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Intradural extramedullary mass - a case on MRI

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Intradural extramedullary mass - a case on MRI

  1. 1. Intradural extramedullary mass: a case on MRI DR REKHA KHARE MD RADIOLOGY DR VIMLESH CONSULTANT NEUROLOGY
  2. 2. Clinical picture  A young boy about 18year came to radiology department for MRI thoracic spine  His problem was for about 6 months.  Symptoms were persistent progressive lower back pain and lower extremity weakness on left more than right. Pain was radiating to his left thigh region .  There was no remarkable medical history  There was no significant family history  Routine blood and urine examination was with in normal limit  Neurological findings : recorded in case file by neurologist were Radicular pain and Babinski sign present on left side
  3. 3. T2 sequence sagittal hyperintense paravertebral mass
  4. 4. T2 sagittal hyperintense spinal & paravertebral mass
  5. 5. T2 sequence sagittal
  6. 6. T1 sequence sagittal hypointense spinal & paravertebral mass
  7. 7. T1 sequence sagittal
  8. 8. T2 sequence axial hyperintense spinal & paravertebral mass
  9. 9. T2 sequence axial intradural mass on left deviating theca
  10. 10. T2 sequence axial intradural mass deviating cord to right & multiseptate paravertebral mass
  11. 11. T1 sequence axial hypointense paravertebral mass
  12. 12. T1 sequence axial
  13. 13. stir sequence coronal lobulated hyperintense paravertebral mass
  14. 14. stir sequence coronal lobulated paravertebral hyperintense mass
  15. 15. contrast T1 sagittal Multloculated fusiform rim enhanced hypointense lesion in anterior paravertebral region D7-L1
  16. 16. contrast T1 sagittal enhanced intradural mass lesion
  17. 17. contrast T1coronal paravertebral mass
  18. 18. contrast T1 coronal
  19. 19. contrast T1 coronal
  20. 20. contrast T1 axial paravertebral mass & intradural mass
  21. 21. contrast T1axial rim enhanced hypointense paravertebral mass lesion & enhanced intradural mass
  22. 22. Summary MRI findings  A well outlined Isointense on T1, Hyperintense on T2 , moderately enhanced mass lesion on contrast in extramedullary intradural compartment from D10- D12 on left side compressing and deviating theca to right  Another long multi septate fusiform rim enhanced hypointense mass lesion in anterior paravertebral region extending from T7 –L1 level  Intervertebral disc spaces are maintained  No obvious vertebral bony involvement
  23. 23. Radiological impression  In correlation with clinical picture of radicular pain and Babinski sign contrast MRI findings …….. lesion is considered to be extramedullary intradural lesion with paraspinal mass lesion  Provisional preoperative diagnosis was considered Neurofibroma  Case has been referred to higher centre for further surgical management and histopathological confirmation  Patient didn’t turn back for follow up
  24. 24. Spinal tumours  Spinal tumours account for 15% of all CNS tumour  Incidence is 0.5-2.5/ 100,000  History is for months or years of Radiculopathy or symptoms of Myelopathy  It can be Primary in origin or Metastatic  Diagnosis is based on clinical symptoms, duration of presentation ,site in cord and MRI findings  Confirmation requires Biopsy  Treatment for many spinal tumour is surgical if possible
  25. 25. Spinal Tumour: Extradural • Tuberculosis/ Potts spine • Metastasis • Osteoblastoma • Osteochondroma • Chondrosarcoma • Giant cell tumour • Myeloma Intradural- Extramedullary • Nerve sheath tumour: Schwannoma neurofibroma • Meningioma • Metastasis • Haemangioblastoma • Paraglioma Intradural- Intramedullary • Ependymoma • Astrocytoma • Haemangioblastoma • Metastasis
  26. 26. Spinal tumour Intramedullary mass Intradural mass Extradural mass
  27. 27. Imaging modality  MRI is the modality of choice for assessment of intra spinal lesion as it has excellent anatomical contrast and structural resolution  MRI is able to image all compartments  MRI can assess enhancement, cystic change and blood products etc.
  28. 28. Other Imaging modality  CT remains next best modality to assess the bony structure although it is usually not required for intradural tumours as the vertebral bodies are essentially unaffected  Myelography is of historical importance but sometimes now is done only in patients for whom MRI is contraindicated  Ultrasound except in the infants plays no role in diagnosis  Spinal angiography is useful selectively in those patients who have vascular lesion
  29. 29. MRI Protocol Routinely following sequences are done  T1 sagittal and axial  T2 sagittal and axial  T1 contrast + sagittal ,axial and coronal
  30. 30. MRI: General signal characteristics  T1---Most intradural masses are Isointense or hypointense Hyperintense if Haemorrhagic or fat content in mass Ganglioglioma usually mixed signal on T1( unique finding )  T2----Spinal cord tumours are usually Hyperintense Tumour with abundant collagen are Hypointense on T2 Calcification in tumour reflects Hypointensity T2  Peritumoural oedema is as perilesional T2 hyperintensity  Massive oedema disproportionate is typical of Metastasis  Prominent vascular flow voids indicates vascular lesion like Haemangioblastoma or spinal dural AV fistula
  31. 31. Nerve sheath tumour: NSTs  MRI can not distinguish Neurofibroma from Schwannoma ,may manifest as round paravertebral masses that span one or two vertebral bodies. They are soft tissue attenuation masses  MRI Imaging findings: T1- isointense and hyperintense on contrast T2 Hyperintense Target lesion : Decreased central signal with increased peripheral signal common in schwannoma Sometimes split fat sign( thin peripheral rim of fat) or fasicular sign( multiple small ring like structure) could be in schwannoma *Paraspinal extension common in Neurofibroma can cause bone erosion
  32. 32. Nerve sheath tumour  Neurofibroma: Most common NST in young patient & have no predilection for either sex Arises from dorsal sensory nerve roots of thoracic spine usually Not always associated with Neurofibromatosis 1. Usually painless, slow growing and aymptomatic Dumbell shaped thoracic neurofibroma represents distinct type of tumour it can involve spinal canal & thoracic cavity *Autosomal dominant inherited condition arises from nonmyelinating type schwaan cell that exhibit biallelic inactivation of NF1 that codes for the protein Neurofibromin which is responsible for regulating RAS mediated cell growth signalling pathway
  33. 33. Schwannoma Benign slow growing tumours of schwaan cell origin Peak presentation in 5-6th decade with no sex predilection When scwannoma present with NF 2 it can present in 3rd decade Most common tumour of peripheral nerves and common posterior fossa masses Arises from ventral motor nerve root of thoracic spine Clinical symptoms depends on location of the tumour
  34. 34. Neurofibroma
  35. 35. NSTs contd….. Meningioma:  2nd most common intradural extramedullary tumour  It is benign slow growing tumour that arises from arachnoid cells  Average age 40-60years  Females are affected more than males  Usually in thoracic vertebra MRI imaging finding: T1- hypo/iso intense T2 –hyper / iso intense Contrast/Gadolinium- homogenous enhancement CT/ plain film- calcification +
  36. 36. Intramedullary tumour Ependymoma  Most common intramedullary intradural mass  Usually seen in cervical spine or conus  Arises from ependymal cells of spinal cord  Presents with more neurological deficit than radiculopathy  Peak incidence at 30-50 year Imaging finding: Besides Hypointense T1,Hyperintense T2 and contrast enhanced tumour spinal cord is enlarged and scalloping or sometimes vertebral body erosion
  37. 37. Intramedullary tumour contd……. Astrocytoma  Arises from astrocytes  Peak incidence 20-40 years of age Imaging findings: Difficult to differentiate Astrocytoma from Ependymoma on imaging It needs Biopsy Hypointense , enhanced T1 Hyperintense T2 with enlarge spinal cord
  38. 38. Spinal tumour/ mass Intramedullary Intradural extramedullary Extradural
  39. 39. References  Text book of Radiology and Imaging By; David Sutton  Neurogenic tumours Dr Jeremy Jones etal Radiopaedia. Org.com  Intradural spinal tumour- Lieberman’s eRadiology eradiology.bidmc.harvard.edu/Learning Lab/central/Bhatt.pdf  Intradural spinal mass lesion ( an approach) Prof Frank Gaillard Radiopaedia.org.www  Intradural nerve sheath tumour-UpToDate www.uptodate.com/contents/intradural-nerve-sheath-tumors  Intradural extramedullary tumour Definition www. spine-health.com/glossary/intradural-extramedullary-tumor
  40. 40. Thank you HAVE A NICE DAY

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