Radiological evaluation of spinal tumors

1. APPROACH TO SPINAL TUMORS
MODERATOR: DR. JHONY PRASAD
Assistant professor
PRESENTER : Dr. AASRITHA K

2. In establishing the differential diagnosis for a spinal
lesion, location is the most important feature, along
with the clinical presentation age and gender.

3. CLASSIFICATION OF LESIONS
Spinal tumors are subdivided according to
their point of origin:
Intramedullary
Extramedullary – Intradural
Extradural

5. APPROACH
STEP 1 : LOOK AT CORD
EXPANDED
INTRAMEDULLARY
NOT EXPANDED/ COMPRESSED
STEP 2 : LOOK AT CSF
(subarachnoid space)
EXPANDED NOT EXPANDED
INTRADURAL
EXTRAMEDULLARY
EXTRADURAL

6. INTRAMEDULLARYTUMORS
Solitary : Multiple :
Hemangioblastomas
Metastases
Lymphoma
Ependymoma
Astrocytoma
Ganglioglioma
Hemangioblastoma
Subependymoma
Paraganglioma

7. INTRADURAL-EXTRAMEDULLARY
TUMORS
Solitary :
 Meningiomas
 Nerve sheath tumors
 Myxopapillary
ependymoma
 Intradural metastases
 Lymphoma/leukemia
 Paraganglioma
Multiple:
All except
paraganglioma

8. ExtraduralTumors : Epidural Lesions:
Angiolipoma
Angiomyolipoma,
Epidural lipomatosis,
Lymphoma

9. ExtraduralTumors
Solitary:
 Aneurysmal bone cyst
 Giant cell tumor
 Osteoblastoma
 Osteochondromas
 Chordoma
 Chondrosarcoma
 Chondroblastoma
 Metastasis
 Hemangioma
 Plasmacytoma
 Lymphoma
Multiple:
 Metastatic disease
 Hemangiomas
 Multiple myeloma
 Lymphoma

10. Intramedullary tumors
Rare tumors, accounting for about 4-10% of all
central nervous system tumors.
Cause expansion of cord.
Intramedullary tumors include
1. Gliomas (ependymomas, astrocytomas and
gangliogliomas) and
2. Nonglial tumors (such as
hemangioblastomas, lymphoma and
metastases).

11. Ependymomas
MC intramedullary neoplasm in adults
Usually occurs in the cervical region
Cause symmetrical cord expansion
Slightly more common in women of 40to 50 years of
age.
Increased incidence inpatients with NF-2.

12. characterized by slow growth and compress rather
than infiltrate adjacent spinal cord tissue, generally
yielding a cleavage plane that aids in surgical
resection.
These lesions arise from ependymal cells that line the
central canal and therefore tend to be central in
location with respect to the spinal cord.
Almost all spinal cord ependymomas are low grade.

13. Imaging
On MRI, iso- to hypointense on T1WI and
hyperintense on T2WI.
Ependymomas tend to produce symmetric spinal
cord expansion and usually have solid and cystic
components.
NON TUMORAL CYSTS TUMORAL CYSTS
Occur @ poles Located within the solid
tumor
Dilation of central canal Lined by tumor cells
Do not enhance Peripheral enhancement
Resolve once tumor is
resected
Should be resected with the
tumor

14. • The solid components of ependymomas usually enhance
avidly, although the degree of enhancement may vary
considerably.
• In addition, ependymomas can hemorrhage, resulting in
the “cap sign” a hypointense rim at the
periphery of the tumor on T2-weighted imaging that is
related to hemosiderin deposition from prior hemorrhage.
• Clear tumor margins, more uniform enhancement
and central location can help differentiate
ependymomas from other intramedullary spinal cord
tumors
• Metastases in the subarachnoid space.

16. ASTROCYTOMAS
They are the most common childhood intramedullary
neoplasms of the spinal cord and are second only to
ependymomas in adults.
In contradiction to ependymomas, astrocytomas
are located eccentrically within the spinal cord.
However, spinal cord astrocytomas tend to infiltrate the
cord and are, therefore, difficult to resect completely and
have worse prognosis.

17. Imaging
The cervicomedullary junction and the cervico-thoracic cord.
On MR imaging, pilocytic astrocytomas are characterized by
enlargement of the spinal cord within a widened spinal canal.
They frequently involve a large portion of the cord, spanning
multiple vertebral levels in length.
Tumors can show areas of necrotic-cystic degeneration, can have a
cyst with mural nodule appearance or can be solid.
solid components are iso- to hypointense on T1WIs and
hyperintense on T2WI.

18. The pattern of enhancement can be focal nodular,
patchy or inhomogeneous, diffuse enhancement and
does not define tumor margins.
Nonenhancing intramedullary astrocytomas are not
uncommon.
Like ependymomas, they can have intratumoral or polar
cysts but do not tend to hemorrhage and, therefore, do
not usually display a cap sign.
Associated with NF1.

19. EPENDYMOMA ASTROCYTOMA
AGE Adult Pediatric
LOCATION Central Eccentric
MORPHOLOGY Well circumscribed Ill defined
HEMORRHAGE common uncommon
ENHANCEMENT Focal intense, homogenous Patchy irregular
inhomogenous
CONUS OR FILUM yes atypical
ASSOCIATIONS NF2 NF1
ROLE OF DTI Displacement of central
tracts peripherally
Interruption or disruption of
fibres

21. SUBEPENDYMOMA
Rare tumors
WHO grade 1
fusiform dilatation of the spinal cord with well-defined
borders.
Unlike other ependymomas, they are eccentrically
located.
Enhancement has sharply defined margins (50
% of cases), whereas those that do not enhance
have diffuse symmetric spinal cord enlargement.

22. BAMBOO LEAF SIGN

23. Ganglioglioma
Gangliogliomas are the second most common intramedullary
tumor in the pediatric age group and mostly affect children
between 1 and 5 years of age, as do pilocytic astrocytomas.
Cervical spine > thoracic region.
These tumors tend to have a low malignant potential, slow
growth, but they have a significant propensity for local
recurrence.
Gangliogliomas tend to be extensive on presentation, occupying
an average length of 8 vertebral segments, compared with
ependymomas and astrocytomas, which average 4 vertebral
segments in length.

24. Imaging
Calcification is probably the single most suggestive
feature of gangliogliomas.
In the absence of gross calcification, the MR imaging appearance
of gangliogliomas is nonspecific and does not allow differentiation
from astrocytomas.
Solid portions have mixed iso-hypointensity on T1WI and
heterogeneous iso- hyperintensity on T2WI.
Like astrocytomas, gangliogliomas tend to be eccentrically located
within the spinal cord.
Tumoral cysts are more common in gangliogliomas than in either
astrocytomas or ependymomas.

25. Chronic bony changes, including scoliosis and erosions, are often
seen with gangliogliomas due to their relatively slow growth; these
are rarely seen with ependymomas or astrocytomas.
T1 signal characteristics of gangliogliomas are most often mixed,
possibly secondary to the fact that gangliogliomas have a dual cell
population composed of ganglion cells and glial elements.
T2 signal characteristics of gangliogliomas are generally
hyperintense, although surrounding edema is not as commonly
seen as with ependymomas or astrocytomas.
majority of gangliogliomas show patchy enhancement.

27. HEMANGIOBLASTOMA
Nonglial, highly vascular neoplasms of unknown cell
origin.
Although most of these tumors (75%) are
intramedullary, they may involve the intradural space
or even be extradural.
Thoracic spinal cord > cervical spinal cord
Superficial location (subpial aspect)
Large size of syrinx compared to tumor
Vasuclar flow voids
Cyst with enhancing nodule
Edema
in association with Von Hippel-Lindau disease.

28. IMAGING
MR features of spinal hemangioblastoma depend on
the size of the tumor.
Small (<10 mm)- isointense on T1WI
hyperintense on T2WI
homogeneous enhancement,
Large (>10mm) - hypo or mixed onT1WI
heterogeneous on T2WI
heterogeneous enhancement

30. INTRAMEDULLARYLYMPHOMA
Primary are extremely rare.
Non-Hodgkin variety and can occur in both immunocompromised
and immunocompetent patients.
Majority of these tumors occur in the cervical or thoracic regions of the
spinal cord.
solid tumors without necrosis.
Marked T2 hyperintensity and enhance following gadolinium
administration.
There is no associated syringomyelia.
Clinically, these patients initially respond to steroid treatment for a short
time but usually recur after treatment.

31. INTRAMEDULLARYMETASTASES
Intramedullary spinal cord metastases are rare.
Usually involve the cervical cord.
Most common primary tumors that metastasize to the spinal cord
include lung, breast, colon, lymphoma and kidney.
On MRI, metastases are
T1 hypointense,
T2 hyperintense and demonstrate
homogeneous enhancement.
The amount of surrounding edema is out of proportion to the size of
the lesion.

33. PARAGANGLIOMA
Although spinal paragangliomas are rare, they are the third most
common primary tumor to arise in the filum terminale (after
ependymoma and astrocytoma).
MR typically reveal a well-circumscribed mass that is isointense
relative to the spinal cord on T1WI and iso- to hyperintense on
T2WI.
Hemorrhage is common (third most common after ependymoma
and hemangioblastoma) and a low signal- intensity rim (cap sign)
may be seen on T2WI.
Heterogeneous and intense enhancement.
Multiple punctate and serpiginous structures of signal void due
to high-velocity flow may be seen around and within the tumors on
all sequences.

36. INTRADURALEXTRAMEDULLARY
TUMORS
Since the arachnoid is essentially continuous
with the dura in the spine, intradural lesions
are located in the subarachnoid space.

37. MENINGIOMAS
Most spinal meningiomas are found in the thoracic spine,
followed by the craniocervical junction and the lumbar
region.
Although most thoracic and lumbar meningiomas are based
on the posterior dura, craniocervical ones may be anterior or
posterior in location.

38. Typically, these lesions demonstrate T1 and T2 signal that is
isointense with the spinal cord and display intense
homogeneous enhancement.
A dural tail may be seen, reflecting tumor spreador reactive
changes in the dura adjacent to the tumor.
CT may show intratumoral calcifications and this finding may aid
in distinguishing between meningiomas and nerve sheath tumors,
which do not contain calcifications.
Occasionally, spinal meningiomas have a plaque-like configuration
and may encircle the cord.

40. GINKGO LEAF SIGN

41. NERVE SHEATHTUMORS
Schwannomas and Neurofibromas.
Schwannomas are most common, while neurofibromas generally
occur in association with neurofibromatosis (especially NF-1).
Approximately 50% of nerve sheath tumors are Intradural-
Extradural (dumbbell- shaped) in location and 50 % are Purely
Extradural.
Malignant degeneration of neurofibromas may occur in patients with
NF-1, but schwannomas rarely undergo malignant transformation.
Both masses are slow growing and cause bone remodeling
(e.g., expansion of neural formina) and both show low T1 and
high T2.

42. .
 Cystic spaces and hemorrhage, however, are more common in
schwannomas than in neurofibromas.
 Both may show homogeneous or inhomogeneous
enhancement, but neurofibromas may have typical ring or
target type of enhancement in which the central portion of the
mass remains relatively hypointense after contrast
administration.

45. MyxopapillaryEpendymoma
Myxopapillary ependymomas represent the most frequent
type of ependymomas found at the conus medullaris-
cauda equina- filum terminale level.
Neuroectodermal tumors.
Mainly observed during the fourth decade of life.
The vast majority are intradural and extramedullary spinal
tumors

46. Imaging
Myxopapillary ependymomas are lobulated, sausage-shaped
masses that are often encapsulated.
Isointense relative to the spinal cord on T1WI a finding that reflects
mucin content or hemorrhage
and overall hyperintense on T2WI , low density may be due to
hemorrhage/calcifications.
T1 C+ (Gd)
• enhancement is virtually always seen
• the enhancement pattern is typically homogeneous. However,
they can have a variable enhancement pattern that, in part,
depends on the amount of hemorrhage present

48. The differential diagnoses of a mass arising
in the filum terminale are:
Ependymoma,
Astrocytoma,
Nerve sheath tumor,
Metastases,
Paraganglioma,
Hemangioblastoma.

49. Leptomeningeal metastases
 Frequently seen (5-15%) in the setting of solid tumors (most commonly melanoma,
small cell lung cancer, and breast cancer) and hematologic malignancies.
 In children, the most common intradural extramedullary neoplasms are drop
metastases from primary brain tumors (most commonly medulloblastoma, others
include ependymoma,choroid plexus carcinoma, germinoma, ).
 In adults, the most common drop metastases are from glioblastoma, anaplastic
astrocytoma, however non-CNS tumors are most commonly encountered. Multiple
lesions are common.
 MRI
 MRI without contrast may be normal, and thus when suspected contrast should be
administered. Typical signal characteristics include:
 T1: thickened nerve roots or nodular lesions that are isointense with the spinal
cord.
 T2: cord edema may be seen with more extensive disease, especially if there is an
intramedullary component
 T1 C+ (Gd): enhancing tumor nodules on the spinal cord, nerve roots or cauda
equina, "sugar coating” of the spinal cord and nerve roots.

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