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Top 10 MassTop 10 Mass

LesionsLesions -- SpineSpine

 Alice Boyd Smith, Lt. Col., USAF MC Alice Boyd Smith, Lt. Col., USAF MC

Chief, Neuroradiology Chief, Neuroradiology 

Department of Radiologic Pathology Department of Radiologic Pathology 

 Armed Forces Institute of Pathology  Armed Forces Institute of Pathology 

 Washington, DC Washington, DC

&&

 Assistant Professor of Radiology & Radiological Sciences Assistant Professor of Radiology & Radiological Sciences

Uniformed Services University of the Health SciencesUniformed Services University of the Health Sciences

Bethesda, MDBethesda, MD

ObjectivesObjectives

Be able to identify lesions of the spinalBe able to identify lesions of the spinal

column in relation to their location. (column in relation to their location. ( ieie..intramedullary, extramedullary intradural,intramedullary, extramedullary intradural,

extradural)extradural)

Be able to identify imagingBe able to identify imaging

characteristics of spinal lesions that allowcharacteristics of spinal lesions that allow

for narrowing of the differential diagnosis.for narrowing of the differential diagnosis.

Spinal LesionsSpinal Lesions Intramedullary:Intramedullary:

EpendymomaEpendymoma

 Astrocytoma Astrocytoma

HemangioblastomaHemangioblastoma

Intradural/Extramedullary:Intradural/Extramedullary:

Nerve sheath tumor: Schwannoma,Nerve sheath tumor: Schwannoma,neurofibromaneurofibroma

MeningiomaMeningioma

Myxopapillary ependymomaMyxopapillary ependymoma

Lipoma/Dermoid/EpidermoidLipoma/Dermoid/Epidermoid

Extradural:Extradural:

Degenerative: Synovial cyst, discDegenerative: Synovial cyst, disc Infection/abscessInfection/abscess

Metastasis

IntramedullaryIntramedullary

Intramedullary NeoplasmsIntramedullary Neoplasms

 Account for 4 Account for 4--10% of CNS10% of CNStumorstumors

Most malignant: 90Most malignant: 90--95%95%

gliomasgliomas Expand cordExpand cord

Majority enhanceMajority enhance

BiopsyBiopsy

Cysts a common findingCysts a common finding

TumoralTumoral

NonNon--tumoraltumoral Ast rocytoma

EpendymomaEpendymoma

Most commonMost common

intramedullary spinalintramedullary spinal

neoplasm in adultsneoplasm in adults

 Arises from ependymal Arises from ependymal

cells of central canalcells of central canal

Most WHO grade IIMost WHO grade II

Slow growingSlow growing

Compress rather thanCompress rather than

infiltrate cordinfiltrate cord Grade II Ependymoma

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EpendymomaEpendymoma

CT: Canal widening &CT: Canal widening & vertebral body scalloping vertebral body scalloping

Calcification not commonCalcification not common

MR:MR:

 T1: Iso T1: Iso-- or hypointenseor hypointense EnhanceEnhance

 T2: Iso T2: Iso-- or hyperintenseor hyperintense

Cystic degeneration commonCystic degeneration common

““Cap signCap sign””

 Average number vertebral Average number vertebralsegments involved: 3segments involved: 3--44

EpendymomaEpendymoma

EpendymomaEpendymoma  Astrocytoma Astrocytoma

1/3 of spinal cord1/3 of spinal cord

gliomasgliomas

Most commonMost common

intramedullary tumorintramedullary tumor

in childrenin children

HolocordHolocord

involvement commoninvolvement common

in childrenin children

 Astrocytoma Astrocytoma

 WHO: WHO:

Grade I: 75%Grade I: 75%

Grade IV: Uncommon (0.2Grade IV: Uncommon (0.2--1.5%)1.5%)

Imaging: CTImaging: CT

Canal widening & vertebralCanal widening & vertebral

body scallopingbody scalloping

Grade IV 

 Astrocytoma Astrocytoma

MR:MR:

Poorly defined marginsPoorly defined margins

T1: IsoT1: Iso-- to hypointenseto hypointense

T2: HyperintenseT2: Hyperintense

EnhancementEnhancement

Cysts commonCysts common

 Average length of Average length of

involvement: 7 vertebralinvolvement: 7 vertebral

segmentssegments

Courtesy Steven Goldstein, MD

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Pilocytic AstrocytomaPilocytic Astrocytoma Grade IV Grade IV 

Ependymoma vs. Astrocytoma

NoNo Yes YesConus or filumConus or filum

Patchy, irregularPatchy, irregularFocal, intenseFocal, intense

homogeneoushomogeneousEnhancementEnhancement

UncommonUncommonCommonCommonHemorrhageHemorrhage

IllIll--defineddefined Well Well--circumscribedcircumscribedMorphologyMorphology

EccentricEccentricCentralCentralLocationLocation

PediatricPediatric Adult AdultPopulationPopulation

 Astrocytoma AstrocytomaEpendymomaEpendymoma

Koeller et al, RadioGraphics 2000;20:1721-1749.

HemangioblastomaHemangioblastoma

11--7% of spinal cord7% of spinal cord

neoplasmsneoplasms

Cell of originCell of origin –  – unknownunknown

 WHO grade I WHO grade I

Most solitaryMost solitary

MultipleMultiple –  – think VHLthink VHL

(approximately 1/3)(approximately 1/3)

 Associated syrinx common Associated syrinx common

HemangioblastomaHemangioblastoma

Most intramedullaryMost intramedullary

1010--15% along nerve15% along nerve

rootsroots

Occasionally exophyticOccasionally exophytic

Diffuse cordDiffuse cord

expansionexpansion

Highly vascularHighly vascular

Rarely may be a sourceRarely may be a source

of hematomyelia orof hematomyelia or

SAHSAH

HemangioblastomaHemangioblastoma

 T1: Variable, most common T1: Variable, most common

isointenseisointense

 T2: Hyperintense T2: Hyperintense

May see flow voidsMay see flow voids

Intense enhancementIntense enhancement

May have surroundingMay have surrounding

edemaedema

Cyst formation commonCyst formation common

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HemangioblastomaHemangioblastoma Intramedullary MetastasisIntramedullary Metastasis

RareRare

Usually round/ovalUsually round/oval

Fairly wellFairly well--circumscribedcircumscribed

Extensive edemaExtensive edema

EnhanceEnhance

Full craniospinal imagingFull craniospinal imaging

Intradural ExtramedullaryIntradural Extramedullary Intradural ExtramedullaryIntradural Extramedullary

Expansion of ipsilateralExpansion of ipsilateral

subarachnoid spacesubarachnoid space

Displacement of cord toDisplacement of cord to

opposite sideopposite side

Meningiomas & nerveMeningiomas & nerve

sheath tumors accountsheath tumors account

for up to 90%for up to 90%

Meningioma

Nerve Sheath TumorNerve Sheath Tumor

2 histopathologic2 histopathologic

types:types:

SchwannomaSchwannoma

NeurofibromaNeurofibroma

NeurofibromatosisNeurofibromatosis

type 1type 1

NeurofibromaNeurofibroma

NeurofibromatosisNeurofibromatosis

type 2 Schwannomatype 2 Schwannoma

NF-2Nerve Sheath Tumor: ImagingNerve Sheath Tumor: Imaging

Difficult to separate byDifficult to separate by

imagingimaging

 Tend to erode bone Tend to erode bone  T1: Isointense T1: Isointense

 T2: Hyperintense T2: Hyperintense

EnhanceEnhance

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Neurofibromatosis Type INeurofibromatosis Type I

Other spinalOther spinalfindings:findings:

Dural ectasiaDural ectasia

Lateral meningoceleLateral meningocele

 Arachnoid cyst Arachnoid cyst

KyphoscoliosisKyphoscoliosis

IntramedullaryIntramedullary

astrocytomasastrocytomas

Lateral MeningoceleLateral Meningocele

Neurofibromatosis Type IINeurofibromatosis Type II

Other spinal findingsOther spinal findings

MeningiomasMeningiomas

EpendymomasEpendymomas

MeningiomaMeningioma

Majority in thoracic levelMajority in thoracic level

Most common in middleMost common in middle--

aged womenaged women

>95% WHO grade I>95% WHO grade I

Majority intraduralMajority intradural

3.53.5--7% epidural7% epidural

Lack of foraminalLack of foraminal

extensionextension

MeningiomaMeningioma

CT: Hyperattenuation; avidly enhancesCT: Hyperattenuation; avidly enhances

MR:MR:

 T1 & T2: Isointense to spinal cord T1 & T2: Isointense to spinal cord

 Avidly enhances post contrast Avidly enhances post contrast

Meningioma: PsammomatousMeningioma: Psammomatous

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Myxopapillary EpendymomaMyxopapillary Ependymoma

 WHO grade I WHO grade I

Predilection for conus orPredilection for conus or

filumfilum

 Thought to arise from Thought to arise from

ependymalependymal gliaglia

Lobulated soft mass oftenLobulated soft mass often

ecapsulatedecapsulated

Slow growingSlow growing

Occasionally extraduralOccasionally extradural

Myxopapillary EpendymomaMyxopapillary Ependymoma

Subcutaneous SacrococcygealSubcutaneous Sacrococcygeal

Myxopapillary EpendymomaMyxopapillary Ependymoma Myxopapillary EpendymomaMyxopapillary Ependymoma

Most commonMost common

ependymoma subtype toependymoma subtype to

hemorrhagehemorrhage

Superficial siderosisSuperficial siderosis

Subarachnoid hemorrhageSubarachnoid hemorrhage

May have subarachnoidMay have subarachnoid

disseminationdissemination

Intradural LipomaIntradural Lipoma

 Any portion of Any portion ofspinal cord can bespinal cord can beinvolvedinvolved

May have localizedMay have localizeddysraphismdysraphism

Etiology: ThoughtEtiology: Thoughtto be prematureto be prematureseparation ofseparation ofcutaneous ectodermcutaneous ectodermfromfrom neuroectodermneuroectodermduring neurulationduring neurulation

Intradural LipomaIntradural Lipoma

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Epidermoid & DermoidEpidermoid & Dermoid

Epidermoid:Epidermoid:

Squamous epitheliumSquamous epithelium –  – only ectodermonly ectoderm

Symptoms typically 3Symptoms typically 3rdrd

to 5to 5thth decadedecade

Dermoid:Dermoid:

Squamous epithelium +Squamous epithelium +dermaldermal adnexaadnexa –  – onlyonlyectodermectoderm

Symptoms typicallySymptoms typicallybefore age 20before age 20

Epidermoid

Epidermoid & DermoidEpidermoid & Dermoid

((Epi)dermoidsEpi)dermoids comprise 0.5comprise 0.5--2% of spinal tumors2% of spinal tumors

40% intramedullary40% intramedullary

20% dermal sinus20% dermal sinus

Dermoid 100% congenitalDermoid 100% congenital

Epidermoid 60% congenitalEpidermoid 60% congenital

Epidermoid/DermoidEpidermoid/Dermoid

CT:CT:

Epidermoid: HypodenseEpidermoid: Hypodense

Dermoid: Isodense +/Dermoid: Isodense +/--

calcification, fatcalcification, fat

MRI:MRI:

Epidermoid: T1 isointenseEpidermoid: T1 isointense

to CSFto CSF

Dermoid: T1 HypoDermoid: T1 Hypo-- toto

hyperintensehyperintense

Both T2 hyperintenseBoth T2 hyperintense

DWI: epidermoidDWI: epidermoid

hyperintensehyperintense

Epidermoid: IntramedullaryEpidermoid: Intramedullary

EpidermoidEpidermoid DermoidDermoid

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MetastasisMetastasis

 Any point along CSF pathway Any point along CSF pathway

EnhanceEnhance

Patterns:Patterns:

““Sugar coatingSugar coating””

Single/multiple nodulesSingle/multiple nodules

Image entire neuroaxisImage entire neuroaxis

ZuckergussZuckerguss

Metastasis: EtiologyMetastasis: Etiology

HematogenousHematogenous

Lung & breastLung & breast

Drop metastasisDrop metastasis

 Adults: Anaplastic Adults: Anaplastic

astrocytoma, GBM,astrocytoma, GBM,

ependymomaependymoma

Children: Medulloblastoma,Children: Medulloblastoma,

germinoma, CPP/CPCgerminoma, CPP/CPC

ExtraduralExtradural

MetastasisMetastasis

 Vertebral body & Vertebral body &

 posterior elements posterior elements

Solitary or multipleSolitary or multiple

IntervertebralIntervertebral discsdiscs

sparedspared

May haveMay have

 paraspinal paraspinal/epidural/epidural

massmass

Lung Cancer

MetastasisMetastasis

Pancreatic Adenocarcinoma

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LymphomaLymphoma

Primary orPrimary or

secondary secondary  B cell NHL mostB cell NHL most

commoncommon

Most commonMost common

malignancy ofmalignancy of

epidural spaceepidural space

Degenerative: Synovial CystDegenerative: Synovial Cyst

Posterolateral to thecal sacPosterolateral to thecal sac

 Adjacent to facet joint Adjacent to facet joint 90% lumbar spine90% lumbar spine

 Wall enhancement Wall enhancement

Synovial CystSynovial Cyst Hemorrhagic synovial cystHemorrhagic synovial cyst

Degenerative: Disk Degenerative: Disk 

ProtrusionProtrusion

ExtrusionExtrusion

SequesteredSequestered MigratedMigrated

Disc HerniationDisc Herniation

Most commonMost common

location: L4location: L4--5 or L55 or L5--S1S1

Sagittal imaging bestSagittal imaging best

at discriminatingat discriminating

extrusion fromextrusion from

 protrusion protrusion

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Fungal SpondylitisFungal Spondylitis

May beMay be

indistinguishable fromindistinguishable from TB TB

Lesser degree ofLesser degree of

 paraspinal paraspinal involvementinvolvement

Disc space may beDisc space may be

sparedspared

 Vertebral deformity Vertebral deformity

less commonless common

Spinal LesionsSpinal Lesions Intramedullary:Intramedullary:

EpendymomaEpendymoma

 Astrocytoma Astrocytoma

HemangioblastomaHemangioblastoma

Intradural/Extramedullary:Intradural/Extramedullary:

Nerve sheath tumor: Schwannoma,Nerve sheath tumor: Schwannoma,neurofibromaneurofibroma

MeningiomaMeningioma

Myxopapillary ependymomaMyxopapillary ependymoma

Lipoma/Dermoid/EpidermoidLipoma/Dermoid/Epidermoid

Extradural:Extradural:

Degenerative: Synovial cyst, discDegenerative: Synovial cyst, disc

Infection/abscessInfection/abscess

Metastasis

SummarySummary

Identification of the lesion asIdentification of the lesion as

intramedullary, extramedullary intradural, orintramedullary, extramedullary intradural, or

extradural helps to narrow the differentialextradural helps to narrow the differential

diagnosis.diagnosis.