumors showed swelling of the spinal cord itself. In all five extradural tumors a low intensity band was visualized between the spinal cord and tumor. On the other hand, a low intensity band was demonstrated in no cases with intradural tumors. Visualization of this low intensity band is important in differentiating extradural from intradural-extramedullary lesions. We call this low intensity band, the extradural sign. Signal intensity of intradural tumors varied with histology. In extramedullary tumors, signal intensity of schwannomas was similar to that of the cerebrospinal fluid (CSF) both on T1 weighted (inversion recovery) and T2 weighted spin echo (SE) images. On the other hand, meningiomas tended to be isointense to the spinal cord on both T1 and T2 weighted SE images. We found relatively reliable signal characteristics to discriminate meningioma from schwannoma.     

Intramedullary spinal cord metastases, mainly of nonneurogenic origin

The clinical data and imaging studies of 12 patients with intramedullary metastases were reviewed retrospectively to see if these lesions had a typical radiographic appearance and to determine the sensitivity of the various radiologic examinations. The lesions were identified antemortem by either myelography, CT, MR, and/or intraoperative spinal sonography (IOSS). Final diagnosis was based on biopsy material from either the spinal cord lesion, another metastatic site, and/or the primary tumor. Ten patients had primary tumors located outside the central nervous system, while only two patients had primary brain tumors. Metrizamide myelography and CT demonstrated a definite intramedullary mass in nine of 11 patients. In five patients the mass was relatively small, well-defined, single, and resembled a primary spinal cord neoplasm. In the other four patients, longer and sometimes several segments of the cord were involved. These appeared irregular and nodular and were often associated with intradural lesions at separate sites. MR detected not only enlargement and abnormal signal in the cord but also clinically unsuspected brain lesions. IOSS localized lesions for biopsy and monitored tumor resection. These various imaging procedures showed that cord metastases were often more extensive than anticipated clinically. Spread of tumor into the spinal and intracranial subarachnoid space was common. Imaging of the entire spinal canal and brain, preferably with MR, is therefore recommended to aid in diagnosis, prognosis, and treatment.     

Spinale Tumoren

Spinal tumors can be intramedullary, intradural (within the meninges), or extradural (between the meninges and the bones), or they may extend secondary to the spine from other locations. Vertebral hemangioma represents the most common benign tumor of the spine. Metastases, lymphoma, and multiple myeloma are the most frequent malignant spinal tumors. Primary osseous tumors of the spine, in contrast, are rare conditions but may demonstrate typical imaging findings. For the differential diagnosis, the patient’s age, the topographic localization of the mass, and morphologic features of the lesion as depicted by computed tomography and magnetic resonance imaging play important roles.     

Advantages of supplementary CT in myelography of intraspinal masses

Computed tomographic (CT) myelography subsequent to nonionic water-soluble contrast medium myelography has provided additional diagnostic information for evaluating intraspinal mass lesions. In 20 patients thus studied, there were eight intramedullary tumors, eight intradural extramedullary masses, and four extradural neoplasms. In intramedullary tumors CT enabled more precise delineation of the extent and location of expansion of the spinal cord. In intradural and extradural tumors, rotation and compression of the spinal cord as well as bony and paraspinal soft-tissue changes were more accurately demonstrated in the axial plane. When a complete block was present, the greater contrast sensitivity of CT permitted visualization beyond the level of the block. Histologic prediction is not feasible by CT myelography except for hyperlucent lipoma. CT can provide useful supplemental information to conventional metrizamide myelography.     

Spinal cord tumors

Spinal cord tumors are rare; however, every radiologist should be able to recognize and readily identify those lesions often found in younger patients or children [1, 2, 3, 4, 5, 6, 7, 8,9]. Early diagnosis plays an important role in the management of the lesions and interferes with the prognosis and final outcome of the patient [10]. Plain X-ray of the spine and CT are of limited diagnostic value in cases of intramedullary pathology. Magnetic resonance imaging should be performed as soon as possible and as the first technique whenever an intrinsic spinal cord lesion is clinically suspected. Systematic analysis of the MR images together with a basic knowledge of the most common spinal cord tumors encountered, including astrocytomas, ependymomas, and hemangioblastomas, should provide a correct diagnosis and lead to appropriate treatment subsequently.     

Bildgebung extraduraler Raumforderungen

There is a wide variety of spinal extradural tumors. In addition to real neoplasms, degenerative diseases, congenital abnormalities and inflammatory disorders can be causes of extradural masses. Due to the bony boundary of the spinal canal, both benign as well as malignant masses can cause progressive neurological deficits including paraplegia. Most of the spinal tumors are benign (hemangioma of the vertebral body, degenerative diseases). In younger patients congenital abnormalities and primary tumors of the spine have to be considered, whereas in adults the list of differential diagnoses should include secondary malignancies such as metastases and lymphomas as well as metabolic disorders such as osteoporotic vertebral compression fracture and Paget's disease. Cross-sectional imaging techniques such as magnetic resonance imaging (MRI) and computed tomography (CT) of the spine often help to make a specific diagnosis of extradural spinal lesions and represent important tools for tumor staging and preoperative evaluation.     

Intradural spinal tumors: current classification and MRI features

The differential diagnosis of intradural spinal tumors is primarily based on location, but the clinical presentation, age, and gender of the patient are also important factors in determining the diagnosis. This comprehensive review focuses on the current classification, clinical symptoms, and MRI features of the more common intradural extramedullary and intramedullary neoplastic lesions. This review does not include extradural lesions.     

Diagnostic imaging of the occipito-cervical junction in patients with rheumatoid arthritis. Plain films, computed tomography, magnetic resonance imaging

Fifty-five patients with confirmed chronic polyarthritis were admitted to this prospective study. The occipito-cervical region was visualized by plain radiography, computed tomography (CT) and magnetic resonance (MR) imaging. These modalities and the results are compared. In the presence of chronic polyarthritis, radiography of the occipito-cervical region visualized only bone lesions, while CT provided a good picture of both bone lesions and soft-tissue alterations. CT is an effective modality for the diagnosis of chronic polyarthritis in the occipito-cervical region. MR imaging was less sensitive in depicting bone lesions. In comparison with CT, however, MR images produced more frequent and more impressive visualization of soft-tissue alterations. MR imaging is most suitable for visualizing complications of the spinal cord.     

Magnetic resonance imaging of malignant extradural tumors with acute spinal cord compression

Thirty-six cancer patients with extradural spinal metastatic disease and acute symptoms of spinal cord compression underwent magnetic resonance (MR) imaging at 1.5 T. Cord involvement was found in all 36, 7 of whom had lesions at 2 different sites. Vertebral metastases in addition to those corresponding to the cord compressions were detected in 27 patients, and 18 of these had widespread deposits. MR displayed the extent of the tumors in the craniocaudal and lateral directions. The ability to identify multiple sites of cord and vertebral involvement and to delineate tumor accurately makes MR the examination of choice in cancer patients with suspected spinal cord compression. It obviates the need for myelography and postmyelography CT in this group of patients.     

MR imaging of Hippel-Lindau disease: value of gadopentetate dimeglumine.

Hippel-Lindau disease is an autosomal dominant disorder characterized by tumors of the central nervous system and abdominal viscera. Frequent multisystem radiologic evaluation of persons at risk is desirable. Twenty-seven patients with Hippel-Lindau disease or a family history of the disease were examined with both unenhanced and gadopentetate dimeglumine-enhanced magnetic resonance (MR) imaging to study the usefulness of the contrast medium in the evaluation of these patients. The MR studies were correlated with computed tomographic (CT) scans in seven patients and cerebral angiograms in five. Twelve patients had hemangioblastomas in the brain, and eight of these patients also had spinal cord lesions (most were multiple), well demonstrated with gadopentetate dimeglumine. Contrast-enhanced MR imaging enabled detection of more central nervous system lesions and provided better delineation than unenhanced MR imaging, CT, or angiography. In addition, four patients with multiple renal cysts seen on CT scans and unenhanced MR images had enhancing lesions that were later proved to be renal cell carcinoma at angiography and/or surgery. Four patients had cystic lesions in the pancreas that did not enhance and were later proved to be pancreatic cysts. The authors conclude that gadopentetate dimeglumine-enhanced MR imaging appears to be a useful method for evaluating and following up patients with Hippel-Lindau disease.     

Central nervous system tumors in children: detection by magnetic resonance imaging

Fifty-one pediatric patients who were suspected of having central nervous system (CNS) tumors underwent magnetic resonance (MR) imaging using a 0.35 T Diasonics MT/S system. Pulse intervals (TR) ranged from 0.5 to 2.0 seconds with echo delays (TE) of 28 and 56 msec. The ability of MR and contrast-enhanced CT to detect focal lesions, determine lesion extent, and evaluate associated abnormalities was compared. In most patients in whom there was suspected spinal cord disease, comparison with myelography was made. Thirty-three intracranial lesions were detected with at least one imaging modality in 43 cranial examinations. MR was judged superior to CT in 14 of these cases and CT superior to MR in only one. Of eight spinal examinations, there were six that demonstrated abnormal findings. MR was superior to CT in all six cases and better than myelography in four of five cases where myelography was performed. Spin echo (SE) sequences with long pulse intervals were the most sensitive, but in some cases short pulse intervals permitted further characterization of the lesion. Patient motion was not a problem; sedation was routinely used in children younger than five years of age. MR imaging has rapidly become a valuable diagnostic modality in neuroradiology. The lack of ionizing radiation and the ability to evaluate the spinal cord noninvasively makes it particularly attractive in examination of children.     

Secondary ependymoma presenting as a presacral mass

Ependymomas are common types of tumors occurring within the brain and usually derive from the ependymal lining, especially of the ventricles. Ependymomas also occur, usually within the spinal canal, as primary intramedullary lesions or as late "drop" metastases from intracranial ependymomas. Extradural ependymomas are rare. They could occur as intraspinal or extraspinal lesions. We hereby report a case of an extradural (intraspinal) lesion with extraspinal extension, the extraspinal lesion being presacral in position, which presented with urinary and colonic symptoms. The lesions were secondary ependymoma subsequent to an intracranial ependymoma previously treated by combined surgery, radiotherapy, and chemotherapy 4 years earlier. The extradural and extraspinal site of the secondary lesion as well as its mode of presentation are noteworthy.     

髓内肿瘤的磁共振诊断与鉴别诊断

本文通过对30例髓内肿瘤和20例非肿瘤病变MR表现的回顾性对比分析,总结了髓内肿瘤MR诊断和鉴别诊断经验。指出髓内肿瘤的MR主要征象为脊髓局部增宽、膨大,病灶Gd-DTPA明显强化,以及伴有囊变。而非肿瘤病变脊髓轮廓改变较轻,Gd-DTPA为轻至中度强化。增强特点为偏心性、点片状或环状,较具特异性。     

Pädiatrische intraspinale Neoplasien

With an overall incidence of 10?% of all central nervous system tumors, spinal tumors are relatively rare in children. The majority of these tumors are astrocytomas and ependymomas (70?%) followed by rare non-glial tumor entities, such as gangliogliomas. They can be differentiated into intramedullary, extramedullary intradural and extramedullary extradural tumors according to their occurrence within the anatomical intraspinal compartments. The clinical presentation is generally unspecific. Longer lasting back pain or a gradually worsening scoliosis are often the first signs of the disease. Neurological deficits, such as gait disturbances and paresis often occur after a time delay. In rare cases increased intracranial pressure has been reported. Knowledge concerning potential organ manifestations, resulting complications and typical radiological presentation, especially in magnetic resonance imaging are mandatory for adequate diagnosis and treatment of affected patients.     

Extradurale Tumoren

Approximately 50-60% of spinal tumors are extradural and depending on the origin and location are classified into tumors of the vertebrae, tumors of the epidural space and primarily extraspinal tumors growing into the spine. Presenting complaints include back pain and weakness as well as myelopathy and radiculopathy due to compression of the spinal cord or the nerve roots, respectively. Imaging of extradural tumors mostly requires both magnetic resonance imaging (MRI) and computed tomography (CT). Extradural masses and infiltration of the cord can be depicted by MRI and CT depicts osteolytic and osteosclerotic lesions and the extent of osseous involvement. Bone scintigraphy is often helpful in detecting metastases and characterizing osteoid osteomas.