Intramedullary spinal cord tumors Rekha Meesa, MD MS Summit/Synergy Radiology edited by Akash Meesa

Introduction Spinal cord tumors account for 2-5% of central nervous neoplasms in adults Intramedullary tumors - 20% of intraspinal tumors in adults - 35% of intraspinal tumors in children Often a history of long duration of symptoms prior to diagnosis

Classification Various types of classifications Intramedullary neoplastic lesions a. Glial neoplasms 1. Spinal ependymoma 2. Spinal astrocytoma 3. Spinal ganglioma b. Non-glial neoplasms 1. Highly vascular lesions - spinal hemangioblastoma 2. Other rare lesions - intramedullary metastasis Intramedullary benign masses a. Spinal canal lipoma

Spinal Astrocytoma Intramedullary astrocytomas represent only 6-8% of spinal cord tumors Cord expansion often <5 segments Most common intramedullary tumor in young children Imaging: Intramedullary enhancing mass Often slow-growing Treatment: Microsurgical resection

Aggressive Anaplastic Astrocytoma with intracranial metastasis Intracranial dissemination of spinal cord gliomas is rare Metastasize to the brain by direct leptomeningeal, cerebrospinal fluid (CSF) pathways and rarely by bloodstream - Tumor cells can disseminate to the basal cisterns, cistern magna causing communicating hydrocephalus

Sagittal T1 weighted image of the cervical and upper thoracic spine demonstrate heterogeneous expansile masses in the thoracic cord and some lesions in the cervical cord.

Sagittal T2 weighted image of the spine demonstrates multiple T2 bright expansile lesions in the cord.

Sagittal post contrast T1 weighted image of the spine demonstrates a large enhancing intramedullary mass and other small enhancing lesions. Note is also made of abnormal leptomeningeal enhancement along the surface of the cord.

Axial post contrast image of the brain demonstrates abnormal enhancement of the basilar cisterns consistent with leptomeningeal spead of disease.

Spinal Ependymoma Neoplasm of ependyma lining of spinal cord canal Circumscribed, enhancing cord mass with hemorrhage

Age: 35 – 45 yo WHO grade II or grade III Associated with: subarachnoid hemorrhage, superficial siderosis, NF2 Treatment: surgical resection

Sagittal T1 MR image of the cervical spine demonstrates a large expansile mass in the upper cervical cord.

Sagittal T2 weighted MR image of the cervical spine demonstrates a T2 bright expansile mass in the upper cervical spine.

Sagittal post contrast T1 weighted MR image of the cervical spine demonstrates a mildly enhancing mass in the upper cervical cord.

Spinal Hemangioblastoma Low grade, capillary rich neoplasms of cerebellum and spinal cord a. Occur sporadically(75% or in setting of von Hippel-Lindau (VHL syndrome) b. Intramedullary mass with “flow voids” c. Extramedullary spinal HBs occur, but rare

Sagittal T2 weighted MR image of the cervical spine demonstrates a cystic mass with a mural nodule in the cervical cord.

Sagittal post contrast T1 weighted MR image of the cervical spine demonstrates a cystic mass with an enhancing mural nodule in the cervical cord.

von Hippel-Lindau syndrome Cerebellar HBs, retinal angiomas, pheochromocytoma, renal cell carcinoma, angiomatous or cystic lesions of kidneys, pancreas, and epididymis

Differential Diagnosis a. Arteriovenous malformation b. Cavernous malformation c. Hypervascular cord neoplasms d. Intradural/extramedullary tumors

Symptoms - Nonspecific - Sensory/motor > pain 95% symptoms-producing associated with syringomyelia Treatment - Microsurgical resection

References Kataria R, Bhasme V, Chopra S, Sinha VD, Singhvi S. Intracranial metastasis of spinal intramedullary anaplastic astrocytoma. Asian J Neurosurg. 2011 Jul-Dec; 6(2): 116-118. Statdx