Objectives

Top 10 Mass Lesions - Spine

Alice Boyd Smith, Lt. Col., USAF MC Chief, Neuroradiology Department of Radiologic Pathology Armed Forces Institute of Pathology Washington, DC & Assistant Professor of Radiology & Radiological Sciences Uniformed Services University of the Health Sciences Bethesda, MD

Be able to identify lesions of the spinal column in relation to their location. ( ie. ie. intramedullary, extramedullary intradural, extradural) Be able to identify imaging characteristics of spinal lesions that allow for narrowing of the differential diagnosis.

Spinal Lesions

Intramedullary

Intramedullary:

Ependymoma Astrocytoma Hemangioblastoma Nerve sheath tumor: Schwannoma, neurofibroma Meningioma Myxopapillary ependymoma Lipoma/Dermoid/Epidermoid Degenerative: Synovial cyst, disc Infection/abscess

Intradural/Extramedullary:

Metastasis

Extradural:

Intramedullary Neoplasms

Ependymoma

Account for 44-10% of CNS tumors Most malignant: 9090-95% gliomas Expand cord Majority enhance

Biopsy

Cysts a common finding

Tumoral NonNon-tumoral

Most common intramedullary spinal neoplasm in adults Arises from ependymal cells of central canal Most WHO grade II Slow growing Compress rather than infiltrate cord

Grade II Ependymoma

Astrocytoma

Ependymoma

Ependymoma

CT: Canal widening & vertebral body scalloping

Calcification not common T1: IsoIso- or hypointense

Enhance

MR:

T2: IsoIso- or hyperintense Cystic degeneration common Cap sign sign

Average number vertebral segments involved: 33-4

Ependymoma

Astrocytoma
1/3 of spinal cord gliomas Most common intramedullary tumor in children Holocord involvement common in children

Astrocytoma

Astrocytoma

WHO:
Grade I: 75% Grade IV: Uncommon (0.2(0.21.5%)

MR:
Poorly defined margins T1: IsoIso- to hypointense T2: Hyperintense Enhancement Cysts common Average length of involvement: 7 vertebral segments

Imaging: CT

Canal widening & vertebral body scalloping

Grade IV

Courtesy Steven Goldstein, MD

Pilocytic Astrocytoma

Grade IV

Ependymoma vs. Astrocytoma

Ependymoma Population Location Morphology Hemorrhage Adult Central WellWell-circumscribed Common Astrocytoma Pediatric Eccentric IllIll-defined Uncommon Patchy, irregular

Hemangioblastoma
1-7% of spinal cord neoplasms Cell of origin unknown WHO grade I Most solitary

Enhancement Focal, intense homogeneous Conus or filum Yes

Multiple think VHL (approximately 1/3)

No

Associated syrinx common

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

Hemangioblastoma

Hemangioblastoma

Most intramedullary
1010-15% along nerve roots Occasionally exophytic

T1: Variable, most common isointense T2: Hyperintense

Diffuse cord expansion Highly vascular

May see flow voids

Rarely may be a source of hematomyelia or SAH

Intense enhancement May have surrounding edema Cyst formation common

Hemangioblastoma

Intramedullary Metastasis
Rare Usually round/oval Fairly wellwell-circumscribed Extensive edema Enhance Full craniospinal imaging

Intradural Extramedullary

Intradural Extramedullary
Expansion of ipsilateral subarachnoid space Displacement of cord to opposite side Meningiomas & nerve sheath tumors account for up to 90%

Meningioma

Nerve Sheath Tumor

NF-2

Nerve Sheath Tumor: Imaging

Difficult to separate by imaging Tend to erode bone T1: Isointense T2: Hyperintense Enhance

2 histopathologic types:

Schwannoma Neurofibroma

Neurofibromatosis type 1 Neurofibroma Neurofibromatosis type 2 Schwannoma

Schwannoma vs Neurofibroma

Schwannoma

May hemorrhage Fatty degeneration Rarely undergo malignant change Noninfiltrative Encapsulated

Hemorrhage uncommon Rare fatty degeneration May progress from benign to malignant Tumor & nerve fascicles intermixed May be plexiform Not Encapsulated

Courtesy of Tarik Tihan, MD PhD

Neurofibroma

Schwannoma

Schwannoma

Neurofibromatosis Type 1

Neurofibromatosis Type I

Lateral Meningocele

Other spinal findings:

Dural ectasia Lateral meningocele Arachnoid cyst Kyphoscoliosis Intramedullary astrocytomas

Neurofibromatosis Type II

Meningioma

Other spinal findings

Meningiomas Ependymomas

Majority in thoracic level Most common in middlemiddleaged women >95% WHO grade I Majority intradural

3.53.5-7% epidural

Lack of foraminal extension

Meningioma

Meningioma: Psammomatous

CT: Hyperattenuation; avidly enhances MR:

T1 & T2: Isointense to spinal cord Avidly enhances post contrast

Myxopapillary Ependymoma

Myxopapillary Ependymoma

WHO grade I Predilection for conus or filum

Thought to arise from ependymal glia

Lobulated soft mass often ecapsulated Slow growing Occasionally extradural

Subcutaneous Sacrococcygeal Myxopapillary Ependymoma

Myxopapillary Ependymoma
Most common ependymoma subtype to hemorrhage

Superficial siderosis Subarachnoid hemorrhage

May have subarachnoid dissemination

Intradural Lipoma

Intradural Lipoma

Any portion of spinal cord can be involved May have localized dysraphism Etiology: Thought to be premature separation of cutaneous ectoderm from neuroectoderm during neurulation

Epidermoid & Dermoid

Epidermoid & Dermoid

Epidermoid:
Squamous epithelium only ectoderm Symptoms typically 3rd to 5th decade

Dermoid:
Squamous epithelium + dermal adnexa only ectoderm Symptoms typically before age 20

(Epi)dermoids comprise 0.50.52% of spinal tumors 40% intramedullary 20% dermal sinus Dermoid 100% congenital Epidermoid 60% congenital

Epidermoid

Epidermoid/Dermoid

Epidermoid: Intramedullary

CT:

Epidermoid: Hypodense Dermoid: Isodense +/+/calcification, fat Epidermoid: T1 isointense to CSF Dermoid: T1 HypoHypo- to hyperintense Both T2 hyperintense DWI: epidermoid hyperintense

MRI:

Epidermoid

Dermoid

Metastasis

Zuckerguss

Any point along CSF pathway Enhance Patterns:

Sugar coating coating Single/multiple nodules

Image entire neuroaxis

Metastasis: Etiology

Extradural

Hematogenous

Lung & breast

Drop metastasis
Adults: Anaplastic astrocytoma, GBM, ependymoma Children: Medulloblastoma, germinoma, CPP/CPC

Metastasis

Metastasis

Vertebral body & posterior elements Solitary or multiple Intervertebral discs spared May have paraspinal/epidural paraspinal/epidural mass
Lung Cancer Pancreatic Adenocarcinoma

Lymphoma

Degenerative: Synovial Cyst

Primary or secondary B cell NHL most common Most common malignancy of epidural space

Posterolateral to thecal sac Adjacent to facet joint 90% lumbar spine Wall enhancement

Synovial Cyst

Hemorrhagic synovial cyst

Degenerative: Disk

Disc Herniation

Protrusion Extrusion Sequestered Migrated

Most common location: L4L4-5 or L5L5-S1 Sagittal imaging best at discriminating extrusion from protrusion

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Extruded Disc

Epidural Abscess
Adjacent infection, bacteremia, bacteremia, or direct inoculation S. aureus most common Surgical decompression

Pyogenic Osteomyelitis

HIV: Osteomyelitis

Peak incidence older patients Lower lumbar spine most frequent Initial: Subchondral bone adjacent to endplate Vertebral height loss

Infectious: Tuberculous Osteomyelitis

Tuberculosis

Multiple vertebral bodies

Thoracic most common

Paravertebral abscesses Relatively intact intervertebral disc Gibbus deformity

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Fungal Spondylitis

Spinal Lesions
Intramedullary:

May be indistinguishable from TB

Lesser degree of paraspinal involvement Disc space may be spared Vertebral deformity less common

Ependymoma Astrocytoma Hemangioblastoma Nerve sheath tumor: Schwannoma, neurofibroma Meningioma Myxopapillary ependymoma Lipoma/Dermoid/Epidermoid Degenerative: Synovial cyst, disc Infection/abscess

Intradural/Extramedullary:

Metastasis

Extradural:

Summary

Identification of the lesion as intramedullary, extramedullary intradural, or extradural helps to narrow the differential diagnosis.

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