Neoplastic disorders of spinal cord by Dr. Amit rauniyar

1. IMAGING IN NON TUMORAL
SPINAL CORD LESIONS
DR. AMIT RAUNIYAR

2. Lesions of the spinal cord
• Ischemic disease
• Vascular malformations
• Neoplastic
• Infectious
• Inflammatory
• Demyelinating

4. Vascular
• Ischemia/Infarction
• Vascular malformations
• Cavernous angiomas

6. Blood supply
2 posterior spinal arteries & 1 anterior spinal artery.
segmental spinal arteries and the radicular arteries.

7. Ischaemia
Causes:-
• Trauma to or dissection of the arterial supply
• Atherosclerotic and embolic disease
• Hypotension (e.g., cardiac arrest)
• Thoracoabdominal surgery (aneurysm repair)
• Spinal angiography
• Vasculitis
• Infection.
• Hypercoagulation
• Vascular malformations
• Antiphospholipid antibodies.

8. • The most common location is the central territory of
the anterior spinal artery, which produces hyper
intensity limited to the paired anterior horns of the
central gray matter , pattern labeled “owl's eyes.”
• Next, the paired posterior horns of the gray matter are
involved in a pattern reminiscent of a butterfly .
• Insults in anterior horns most often have a better
functional outcome
• Embolic events to spinal arteries arising during
catheter angiography have been reported to resolve
spontaneously.

10. Butterfly pattern of cord
infarction involving B/l ant &
posterior horns of gray matter.

11. • Spinal cord ischemia is a clinical diagnosis, and early
conventional scans may be normal in up to 50% of
patients.
• T2-weighted images are the most sensitive and
demonstrate pencil-like hyperintensities on sagittal
images and possibly cord enlargement
• Diffusion restriction – after 3 hours after onset of
symptoms, with resolution by 1 week
• Gadolinium-enhanced T1-weighted images may show
disruption of the blood-brain barrier in the late acute
and subacute phases of infarction, as evidenced by
peripheral, irregular enhancement

12. Vascular Malformations
• Arteriovenous malformations (AVMs)
• Arteriovenous fistulas (AVFs)
• Cavernous angiomas
• Hemangioblastomas.
• Can simply be classified as
• AVMs and AVFs

13. • Vascular lesions other than cavernous
angiomas have been traditionally classified
into four types:
(1) Dural arteriovenous fistula (DAVF)
(2) Intramedullary glomus AVM
(3) juvenile AVM (intramedullary and extramedullary)
(4) intradural extramedullary/perimedullary AVF

14. Arteriovenous Malformations
• Spinal cord AVMs are congenital
• Composed of
– Cluster or nidus of abnormal vessels between the
feeding artery and draining vein

15. • Spinal AVMs are fed by spinal arteries, either
radicullomedullary and/or radiculopial,
located in an intra or perimedullary location,
respectively.

16. Types of AVM
• Glomus -AVMs with a typically compact,
wholly intramedullary
• Juvenile - loose configuration that often
extends into the extramedullary spaces

18. • AVMs most prone to hemorrhage among
vascular malformations
– associated spinal artery aneurysm formation,
most likely the result of longstanding high flow.
When such aneurysms occur, they frequently
hemorrhage.
– venous hypertension and vascular steal
phenomenon, which may include spinal cord
edema, ischemia, or infarct.

19. • Serpiginous flow voids on T2 in MRI ( dilated
intra- and/or perimedullary veins ) with
enhancement
• Intramedullary T2 hyperintensity
• Cord expansion - venous congestion, oedema
• If haemorrhage is present, various intramedullary
signal intensities are seen
• Subarachnoid haemorrhage
• Intranidal aneurysm
• Infarct - T2 hyperintensity

21. • CT myelography - curvilinear filling defects of
an AVM
• CT angiography allows excellent anatomic
definition, although the spatial resolution may
be limited
• Spinal angiography remains the gold standard
for diagnosis

22. Dural Arteriovenous Fistulas
• Dural AVFs comprise the majority of spinal
vascular malformations
• Involves a single or multiple feeding
radiculomedullary arteries forming fistula
with radicular veins

23. Types
• Dural AVF – involving dural branches of a
radicular artery, acquired
• Intradural AVFs - directly from the spinal
arteries, congenital

24. • Most common in midthoracic to upper
lumbar region
• T2 sequences show an ill-defined
hyperintensity extending to multiple levels,
cord expansion.
• Hypointense rim - due to deoxygenated blood
• Flow voids - Engorged perimedullary veins
• Diffuse post-contrast enhancement of spinal
cord - breakdown of blood–brain barrier.

26. • Dural AVFs - an indication for DSA.
• When searching for a dural fistula, imaging
should be slow, say one frame rate every 2 s due
to delayed venous return.
• A large number of arteries may have to be
injected before the lesion is found.
• The study should not be regarded as negative
unless:
1. All the spinal arteries from the foramen magnum
to the coccyx have been opacified adequately

27. 2. Veins thought to be abnormal have been
opacified and shown to drain normally.
If a lesion is found, adjacent levels should also
be injected and the major radiculomedullary
arteries supplying the region must be
identified.

28. Cavernous Angiomas
• Cavernous angiomas are most often
intramedullary
• Risk of hemorrhage into spinal cord
• These angiomas show a typical reticulated
pattern of heterogeneous signal intensity on
all MR sequences, producing the classic
“popcorn” appearance best demonstrated on
T2-weighted sequences

30. Infection
• Infectious diseases typically occur around the spinal cord,
as in osteomyelitis, diskitis, and epidural abscesses
• Haematogenous route - pyogenic bacteria, syphilis or
tuberculosis
• Very rarely they can involve the intramedullary spinal cord
• Cord infection - increased intensity on T2-weighted images
and enhancement
• Abscess- show typical rim enhancement
• A congenital lesion, such as a dermal sinus, can allow
formation of an unusually high number of intramedullary
abscesses

31. • Viral Disease
• Viral infections of the spinal cord are encountered
most often among patients with immune compromise.
• In patients with AIDS, intramedullary infection with
human immunodeficiency virus type I (HIV-1) causes a
vacuolar myelopathy that shows bilateral, symmetrical
hyperintensity on T2-weighted images located in the
dorsal columns, without cord enlargement.
• Herpes zoster - myelitis that shows cord enlargement,
hyperintensity on T2-weighted images, and variable
enhancement

33. Parasitic Disease
• Although rare, schistosomiasis, toxoplasmosis
and cysticercosis can occur in spinal cord
• Schistosomiasis - nonspecific myelitis,
granulomas
• Cysticercosis - syringomyelia or cystic
intramedullary lesions, associated with brain
parenchymal lesions

34. Fungal Disease
• Involvement of the spinal cord as a direct result of
fungal disease occurs only rarely
• Immune compromise.
• Aspergillosis is the most common fungal disease of the
cord, typically presenting as a myelopathy but also
reported as occluding principally the anterior spinal
artery.
• Cord abscesses caused by Candida, Coccidioides, and
Nocardia species
• Similarly, cord granulomas caused by Cryptococcus and
Histoplasma species have been described in isolated
reports.

35. Granulomatous Disease
• Intramedullary involvement in granulomatous
diseases, such as tuberculosis and sarcoidosis,
is rare reported from developing countries
and patients with AIDS.
• Tuberculoma - T1 hypointensity and T2
hyperintensity with focal or conglomerate ring
enhancement seen.
• Central low T2 signal intensity may suggest a
tuberculoma.

37. Sarcoidosis
• Sarcoidosis - CNS involvement in systemic
sarcoidosis occurs in about 5% of patients,
• Direct primary cord lesions have been
reported in fewer than 100 cases.
• Cord enlargement and multifocal patchy areas
of enhancement
• Frequently in association with meningitis

38. • The most common spinal cord manifestation is
leptomeningeal enhancement.
• Dural involvement is more nodular in
appearance, often with enhancing dural-based
mass-like lesions that may mimic meningiomas.
• Enhancing mass that is hyperintense on T2
sequences with associated fusiform enlargement
of the spinal cord.
• If cauda equina involved - enhancement and
clumping of the nerve roots.

39. Syringomyelia
• The term ‘syringomyelia’ describes conditions
in which there is a cavity within the spinal
cord and containing fluid that is similar or
identical with CSF.
• The cervical cord is involved most often,
although occasionally only the thoracic cord.

40. • The spinal cord is enlarged in about 80% of
cases, normal in size in 10% and diffusely
atrophic in 10%.
• Causes:-
• Intramedullary tumours
• spinal cord trauma
• Inflammatory processes
• no cause or association (10–20% )

42. Demyelinating diseases
• Multiple sclerosis
• Acute transverse myelitis
• NMO
• ADEM

43. Multiple sclerosis
• Etiology: Unknown, possibly d/t autoimmune-
mediated demyelination.
• Commonest demyelinating disease
• F>M (particularly in children & adolescent),
• 15-50 years; peak age 3rd-4th decade.
• Spinal cord plaque distribution – predilection
for cervical spinal cord in early dis; evenly
distributed in later stages.

44. • Multiple lesions disseminated over time and
space.
• 1/3 MS pts will have spinal symptoms.
• 1/3 MS pts have isolated spinal MS without
any findings in brain.
• However pathologic studies have shown that
95% MS pts have spinal cord lesions, whether
they have spinal symptoms or not.

45. REVISED McDONALD CRITERIA FOR MS
DIAGNOSIS
• Dissemination in Space
• ≥ 1 T2 hyperintense lesion(s)
• In at least 2 of the following 4 areas
• Periventricular
• Juxtacortical
• Infratentorial
• Spinal cord
• Dissemination in Time
• Either new T2 or Gd-enhancing lesion(s) on follow-up MR
Or simultaneous presence of
• Asymptomatic Gd-enhancing and
• Nonenhancing lesions at any time

46. Types:
(1) focal well-demarcated high-signal areas
(2) diffuse poorly demarcated high-signal areas
(3) spinal cord atrophy.

47. • These lesions are best depicted with fast STIR sequences
and, in contrast to similar lesions in the brain, they are not
well demonstrated by FLAIR sequences
• Focal lesions or plaques are generally multiple , peripheral
and eccentric in the cord , less than one half the cross-
sectional area, and less than two vertebral body segments
in length – D/D Transverse Myelitis.
• Post contrast images may show enhancement that is
nodular or ring like.
• Enhancing lesions in the spine are much less common than
those in the brain. The majority of plaques are located in
the cervical spine, dorsally and laterally.

49. Acute Transverse Myelitis
• ATM is a clinical syndrome of bilateral motor,
sensory, and autonomic disturbances.
• Associated with a wide variety of
– systemic disorders such as vasculitis,
neurosarcoidosis, and lupus
– Antecedent viral illness
– Idiopathic.

50. • On imaging, ATM lesions are central, greater
than two vertebral segments in length, and
greater than one half the cross-sectional area
of the cord.
• ATM lesions demonstrate focal enlargement
and may have patchy or diffuse enhancement
in a minority of cases.

52. Neuromyelitis Optica
• Neuromyelitis optica (NMO) is a severe
inflammatory disorder that predominantly
affects the optic nerves and the spinal cord.
• It has a relapsing course in 80% of the cases
• Females are more commonly affected.
• Associated with optic neuritis

53. • Optic neuritis MRI shows hyperintensity of the
optic nerves with enhancement.
• Spinal cord involvement manifests itself as
intramedullary T2 hyperintense signal often
extending more than three vertebral segments
and full diameter.
• On follow-up magnetic resonance (MR) defects,
atrophy and central cavities, predominately
located in the area of the posterior fascicle.

54. Acute Disseminated Encephalomyelitis
• ADEM develops mostly one or two weeks
following a viral disease or prior vaccinations.
• On MR imaging, non-enhancing hyperintense
lesions are seen in the spinal cord in T2
sequnences.
• ADEM predominately affects the thoracic
cord.
• Almost always brain is involved.

56. Systemic Lupus Erythematosus
• SLE is a relapsing and remitting, chronic,
multisystem autoimmune disease.
• Although the frequency of neuropsychiatric
lupus has been reported as high as 95%, SLE-
related myelitis is rare, with prevalence
varying between 1 and 2%.

57. • SLE myelitis manifests mostly as transverse
myelopathy.
• Vasculitis and arterial thrombosis resulting in
ischaemic cord necrosis.
• Mid-thoracic cord is most commonly affected
• Lesions show T2 hyperintensity

59. Vitamin B12 (cobalamin) deficiency
• Vitamin B12 (cobalamin) deficiency causes
megaloblastic anemia and sub- acute combined-
degeneration of the cord.
• The demyelination usually predates the
appearance of anemia and preferentially involves
the dorsal columns of the cord, causing loss of
proprioception and vibration sense with sensory
disturbance.
• MR - long-segment, bilateral T2 hyperintensity
of the dorsal columns described as an “inverted
V” or “rabbit-ear” appearance.

61. Radiation Myelopathy
• Rare but serious complication of therapeutic irradiation
• Chronic progressive radiation myelopathy (CPRM) is most
common form
• Most CPRM after RT of nasopharyngeal Ca.
• cervical spinal cord commonly affected.
• Latent period b/w termination of irradiation and symptom onset
varies from 3 to 40 months

62. Criteria:
1. Spinal cord included in radiation field
2. Neurological deficit must correspond to cord
segment irradiated
3. Metastasis or other primary spinal cord
lesions must be ruled out

63. • MR Imaging findings
vary:
– Within 8 months of
symptom onset: Long
segment hyperintensity on
T2WI,with or without
associated cord swelling
and enhancement
following contrast
administration.

64. APPROACH

65. Systematic Approach
• Whenever there is an abnormality in spinal
cord, we need a systematic approach.
• Clinical findings can be helpful but can be quite
similar in most spinal cord disorders.
• Look for:
– Short or long segment?
– How much cord involvement in transverse?
– Location of involvement in transverse?
– Swollen?
– Enhancement?
– Brain findings?

66. Short Vs long segment?
• Short segment (<2 segment)
involvement
– common in:
• MS
– uncommon in:
• Transverse myelitis - partial form
• Long segment involvement
– common in:
• Transverse myelitis - complete
form
• Neuromyelitis Optica
• ischemia
– uncommon in:
• MS

67. Transverse involvement
• Transverse images are very helpful in DD.
• We need high resolution images.
• Look for:
– how much is involved (both halves or not)?
– which part is involved?
– what is the form of the involvement?
• Partial involvement is typically seen in MS.
• Complete involvement includes both halves of the cord
and is typically seen in TM and NMO.
• Use high resolution transverse images to detect location
within cord. Is it posterior like in MS, vitamin B12
deficiency, lateral like in MS or anterior like in arterial
infarction.

68. • MS:
– Typically triangular in shape & mostly located dorsally or laterally.
– However MS can look like anything & may uncommonly involve whole
transverse diameter or only anterior part.
• Ischemia as a result of arterial infarction is typically
located in anterior parts, but may involve entire
transverse diameter.
• Transverse myelitis & Neuromyelitis optica typically
involve whole cord.

70. • Is the cord swollen? In TM and tumor the cord is swollen, while
in MS and ADEM the cord is not swollen or less swollen then
you would expect for the size of the lesion.
• Is there enhancement? Many diseases show some
enhancement, but the most important thing is that astrocytoma
has to be included in the differential diagnosis.
• Brain findings? In many cases of myelopathy there will also be
brain abnormalities and these can be a diagnostic clue to the
diagnosis.

71. Conclusion
• MR is the best tool to evaluate intramedullary
processes of the cord.
• Discovery of an intramedullary cord lesion
typically followed by imaging of the remainder of
the neuraxis.
• Infiltrative cord lesion: Image brain to potentially
identify characteristics white matter lesion(s) of
multiple sclerosis.
• Nearly every patient with a syrinx should be
imaged at least once with contrast-enhanced MR
to exclude a cord neoplasm.

72. References
• Grainger and Allison’s Diagnostic radiology,
Sixth edition
• CT and MRI of whole body Sixth edition

73. THANK YOU