INTRAMEDULLARY TUMOR WITH ENHANCING NODULE

Approach towards Intramedullary

tumors CASE

HAEMANGIOBLASTOMA

MERCURY IMAGING INSTITUTE SCO 172-173 SEC 9C CHANDIGARHMERCURY IMAGING CENTRE SCO 16-17 SEC 20D CHANDIGARH

INTRAMEDULLARY NEOPLASMS

TYPES • Glial tumors :

1. Ependymoma 2. Astrocytoma 3. Ganglioglioma

• Non glial tumors :1. Haemangioblastoma 2. Lymphoma 3. Metastasis .

Some points to remember ....• Define Central / eccentric location.• Comment on adjacent cord

( Edema, expansion)• Look for Intratumoral cysts ( usually

malignant –should be rescected)• Look for Peritumoral cysts ( Donot

carry the malignancy – Can be left ) • Cap sign –Lesions with tendency to

haemorrhage have hypointense rim / peripheral border due to haemosiderin ( ependymoma , astrocytoma)

• Salt and pepper – Appreciated in paraganglioma .

Case 1• 58 Year old female with sensory and motor complaints pertaining to

lower extremity with worsening for last one year. • MR Images – Intramedullary cystic lesion ( size 28mmx 08mmx

08mm ) with septations and solitary intensely enhancing tumor nodule is appreciated in the lower dorsal region. Important negative findings are :

1. No cap sign appreciated. 2. No signal voids appreciated .3. No associated syrinx .4. No Intratumoral cysts /Peritumoral cysts .5. No pathological enhancement elsewhere in the tumor.

FAT SAT SEQUENCE WITH HYPERINTENSE

OVOID LESION

GRE SEQUENCE WITH NO E/O

SIGNAL VOID / CAP SIGN

FAT SAT SEQUENCE WITH SMALL NODULE AS

APPRECIATED IN THE PERIPHERY OF THE

LESION.

Intramedullary location with septations.

INTENSLY ENHANCING PERIPHERAL NODULE

ENHANCING PERIPEHRAL NODULE

WHOLE SPINE SCREENING NO SATELLITE LESIONS.

REST OF THE CORD PER SE IS NORMAL.

SCREENING OF THE BRAIN IS ALSO TO BE CONSIDERED.

Haemangioblastoma – some facts .

• Non glial • Highly vascular tumor • 1% to 6% of all the spinal tumors.• Common in dorsal spine followed by

cervical location.• Usually intramedullary , can be

intradural , extradural .• Mostly sporadic , can be associated

with vHLD (von hippel-lindau disease ) hence spine, brain screening should be done. Size <1cm = usually homogenous enhancement.

• Lesion is unlikely to be a haemangioblastoma if it is larger than 25mm and there are not associated signal voids .

• Hemangioblastoma is a common posterior fossa tumor in adults, but it is a relatively rare tumor of the spinal cord, accounting for 1–5% of all spinal cord. About 50–70% of spinal hemangioblastomas have been associated with syringomyelia. This rate increases to 100% in some reports, when only intramedullary hemangioblastomas are considered.

Some Single liners with regard to cord tumors.

• Acute cord lesion like MS plaque has to be differentiated from the tumors – The plaque usually has normal cord signal around it .

• Holocord involvement is common with astrocytoma’s and ganglioglioma’s. ( Usually four vertebra with astrocytoma and 8 vertebra with ganglioglioma’s).

• Intratumoral cysts are most common with gangliglioma .

• Ganglioglioma is only cord tumor where enhancement can be totally absent.

• Intratumoral haemorrhage and hence cap sign is common with –Ependymoma, Haemangioblastoma

• Diagnosis of spinal hemangioblastoma was unlikely when the tumor was ≥ 25 mm, and when vascular flow voidson MRI were absent.