DAVID SUTTON PICTURES NEURORADIOLOGY OF SPINE ONLY FOR STUDY SHARING

1. 54NEURORADIOLOGY OF SPINE
DAVID SUTTON

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. • Fig. 54.1 Normal and
degenerative
lumbar
intervertebral discs.
Sagittal (A) and axial
(B) MRI, T weighted
contrast Normal
discs are surrounded
by low signal from
the annulus fibrosis
and partly divided
horizontally by a
low-signal band, not
present in children's
discs.

4. • Fig. 54.2 Normal and
degenerative cervical
intervertebral discs and general
anatomy. Sagittal MRI. (The
cerebellar tonsus seem to be
low lying).

5. Fig. 54.3 Normal dorsal vertebral, CT axial section.
Normal defects in the cortex of the vertebral
body for the passage of the veins are shown; the
posterior defect is for the basivertebral veins.
Note the circular spinal canal with equal sagittal
and coronal diameters.

6. • Fig. 54.4 Myelogram and CT
myelography in a patient with
rheumatoid arthritis and seemingly
mild anterior atlanto-axial
subluxation and severe spinal cord
damage. (A) Sagittal image
reformatted from multiple axial
slices (no contrast). (B and C) Lateral
views of the myelogram in flexion
and extension. (D) Axial CT images of
the myelogram showing the
flattened damaged spinal cord.

7. • Fig. 54.4 Myelogram and CT
myelography in a patient
with rheumatoid arthritis
and seemingly mild anterior
atlanto-axial subluxation and
severe spinal cord damage.
(A) Sagittal image
reformatted from multiple
axial slices (no contrast). (B
and C) Lateral views of the
myelogram in flexion and
extension. (D) Axial CT images
of the myelogram showing
the flattened damaged spinal
cord.

9. • Fig. 54.6 Extradural
injection of contrast
medium. Myodil
globules have
extended throughout
the lumbar and sacral
epidural space,
through the
intervertebral
foramina and along
the course of the
sacral plexuses.

10. Fig. 54.7 Subdural contrast medium. (A) AP projection. (B) Lateral projection. (C)
Oblique projection. The appearances superficially simulating an enlarged spinal
cord are due to the contrast medium outlining the outer border of the arachnoid
membrane. Note that the inner border of the contrast column appears lobulated
and that its upper border does not form a fluid level with unopacified CSF

11. • Fig. 54.8 Spinal angiogram,
selective injection. Normal study.
The arteria radicularis magna
arises from the left tenth
intercostals artery. It fills the
anterior spinal artery and there is
retrograde filling of other anterior
radiculomedullary vessels. The
posterolateral arteries of the
spinal cord are also filled through
the cruciate anastomosis at the
conus.

12. • Fig. 54.9 Dural
arteriovenous fistula,
left second lumbar
angiogram. AP and
lateral projections. (A
and B) Large arrow, the
fistula; small arrows,
the draining vein.

13. • Fig. 54.10 Cystic
astrocytoma, cervical spine
lateral projection. The
spinal canal is expanded.
The posterior borders are
concave. The line of the
conjoined laminae
bordering the posterior
margin of the spinal canal is
flattened and its length
increased.

14. • Fig. 54.11 Neurofibromatosis. (A,B) Lumbar spine X-ray. The L3/L4
intervertebral foramen is enlarged, with erosion of the inferior border of
the third lumbar pedicle and the adjacent part of the posterior surface of
the vertebral body. (C) Myelogram. A neurofibroma on the fourth lumbar
nerve root is partly intradural, causing a well-defined filling defect within
the theca at the L3 level, and partly extradural, displacing the theca
medially away from the pedicle and intervertebral foramen. There is
another intradural tumour at T11 /T12 level which deviates the
termination of the spinal cord and nerve roots toward the left and causes
complete obstruction. Histology showed this tumour to be a
neurofibrosarcoma.

15. • Fig. 54.12
Lipomyelomeningodysplasia.
Sagittal T,-weighted image. There is
high signal from the epidural fat and
from the lipomatous mass. The latter
is subcutaneous, within the
lumbosacral spina bifida, and
extends through the dura and then
superiorly to blend with the
posterior border of the spinal cord
which extends down to the
lumbosacral region. The dark band
extending centrally within the
intradural part of the lipoma as far as
the cord is presumed to be a fibrous
septum.

16. • Fig. 54.13 Diastematomyelia. (A,B) Myelogram. The width of the spinal
canal is increased in the lower thoracic region and it is divided by a bony
spicule at T10 level. There is a long cleft of the spinal cord extending from
the fourth thoracic to the second lumbar levels; the conus medullaris is at
L3/4 disc level. (C) Computed myelogram. Contiguous axial sections of
lower thoracic region pass through the bony spur which is dividing the
spinal cord and the subarachnoid space.

17. • Fig. 54.13 Diastematomyelia. (A,B) Myelogram. The width of the
spinal canal is increased in the lower thoracic region and it is
divided by a bony spicule at T10 level. There is a long cleft of the
spinal cord extending from the fourth thoracic to the second lumbar
levels; the conus medullaris is at L3/4 disc level. (C) Computed
myelogram. Contiguous axial sections of lower thoracic region pass
through the bony spur which is dividing the spinal cord and the
subarachnoid space.

18. • Fig. 54.14 Diastematomyelia,
lipoma. (A) Sagittal T,-
weighted sequence. (B) Axial
T1 sequence. A posteriorly
situated lipoma at L5 and S1
levels extends through the
dura into the subcutaneous
tissues. A band extends from
the inferior margin of the
posterior surface of the fifth
lumbar vertebral body into the
lipoma. The spinal cord is
divided into two unequal
parts, which extend one
behind the other through the
lumbar region and which both
blend into the anterior border
of the lipoma at L5 level, with
the band passing between
them.

19. • Fig. 54.15 Chiari malformation, syringomyelia. Midsagittal T1 –
weighted section through brainstem and upper cervical region. The
cerebellar tonsils are elongated and extend well below the level of
the arch of the atlas. The medulla is elongated and the depressed
dorsal column nuclei are below the tonsils. The medulla is
compressed between the odontoid and the depressed cerebellar
tonsils. There is a syrinx distending the spinal cord below the
inferior border of C2 and there is four-ventricular hydrocephalus.

20. • Fig. 54.16 Congenital
fusion of cervical
vertebrae with
spondylosis: myelogram.
Congenital fusion of the
fourth, fifth and sixth
cervical vertebrae with
degenerative changes at
discs above and below.
Osteophytes at C3/4 level
compress the spinal cord
and nerve root sheaths.
Osteophytes at C6/7 level
compress the root
sheaths only.

21. • Fig 54.17 Atlanto-occipital assimilation: reformatted CT sections in coronal
(A), sagittal (B,C) through condyles and axial (D) planes. The left occipital
condyle and lateral mass of atlas are small, relatively dense and
completely fused. The joint space between the right occipital condyle and
lateral mass is incomplete. The posterior arch of the atlas is closely
applied but not fused to the skull bone.

22. • Fig. 54.18 Absent thoracic pedicle: CT. The left pedicle
of the seventh thoracic vertebra is almost completely
absent. The bone bordering the defect is corticated and
the articulation with the corresponding rib is
anomalous. The bone defect is filled by fat continuous
with the epidural fat outlining the outer margin of the
dura, which is in a normal position.

23. • Fig. 54.19 (A,B) Dural
ectasia in
neurofibromatosis:
myelogram. The
subarachnoid
• space is markedly expanded
in the lower half of the
thoracic and
• upper lumbar regions. The
corresponding part of the
spinal canal is
• markedly expanded in this
region and there is erosion
of the posterior
• borders of the vertebral
bodies and of the pedicles.

24. • Fig. 54.20 Comminuted fracture of thoracic spine: fractures of
the ninth and eighth thoracic vertebrae with anterior
subluxation of the eighth. Axial sections through the ninth (A)
and the eighth (B) thoracic vertebra, and reformatted sagittal (C)
and coronal (D) sections. There is a comminuted fracture with
disruption of the body and neural arch of the ninth thoracic
vertebra. A fragment has been separated from the posterior
inferior margin of the body of the eighth thoracic vertebra and
there is anterior subluxation of the rest of the vertebra. The
spinal canal is markedly narrowed and the spinal cord is
compressed by displaced bone fragments. The subarachnoid
space is opacified by a blood clot at T9 and T10 levels. (E,F) MRI
of cervical spine. Whiplash injury in road traffic accident 6
months previously. Sagittal sections: T,-weighted (E); T2
weighted (F). The spinal canal is narrowed due to spondylosis. A
small focus of aging haematoma is shown in the spinal cord at
CT, possibly an unrelated cavernoma rather than an evolving
haemorrhagic contusion.

25. • Fig. 54.20 Comminuted fracture of thoracic
spine: fractures of the ninth and eighth
thoracic vertebrae with anterior subluxation of
the eighth. Axial sections through the ninth (A)
and the eighth (B) thoracic vertebra, and
reformatted sagittal (C) and coronal (D)
sections. There is a comminuted fracture with
disruption of the body and neural arch of the
ninth thoracic vertebra. A fragment has been
separated from the posterior inferior margin
of the body of the eighth thoracic vertebra
and there is anterior subluxation of the rest of
the vertebra. The spinal canal is markedly
narrowed and the spinal cord is compressed
by displaced bone fragments. The
subarachnoid space is opacified by a blood
clot at T9 and T10 levels. (E,F) MRI of cervical
spine. Whiplash injury in road traffic accident
6 months previously. Sagittal sections: T,-
weighted (E); T2 weighted (F). The spinal canal
is narrowed due to spondylosis. A small focus
of aging haematoma is shown in the spinal
cord at CT, possibly an unrelated cavernoma
rather than an evolving haemorrhagic
contusion.

26. • Fig. 54.21 Old fracture of odontoid peg with non-union and anterior
subluxation. (A) Reformatted sagittal section. (B-E) Axial sections. B is at the
level of the upper border of the anterior arch of the atlas, C at the level of
the lower border of displaced odontoid, D through the upper border of the
posterior arch of the second cervical vertebra, and E 3mm below D. The
theca is impressed by the posterior margin of the lower fragment of the
second cervical vertebra, and the spinal cord is deformed and compressed
between it and the posterior arch of the first cervical vertebra. Arrows mark
anterior arch of atlas, odontoid fragment, lower fragment of second cervical
vertebra; arrowhead = posterior arch of second cervical vertebra.

27. • Fig. 54.22 Rheumatoid
arthritis. Sagittal MRI, T2 -
weighted contrast. Severe
erosion of the odontoid,
vertical atlanto-axial
subluxation and
degenerate subaxial
disease with spinal cord
damage are shown.

28. • Fig. 54.23. Rheumatoid
arthritis with atlanto-axial
subluxation. (A,B) CT axial
sections at level of the atlas.
(C) Midsagittal reformatted
section. There is erosion of
the odontoid peg and anterior
subluxation of the atlas; the
spinal cord is compressed by
the odontoid peg and
posterior arch of the atlas.

29. • Fig. 54.24 Spondylolisthesis of the fourth lumbar
vertebra at CT. (A,a) At the level of the pedicles
and superior articular facets. (B,b) Through
fractured pars intra-articularis. Images are made
at window setting appropriate to show both soft
tissue and bone. Note that the forward slip of the
body of L4 has elongated the sagittal diameter of
the spinal canal; there is no nerve root
compression.

30. • Fig. 54.25 Degenerative lumbar canal
stenosis: T 2 -weighted sagittal
section of lumbar spine. There is low
signal from all the discs, indicating
ageing, but the decline in intensity is
greater in the lower lumbar region
due to additional disc degeneration
with dehydration. The lower lumbar
discs are narrowed and there is
anterior subluxation of two vertebral
bodies, with minor posterior
protrusion of the annuli impressing
the anterior surface of the theca.
There is more prominent impression
of the posterior surface of the theca
due to infolding of the posterior
ligaments associated with apophyseal
osteoarthritis. The combination is
causing degenerative canal stenosis.

31. • Fig. 54.26 Acute intraspinal haemorrhage.
Sagittal (A) and axial (B) MRI with T,-weighted
contrast. The extensive posteriorly located
haematoma is well shown. This one probabally is
subdural in location, and was spontaneous.

32. • Fig. 54.27 Pyogenic infection,
L5/S1 disc. (A) Axial section at
level of L5; (B) at level of S1. (C)
Axial reformatted section. The
bone is destroyed adjacent to the
disc space, leaving a large cavity
with adjacent sclerosis around
the disc. There is no intraspinal
extension.

33. • Fig. 54.28 Neurofibroma: axial section, cervical region, T 1-
weighte sequence. There is a slightly lobulated mass grossly
enlarging the left inter-vertebral foramen and eroding the
adjacent bone. An intraspinal component of the mass
displaces the theca and spinal cord toward the right and
compresses them. A paravertebral component forms a mass
displacing the deep cervical muscles. The extent of this dumb-
bell neurofibroma is evident from this single study.

34. • Fig. 54.29 Metastasis CT.
Sclerotic metastases
involving the right side
of the sacrum were
shown by plain films but
are seen more clearly by
axial CT. This also shows
bone destruction around
the right sacral foramen
and a vertical
pathological fracture
through the body of the
sacrum.

35. • Fig. 54.30 (A) Osteoblastoma of cervical spine. The right pedicle and lateral mass
of the sixth cervical vertebra are enlarged and sclerotic, with an irregular central
low-density nidus. (B) Osteoid osteoma. CT scan of mid-thoracic spine. There is
sclerosis with focal expansion involving the left lamina. The tumour encroaches
on the epidural space and contains a small nidus which is of low density.

36. • Fig. 54.31 Sacral chordoma. (A) A fairly
well defined region of destruction
involving the bodies and left lateral
masses of the lowest two segments of the
sacrum. (B,C) CT sections through the
fourth and fifth segments of the sacrum. A
mass of density slightly lower than that of
muscle is expanding and destroying the
bone of the bodies and left lateral masses
of the fourth and fifth segments of the
sacrum. (Contrast in loops of small bowel)

37. • Fig. 54.32 Haemangioma of
bone, lateral lumbar spine.
The secondary trabeculae of
the body of the second
lumbar vertebra are
thickened; the vertical
striate appearance is typical
of a haemangioma.

38. • Fig. 54.33 Paget's disease. (A) Lateral thoracic spine. The
body and neural arch of the twelfth thoracic vertebra are
enlarged and the bone texture is abnormal. (B,C) CT axial
sections, lower dorsal vertebra. Note abnormal irregular
bone texture throughout the vertebral body, neural arch
and appendages; the whole vertebra is slightly enlarged.

39. • Fig. 54.34 Far lateral lumbar disc prolapse. (A,B) CT axial sections. (A)
Through L3/4 disc space, showing a soft-tissue mass contiguous with the
right posterolateral aspect of the disc, encroaching into the intervertebral
foramen and extending lateral to it. (B) Section 6mm higher than A, and at
level of the lower part of the body of the third lumbar vertebra. The disc
prolapse forms a soft-tissue mass in the path of the emerging right L3
nerve root, which is not visible due to the absence of epidural fat. The left
L3 root (arrow) is clearly shown. (C,D) MRI L4/5 lateral disc prolapse.
Sagittal T1 -weighted sections. Encroachment of prolapsed disc substance
into the L4/5 intervertebral foramen obliterates the epidural fat around
the emerging nerve root.

40. • Fig. 54.34 Far lateral lumbar disc prolapse. (A,B) CT axial sections. (A)
Through L3/4 disc space, showing a soft-tissue mass contiguous with the
right posterolateral aspect of the disc, encroaching into the intervertebral
foramen and extending lateral to it. (B) Section 6mm higher than A, and at
level of the lower part of the body of the third lumbar vertebra. The disc
prolapse forms a soft-tissue mass in the path of the emerging right L3 nerve
root, which is not visible due to the absence of epidural fat. The left L3 root
(arrow) is clearly shown. (C,D) MRI L4/5 lateral disc prolapse. Sagittal T1 -
weighted sections. Encroachment of prolapsed disc substance into the L4/5
intervertebral foramen obliterates the epidural fat around the emerging
nerve root.

41. • Fig. 54.35 Extruded (sequestrated) disc protrusion. (A) Sagittal T 2- weighted
section of lumbar spine. The L4/5 disc space is narrowed and the signal returned
from the nucleus is decreased. There is a slightly lobulated extradural mass behind
the L4/5 disc and upper half of the body of the fifth lumbar vertebra which is
compressing the spinal theca. The signal returned from it is similar to that of the
normal L3/4 nucleus. It was an extruded fragment removed at surgery. Such
fragments commonly give higher signal than the damaged disc from which they
originate. (B-E) Sequestrated lumbosacral disc prolapse. T,-weighted sections
lumbar spine: B,C sagittal; D,E axial. The disc fragment extends behind the upper
part of the right side of the body of the sacrum. It displaces the first sacral nerve
root posteriorly and erodes the sacral body.

42. • Fig. 54.35 Extruded (sequestrated) disc protrusion. (A) Sagittal T 2-
weighted section of lumbar spine. The L4/5 disc space is narrowed and
the signal returned from the nucleus is decreased. There is a slightly
lobulated extradural mass behind the L4/5 disc and upper half of the body
of the fifth lumbar vertebra which is compressing the spinal theca. The
signal returned from it is similar to that of the normal L3/4 nucleus. It was
an extruded fragment removed at surgery. Such fragments commonly give
higher signal than the damaged disc from which they originate. (B-E)
Sequestrated lumbosacral disc prolapse. T,-weighted sections lumbar
spine: B,C sagittal; D,E axial. The disc fragment extends behind the upper
part of the right side of the body of the sacrum. It displaces the first sacral
nerve root posteriorly and erodes the sacral body.

43. • Fig. 54.36 Extruded fragment from a degenerate
L3/L4 intervertebral disc. (A,B) Sagittal and axial
MRI with T2-weighted contrast. A large migratory
extruded disc fragment ascends on the right
behind the L3 vertebral body. (C,D) Sagittal and
axial MRI 8 weeks later shows spontaneous
resolution of the extrusion.

44. • Fig. 54.37 Ossification of the posterior
longitudinal ligament. Sagittal (A) and axial (B)
MRI with T 2 - weighted contrast. The axial image
is between the intervertebral discs and shows the
large low-signal thickened ligament looking
somewhat like a mushroom.

45. • Fig. 54.38 Lumbar spinal canal
stenosis with entrapment of the
cauda equina. Sagittal MRI with T 2 -
weighted contrast showing stenosis
of the spinal canal at L4-L5; CSF
signal is excluded at the level of the
stenosis, and there is redundant
coiling of many of the intradural
spinal roots above

46. • Fig. 54.39 Canal stenosis. CT sections through lumbar
spinal canal. Note the short pedicles (bottom right image)
and medially placed apophyseal joints. The combination
causes marked reduction of the sagittal diameter of the
lateral parts of the spinal canal, which is further
compromised by osteoarthritic changes in the apophyseal
joints.

47. • Fig. 54.40 Syringomyelia.
Parasagittal T,-weighted
sequence. The low signal
subarachnoid CSF outlines
the expanded spinal cord and
also the intramedullary cyst,
which shows a typical
lobulated appearance. One
of the cerebellar tonsils is
outlined with its lower pole
extending to the level of the
arch of the atlas.

48. Fig. 54.41
Ependymoma.
Sagittal and axial
with T2-weighted
contrast shows an
extensive tumour
filling much of the
lumbosacral spinal
canal and cavitated
spinal cord above.

49. • Fig. 54.42 Intradural lipoma. T1 -
weighted MRI. Sagittal section
through posterior fossa and upper
cervical region. The posterior fossa
and foramen magnum are normal.
There is a large mass returning high
signal and typical of fat. It lies within
the subarachnoid space posteriorly,
enlarging the spinal canal and
displacing the spinal cord anteriorly.
The spinal cord is markedly thinned
and the cord substance appears to be
almost completely replaced by fat
over most of the extent of the tumour.
The appearances are typical of a large
intradural and partially intramedullary
lipoma. These tumours typically
extrude from the posterior surface of
the cord between the dorsal columns.

50. • Fig. 54.43 Multiple sclerosis. An axial T 2 -
weighted MRI at C6 shows a typical plaque in
the right lateral column, reaching to the pial
surface of the spinal cord.

51. • Fig. 54.44 Myelogram neurofibroma. (A) AP projection. (B)
Oblique projection. The tumour is intradural on the right side at
C4/5 level and its margins are clearly outlined by the contrast
medium in the subarachnoid space which is widened around the
tumour. The spinal cord is compressed and displaced by the mass.

52. • Fig. 54.45 Neurofibromatosis with multiple tumours. Sagittal
T,-weighted MRI sections. (A) Posterior fossa and cervical
region. (B) Thoracic region. (C) Cervical region after
gadolinium enhancement. (D) Thoracic region after
gadolinium enhancement. The patient has neurofibromatosis
and there are multiple tumours. Some are intradural
extramedullary schwannomas. A good example is shown
anteriorly at C2 level. The upper border of this tumour is
outlined against the cerebrospinal fluid, but its posterior
border blends with the spinal cord which gives signal of
similar intensity. The extent of this tumour i s evident on the
enhanced scan. Some of the tumours are extradural. An
example is shown posteriorly in the mid-thoracic region B;
the upper and lower borders are outlined against the
extradural fat behind the spinal cord. The anterior margin is
only slightly denser than the cord substance. After injecting
gadolinium (D), the tumour is enhanced. Its anterior border,
which is compressing the dura and the cord, is more evident
but the intensity of signal from the enhanced tumour is
similar to that of the epidural fat, making the upper and
lower limits more difficult to define. An intramedullary
tumour is also present, expanding the cord in the lower
dorsal region. The margins are not distinguished from cord
substance on the plain scan B but are evident with ring
enhancement after gadolinium (arrow in D).

53. • Fig. 54.45 Neurofibromatosis with multiple tumours. Sagittal T,-
weighted MRI sections. (A) Posterior fossa and cervical region. (B)
Thoracic region. (C) Cervical region after gadolinium enhancement.
(D) Thoracic region after gadolinium enhancement. The patient has
neurofibromatosis and there are multiple tumours. Some are
intradural extramedullary schwannomas. A good example is shown
anteriorly at C2 level. The upper border of this tumour is outlined
against the cerebrospinal fluid, but its posterior border blends with
the spinal cord which gives signal of similar intensity. The extent of
this tumour i s evident on the enhanced scan. Some of the tumours
are extradural. An example is shown posteriorly in the mid-thoracic
region B; the upper and lower borders are outlined against the
extradural fat behind the spinal cord. The anterior margin is only
slightly denser than the cord substance. After injecting gadolinium
(D), the tumour is enhanced. Its anterior border, which is
compressing the dura and the cord, is more evident but the
intensity of signal from the enhanced tumour is similar to that of
the epidural fat, making the upper and lower limits more difficult to
define. An intramedullary tumour is also present, expanding the
cord in the lower dorsal region. The margins are not distinguished
from cord substance on the plain scan B but are evident with ring
enhancement after gadolinium (arrow in D).

54. • Fig. 54.46 Meningioma. (A,B)
Myelogram. A partially calcified mass
forms a slightly irregular defect within
the theca on the left side posteriorly in
the upper thoracic region and
compresses the spinal cord. (C,D)
Computed myelogram. The calcification
within the tumour is mainly peripheral
and is well shown on D, where the
subarachnoid space is almost totally
occluded. On C, the irregular medial
margin of the tumour is shown,
together with the flattened spinal cord,
which is displaced anteriorly and
towards the right. (E-G) Cervical
meningioma-MRI: T2 –weighted E; T,-
weighted F; T,-weighted after
gadolinium G. The tumour has a broad
base on the dura anterior to the spinal
cord which is displaced posteriorly and
compressed. The tumour returns high
signal on T 2 -low on T,-weighted, and
enhances markedly.

55. • Fig. 54.46 Meningioma. (A,B) Myelogram. A partially calcified mass
forms a slightly irregular defect within the theca on the left side
posteriorly in the upper thoracic region and compresses the spinal
cord. (C,D) Computed myelogram. The calcification within the
tumour is mainly peripheral and is well shown on D, where the
subarachnoid space is almost totally occluded. On C, the irregular
medial margin of the tumour is shown, together with the flattened
spinal cord, which is displaced anteriorly and towards the right. (E-
G) Cervical meningioma-MRI: T2 –weighted E; T,-weighted F; T,-
weighted after gadolinium G. The tumour has a broad base on the
dura anterior to the spinal cord which is displaced posteriorly and
compressed. The tumour returns high signal on T 2 -low on T,-
weighted, and enhances markedly.

56. • Fig. 54.46 Meningioma. (A,B) Myelogram. A partially calcified mass forms a slightly irregular
defect within the theca on the left side posteriorly in the upper thoracic region and
compresses the spinal cord. (C,D) Computed myelogram. The calcification within the tumour
is mainly peripheral and is well shown on D, where the subarachnoid space is almost totally
occluded. On C, the irregular medial margin of the tumour is shown, together with the
flattened spinal cord, which is displaced anteriorly and towards the right. (E-G) Cervical
meningioma-MRI: T2 –weighted E; T,-weighted F; T,-weighted after gadolinium G. The
tumour has a broad base on the dura anterior to the spinal cord which is displaced
posteriorly and compressed. The tumour returns high signal on T 2 -low on T,-weighted, and
enhances markedly.

57. • Fig. 54.47 Spinal dural
arteriovenous fistula
with intradural
drainage. Sagittal (A)
and coronal (B) MRI
with T2 - weighted
contrast in the cervical
region showing
markedly enlarged
intradural veins.

58. • Fig. 54.48 Dural arteriovenous
fistula, left second lumbar
angiogram. (A) AP projection.
(B) Lateral projection. The
fistula is on the left side of the
dura at L2 level and it drains
superiorly through a vein
ascending along the
posterolateral aspect of the
subarachnoid space to enter
the posterior coronal venous
system at T12 level. Veins then
pass around the left side of
the cord to fill the anterior
coronal plexus also. Large
arrow = fistula; small arrows =
draining vein.

59. • Fig. 54.49 AVM of the
spinal cord. (A) Left
vertebral angiogram. (B)
Left sixth intercostal
angiogram. The AVM is
at the cervico-thoracic
junction. It is supplied
(A) from above by the
enlarged anterior spinal
artery descending from
the cervical region and
(B) by an enlarged
tortuous vessel,
presumably a posterior
spinal artery, ascending
along the posterolateral
aspect of the cord.