Comparison of MRI, Intraoperative characteristics of various intramedullary spinal cord tumors

1. DR. U.S.
INTRAMEDULLARY SPINAL CORD TUMORS
Comparison of characteristics of
Astrocytoma, Ependymoma, Cavernoma, Lipoma, Dermoid Cyst,
Neurocysticercosis
Dr. U. S. SRINIVASAN, M.Ch., IFAANS [USA]
Senior Consultant Neurosurgeon
Sri Balaji Hospital
Guindy, Chennai 600032
Tamil Nadu, India

2. DR. U.S.
INTRODUCTION AND AIM OF THIS PRESENTATION
• In this presentation comparison of MRI imaging, intra-operative characteristics of
intramedullary spinal cord tumors would be made.
• The following intramedullary tumors would be compared:
• Astrocytoma
• Ependymoma
• Cavernoma
• Lipoma
• Dermoid cyst
MRI imaging of Neurocysticercosis of dorsal spinal cord is included since it is extremely rare to
see such a case.

3. DR. U.S.
MRI PICTURES OF INTRAMEDULLARY SPINAL CORD TUMORS ASTROCYTOMA,
EPENDYMOMA, CAVERNOMA, LIPOMA
EPENDYMOMA CAVERNOMAASTROCYTOMA LIPOMA
MRI Sagittal sections

4. DR. U.S.
MRI PICTURES OF INTRAMEDULLARY SPINAL CORD TUMORS ASTROCYTOMA
T1 SAG CONTRAST SAGT2 SAG
CONTRAST AXIAL
Fusiform Enlargements Over Several Segments
T1: Low To Intermediate Signal Intensity –
ISOINTENSE
T2: Prolonged Relaxation Time – Mildly
HYPERINTENSE Compared To Normal Spinal Cord
CONTRAST: PATCHY, LESS MARKED
ENHANCEMENT
Cyst Cavities In The Upper & Lower Pole May Be
Seen

5. DR. U.S.
INTRAMEDULLARY ASTROCYTOMA
DIFFERENT MRI CHARACTERISTICS –
3 DIFFERENT PATIENTS –CHILD TO ADULT
2 YR CHILD ADULT – 40 YRS8 YR CHILD
AXIAL - CONTRAST
HPE - ASTROCYTOMA
INTRAMEDULLARY ASTROCYTOMA CAN HAVE VARIED
MRI CHARACTERISTICS

6. DR. U.S.
MRI PICTURES OF INTRAMEDULLARY SPINAL CORD TUMORS
EPENDYMOMA
Fusiform Enlargements Over Several Segments
T1: Low To Intermediate Signal Intensity
T2: Prolonged Relaxation Time – Mildly Hyperintense Compared To Normal Spinal
Cord
CONTRAST: MARKED ENHANCEMENT, HOMOGENOUSLY, WITH SHARPER
MARGINS
Cyst Cavities In The Upper & Lower Pole May Be Seen

7. DR. U.S.
MRI PICTURES OF INTRAMEDULLARY SPINAL CORD TUMORS
LIPOMA
• Extends over few segments 2-4
• Fusiform enlargement of spinal cord. WELL CIRCUMSCRIBED
• Lesion is ISOINTENSE WITH FAT IN BOTH T1 AND T2 IMAGES
• Contrast: NO ENHANCEMENT
• Thin septa may be observed within the lesion
T1 SAG CONTRAST SAGT2 SAG AXIAL

8. DR. U.S.
MRI OF INTRAMEDULARY LIPOMA

9. DR. U.S.
MRI CHARACTERISTICS OF INTRAMEDULLARY
CAVERNOMA
Few segments 2-3
Shape: ILL- DEFINED IRREGULAR
SHAPE
T1: Isointense mixed with hypointense
T2: Hyperintense
Contrast: MILD HETEROGENOUS
ENHANCEMENT
T1
CONTRAST
T2

10. DR. U.S.
MRI IMAGING CHARACTERISTICS OF
INTRAMEDULLARY DERMOID CYST
•T2 images: Well defined globular shaped lesion which is hyperintense in T2
image. Well defined edges.
•Hyperintense signal noted in T2 images
•CONTRAST: Heterogeneous enhancement.
T2 IMAGES
CONTRAST

11. DR. U.S.
MRI characteristics of spinal intramedullary NEUROCYSTICERCOSIS
[Patient treated conservatively with Albendazole, Methylprednisolone and neurologically improved.
MRI showing fusiform expansion of the spinal cord. Oval shaped area.
Multiple disc / ring like intramedullary lesions with central isointense/ hyperintense
area surrounded by hypointense area covered by a ring which is hyperintense.
CONTRAST: Peripheral enhancement of the disc margins noted in axial section.
Delayed scan showing the enhancing central lesion surrounded by isointense area
CONTRASTT2 IMAGES

12. DR. U.S.
INTRAOPERATIVE CHARACTERISTICS OF
ASTROCYTOMA, EPENDYMOMA, LIPOMA
LIPOMAEPENDYMOMAASTROCYTOMA

13. DR. U.S.
INTRAOPERATIVE CHARACTERISTICS OF
ASTROCYTOMA – Surgical strategy - Management
ASTROCYTOMA
• Colour: Beige or Pinkish cream
• Consistency: Soft to firm in consistency.
• Cysts: May be present with straw coloured fluid
inside the cyst cavity.
• Vascularity: Variable. Usually avascular
• Plane of cleavage cannot be found in 50% of cases.
In few cases there may be a well defined plane
between the tumor and neural tissue.
• Only Internal Decompression can be performed in
majority of cases.
• To stop the surgery once the normal neural tissue
with tumor junction is seen.
• Gross total resection is only possible and yields
excellent long term functional outcome
• ROLE FOR RADIOTHERAPY present in recurrent
tumors – but controversial.
• Periodic observation
UNDER
MICROSCOPE
MACROSCOPIC
VIEW

14. DR. U.S.
Cervical Intramedullary Cystic Astrocytoma
Operated in 2014 – Patient from Bihar – 6 years doing well
POST-OP MRI Sag
T1 and T2
PRE-OP MRI Sag
Astrocytoma

15. DR. U.S.
INTRAOPERATIVE CHARACTERISTICS OF
EPENDYMOMA, Surgical strategy & Management
EPENDYMOMA
• Colour: Dirty reddish brown.
• Consistency: Soft to firm in consistency. Well
circumscribed.
• Vascularity: Avascular
• Plane of cleavage commonly present.
• Total ENMASS EXTRATUMORAL
excision can be performed in majority of
cases. In very long tumors, bit by bit
extratumoral excision to be done and then mass
totally excised.
• Excellent long term functional outcome
• NO ROLE FOR RADIOTHERAPY. But in
recurrent tumors controversial.
• Periodic observation

16. DR. U.S.
INTRAMEDULLARY EPENDYMOMAS CAN BE
COMPLETELY EXCISED
PRE-OP MRI Sag
Ependymoma
POST OP MRI SHOWING
TOTAL EXCISION

17. DR. U.S.
INTRAOPERATIVE CHARACTERISTICS OF
LIPOMA, Surgical strategy & Management
LIPOMA
• Tumor is seen as ORANGE-YELLOWISH
fluffy soft to firm in consistency.
• Definite plane of cleavage cannot be
found.
• Only Internal Decompression can be
performed
• To stop the surgery once the normal spinal
cord with tumor junction is seen.
• Radical subtotal resection only possible
and yields excellent long term functional
outcome
• NO ROLE FOR RADIOTHERAPY OR
CHEMOTHERAPY.
• Periodic observation
Reference:

18. DR. U.S.PRE-OP MRI SCAN
OF CAVERNOMA
• Length: Few segments 1-3
• Colour: Golden Yellow, Reddish
• Consistency:. Well circumscribed.
• Vascularity: Vascular
• Plane of cleavage commonly present.
• ENMASS EXCISION ONLY TO BE
performed.
• DEAL LIKE SPINAL
HEMANGIOBLASTOMA
• NO PIECEMEAL EXCISION
• Excellent long term functional outcome
INTRAOPERATIVE CHARACTERISTICS OF
CAVERNOMA , Surgical strategy & Management

19. DR. U.S.
NEUROSURGICAL INSTRUMENTS
Operating MICROSCOPE: ABSOLUTELY ESSENTIAL
Microinstruments : ABSOLUTELY ESSENTIAL
Image intensifier “C” arm : Preferable to localize the level. If
not available, then MOBILE X-RAY IS A MUST.
Intraoperative Neuro- Monitoring system [IONM]: Useful if
available but not absolutely essential. [Only in one case I have
used among a series of 26 intramedullary cases operated].
CUSA: NOT MANDATORY. If available then needed to be
used with caution.
LASER: NOT NEEDED. Useful only in LIPOMAS.

20. DR. U.S.
I HOPE IT IS INFORMATIVE
& WOULD BE USEFUL AS A QUICK REFERENCE
MATERIAL PRIOR TO SURGERY
ON SPINAL INTRAMEDULLARY LESIONS
THANK YOU