Case 10.1: A young adult with neck pain, numbness, and a weak right arm.

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Case 10.1 A young adult with neck pain,
numbness, and a weak right arm.
10.1 D
Axial T1 wtd. MRI (C)
10.1 A
10.1 B
10.1 C
Precontrast sagittal T1 wtd. MRI of the cervical
spine
Post contrast (C) sagittal T1 wtd. MRI
Sagittal T2 wtd. MRI
DIAGNOSIS PLEASE
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Case 10.2 A middle-aged male with gradual
weakness of both arms.
10.2 A
10.2 C
10.2 B
Post contrast (C) sagittal T1 wtd. MRI
Axial T1 wtd. MRI (C)
Sagittal T2 wtd. MR image of the C-spine
DIAGNOSIS PLEASE
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Name 2 common intramedullary tumors involving the
spinal cord.
A. ?
B. ?
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Name 2 common intramedullary tumors involving the
spinal cord.
A. Astrocytoma
B. Ependymoma
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Case 10.3 A 50-year-old patient with renal cell
carcinoma with back pain and leg weakness.
10.3 A Sagittal T1 wtd. MRI of the lumbar spine
10.3 B Post contrast (C) sagittal T1 wtd. MRI
10.3 C Sagittal T2 wtd. MRI
10.3 D Axial T1 wtd. MRI (C)
DIAGNOSIS PLEASE
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Case 10.4 A 55-year-old lady with gradual lower
extremity weakness.
10.4 A Post contrast (Ct) sagittal T1 wtd. MRI
10.4 B Sagittal T2 wtd. MRI of thoracic spine
10.4 C Precontrast sagittal T1 wtd. MRI
10.4 D Axial CT image of the thoracic spine
DIAGNOSIS PLEASE
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Case 10.5 A 24-year-old male with neck pain and
right arm weakness.
10.5 A Precontrast sagittal T1 wtd. MRI of
C-spine
10.5 B Post contrast (C) sagittal T1 wtd. MRI
10.5 C Precontrast axial T1 wtd. MRI
10.5 D Axial T1 wtd. MRI (C)
DIAGNOSIS PLEASE
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Name 2 common intradural tumors within the spinal
canal
A. ?
B. ?
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Name 2 common intradural tumors within the spinal
canal
A. Nerve sheath tumors (schwannoma, neurofibroma)
B. Meningioma
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Case 10.6 A 42-year-old patient, developed acute
bilateral paraparesis following placement of an
epidural catheter for drug delivery to relive
constant severe back pain.
10.6 A Post contrast sagittal T1 wtd. MRI of the
thoracic spine
10.6 B Post contrast Axial T1 wtd. MRI
DIAGNOSIS PLEASE
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Case 10.7 A 68 yr. Old male with renal cell
carcinoma with progressive difficulty in walking
and weakness involving both legs.
10.7 A Pre-contrast sagittal T1 wtd. MRI of the
thoracic spine
10.7 B Sagittal T2 wtd. MRI
10.7 C Post contrast sagittal T1 wtd. MRI
10.7 D Pre contrast axial T1 wtd. MRI
DIAGNOSIS PLEASE
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Answers
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Case 10.1 A young adult with neck pain,
numbness, and a weak right arm.
C
C
D.
A.
B.
C.
Findings An inhomogeneously enhancing tumor
(red arrow in B) is seen within the upper
cervical cord. Large cysts (C) are seen both
above and below the tumor, best seen on T2 wtd.
image C. Eccentric location of the tumor, more
to the right of the cervical cord (yellow arrow)
is shown on axial image D.
Diagnosis Astrocytoma
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Astrocytoma of the Spinal Cord Incidence Common
intramedullary tumor particularly in children and
young adults. Pathology Usually low grade MRI
Findings         Eccentric location of tumor
within the spinal cord         Multisegmental
involvement         Variable degree of tumoral
enhancement         Cysts are common        
Hemorrhage is rare Treatment         Complete
resection of tumor is not possible due to
infiltrative nature. Radiation therapy is also
used for recurrence or growing tumors.
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Case 10.2 A middle-aged male with gradual
weakness of both arms.
Diagnosis Ependymoma
10.2 A
10.2 C
10.2 B
Post contrast (C) sagittal T1 wtd. MRI
Axial T1 wtd. MRI (C)
Sagittal T2 wtd. MR image of the C-spine
Findings A sausage-shaped intensely enhancing
tumor (yellow arrow in A) is seen within the
upper cervical cord extending from just above the
cranio-cervical junction with involvement of the
dorsal medulla (black arrow in A) down to C5
level. Small amount of old blood is better seen
on T2 wtd. image as an area of dark signal
intensity within the tip of the tumor (white
arrow in B). Central location of tumor (yellow
arrows in C) is better appreciated on axial post
contrast image.
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Ependymoma of the Spinal Cord
Incidence Common intramedullary tumor in adults
Pathology Cellular tumors that originate from
ependymal cells lining the central canal.
Clinical Symptoms Nuchal pain/radicular pain,
Paresthesia, Motor weakness
MRI Findings Moderate to markedly enhancing
tumor, Blood products from hemorrhage within the
tumor is common, Tumor can also contain intrinsic
cysts.
Treatment Surgery. Ependymoma have a
well-defined cleavage plane between the tumor and
adjacent spinal cord. Thus, the tumor can be
completely resected with modern neurosurgical
techniques with relief of clinical
symptomatology. Recurrence is rare following
complete resection.
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Case 10.3 A 50-year-old patient with renal cell
carcinoma with back pain and leg weakness.
10.3 A Sagittal T1 wtd. MRI of the lumbar spine
10.3 B Post contrast (C) sagittal T1 wtd. MRI
10.3 C Sagittal T2 wtd. MRI
10.3 D Axial T1 wtd. MRI (C)
Findings Bony metastasis (yellow arrow in A,
B, C) is seen involving the T12 vertebral body.
Intramedullary location of metastasis within the
distal thoracic cord, is verified on post
contrast sagittal image (red arrow in B) and
axial image (red arrow in D). Edema (green arrow
in C) within the thoracic cord is best shown on
T2 wtd. image C.
Diagnosis Bony Metastasis and metastasis to the
Spinal Cord
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Metastasis to the Spinal Cord
Incidence Rare

• Primary Sites
• Lung
• Breast
• Melanoma
• Kidney
• Lymphoma/Leukemia

• Intracerebral Tumors
• Medulloblastoma
• Ependymoma
• Glioblastoma
• Germ Cell Tumor

Route of Spread Arterial seeding, Batsons
venous plexus, Drop metastasis (from
intracerebral tumor)
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Case 10.4 A 55-year-old lady with gradual lower
extremity weakness.
10.4 A Post contrast (C) sagittal T1 wtd. MRI
10.4 B Sagittal T2 wtd. MRI of thoracic spine
10.4 C Precontrast sagittal T1 wtd. MRI
10.4 D Axial CT image of the thoracic spine
Findings An intradural enhancing meningioma
(arrow in A), the ventrally located tumor has
produced cord compression and with displacement
of the thoracic cord (red arrow in D) to the
right side. Calcified nature of the tumor is
identified on sagittal T2 wtd. image as an area
of dark signal intensity (yellow arrow in B) and
confirmed by CT imaging (yellow arrow in D) as an
area of high attenuation density.
Diagnosis Classic example of calcified
intradural meningioma
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Intraspinal Meningioma

• Incidence
• Second common intradural tumor
• Middle-aged females (80)
• Thoracic spine (80), cervical spine (15)

• MRI Findings
• Intensely enhancing intradural tumor
• Calcification, when seen, clinches the diagnosis

• Treatment
• Surgery

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Case 10.5 A 24-year-old male with neck pain and
right arm weakness.
10.5 A Precontrast sagittal T1 wtd. MRI of
C.spine
10.5 B Post contrast (C) sagittal T1 wtd. MRI
10.5 C Precontrast axial T1 wtd. MRI
10.5 D Axial T1 wtd. MRI (C)
Findings An enhancing intradural nerve sheath
tumor (Schwannoma) is shown (red arrow in B and
D). Dumbbell shape of tumor with intraspinal
component (red arrow in D) producing cord
compression (yellow arrow in D) and paraspinal
tumor extension through an enlarged neural
foramen (green arrow in C D) following the
exiting nerve root is best shown on axial post
contrast image D.
Diagnosis Schwannoma arising from the spinal
nerve root
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Intraspinal Nerve Sheath Tumors

• Incidence Most common intradural tumor
• Solitary nerve sheath tumor is usually
  Schwannoma and commonly seen in adults.
• Multiple nerve sheath tumors are usually
  neurofibromas and commonly seen in the pediatric
  age group with neurofibromatosis

• MRI Findings
• Dumbbell shaped enhancing intradural tumor with
  paraspinal extension through enlarged neural
  foramen is a characteristic feature of nerve
  sheath tumor.
• Can cause cord compression.

Treatment Surgrey
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Case 10.6 A 42-year-old patient, developed acute
bilateral paraparesis following placement of an
epidural catheter for drug delivery to relive
constant severe back pain.
10.6 A Post contrast sagittal T1 wtd. MRI of the
thoracic spine
10.6 B Post contrast Axial T1 wtd. MRI
Diagnosis Epidural abscess
Findings The central portion of the midthoracic
cord is compressed and displaced anteriorly (red
arrows in A outline the thoracic cord both above
and below the level of cord compression) by an
epidural abscess (yellow arrows in A, B). The
capsule of the abscess enhances intensely with
central low signal intensity produced by pus.
Figure B demonstrates ventrally displaced
thoracic cord (red arrow) by dorsally located
epidural abscess (yellow arrows).
Treatment Surgical drainage and antibiotics.
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Case 10.7 A 68 yr. Old male with renal cell
carcinoma with progressive difficulty in walking
and weakness involving both legs.
10.7 A Pre-contrast sagittal T1 wtd. MRI of the
thoracic spine
10.7 B Sagittal T2 wtd. MRI
10.7 C Post contrast sagittal T1 wtd. MRI
10.7 D Pre contrast axial T1 wtd. MRI
Findings Bony metastasis involving the T8
vertebral body, right pedicle/transverse process
and spinous process (arrow in A,B,C,D) with
epidural tumor producing marked degree of cord
compression (red arrow).
Diagnosis Bony metastasis from renal cell
carcinoma with epidural tumor producing cord
compression