A 60-year-old female presented with numbness in both lower limbs for 6 weeks and weakness in both lower limbs for 4 weeks. Neurological examination found loss of sensation below the T6 level and impaired vibration and joint position sense. MRI of the dorsal spine showed a lesion in the D4 and D5 vertebral bodies with extradural and intradural components causing spinal cord compression. Differential diagnoses included aggressive hemangioma, plasmacytoma, and aneurysmal bone cyst. Imaging findings were most consistent with aggressive hemangioma.

1. Presented by DR.ISHWARYA ANNAMALAI, M.D INTERNAL MEDICINE, I YEAR, PROF. DR.GOWRI SHANKAR UNIT.

2. CASE SUMMARY 60 year old female patient rahamed beevi came wit the chief presenting complaints of numbness both lower limbs-6 weeks, weakness of both lower limbs-4 weeks, urinary incontinence-2 weeks Numbness-progressed from toes upto undersurface of breast.(all modalities of sensation lost). 2 weeks later patient developed weakness both lower limbs with difficulty in walking.

3. CNS examination in brief : Higher functions are normal. Cranial nerves function – intact Sensory-pain,temperature-lost below T6 level, vibration sense & joint position sense impaired below T6 Motor-both lower limbs hypertonic, reflexes exaggerated, b/l plantar extensor+ Cerebellar functions-normal.

4. Imaging studies done for the patient : CONTRAST MRI of dorsal spine CT spine.

5. CONTRAST MRI OF DORSAL SPINE SAGGITAL AND CORONAL VIEW

6. CORONAL AND AXIAL VIEWS

9. Contrast MRI of dorsal spine shows: T1 hyperintense area with hypointensities and T2 hyperintensity noted in D4,D5 vertebral bodies. The lesion has both extradural and intradural extra medullary components causing cord compression. The axial view shows widening of neural foramina On the rt side. Multiple vertebral bodies show T2 hyperintense lesions.

10. DIFFERENTIAL DIAGNOSIS 1. AGGRESSIVE HEMANGIOMA 2.Plasmacytoma 3.Aneurysmal bone cyst 4.Non hodgkin lymphoma RARE POSSIBILITIES : 1.Neurofibroma 2.Meningioma 3.Schwannoma

11. 4.Osteosarcoma(telangiectatic) 5.Osteoblastoma 6.Malignant peripheral nerve sheath tumor 7.angiolipoma 8.melanoma 9.rhabdomyo sarcoma 10.chondrosarcoma

12. AGGRESSIVE HEMANGIOMA

13. PLASMACYTOMA Features in favour: site-vertebral body most common site age-common after 55 yrs of age similar MRI findings. Features against this diagnosis: More common in males. More commonly involves posterior element of vertebral body No involvement of contiguous vertebral body. Vertebral body collapse common.

14. ANEURYSMAL BONE CYST Features in favour: Site-spine frequently involved. Lumbosacral>thoracic>cervical Arises in neural arch 75 %-90% extend into vertebral body. Features against this diagnosis: Age-common in first 2 decades. Occasionally T1w shows lobulated neural arch mass.

15. DIAGNOSTIC IMAGING METHOD IN AGGRESSIVE HEMANGIOMA AXIAL BONE ALGORITHM CT Hypodense well circumscribed with coarse vertical trabeculae-white polka dots CONCLUSION: Clinical features and imaging features favour the diagnosis of aggressive hemangioma .

16. THANK YOU