Neuro -- Spinal Tumors

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We are ignoring osseous metastatic disease compressing the cord in this module. It is easy to recognize and don't need to spend much time on it.: ok
What is the first thing to do when seeing a lesion within the spinal cord?: Determine what space you are in
What are the choices?: Intramedullary

Intradural extramedullary

Extradural
Why do it this way?: You only have to know three entities for each of those areas, simplifying your ddx greatly!
What if you still aren't sure whether you have covered the full ddx for a given lesion?: Just throw in Sarcoid and Lymphoma, and you are DONE!
What are non-neoplastic categories that can cause intramedullary masses?: Demyelinating dz

Inflammatory

Vascular lesions

Developmental lesions

Trauma
What sequences are used for the cord?: T1, T1 post, T2, proton density, STIR (or other fat suppressed fluid sens)
Where in the cord are demyelinating lesions located?: Posterior cord, since that is where the bulk of the white matter tracts is
What is the hallmark of spinal neoplasm?: Cord enlargement
What are other features seen in spinal tumors?: 1) Hemorrhage

2) Cystic components

3) Enhancement
How many different types of cysts are seen with cord tumors?: 2
What are they?: Intratumoral cysts -- part of the tumor itself

Tumor associated cysts
Where are tumor associated cysts?: They cap the lesion above and below
What sequence is always done whenever cord tumor is suspected?: T1 Postgado. Must evaluate enhancement
How many intramedullary tumors do we need to remember for adults?: 3
Which ones?: 1) Hemangioblastoma

2) Astrocytoma

3) Ependymoma
When does hemangioblastoma present?: 20s -- 40s
What other lesions are seen in patients with cord hemangioblastomas?: RCCA

Pancreatic cysts

Retinal angiomas
Why?: Because hemangioblastoma is assd with VHL, just like when it is seen in posterior fossa.
What percent of patients with cord hemangioblastoma will have VHL?: 30%
What is their general appearance?: Variable, just like they are in posterior fossa.
What are the variations?: Can be large, can be small

Can be totally solid, can be primarily cystic with mural nodule.

And anything in between
What are the CONSTANT findings in hemangioblastoma?: 1) LIGHT BULB enhancement of its cystic portions

2) Flow voids from large vessels feeding tumor

3) Edema within adjacent cord
What does the edema do to the cord?: It causes cord expansion itself.
Before giving contrast, how do you differentiate hemangioblastoma for holocord astrocytoma?: You really cant. But when you give contrast, BAM, you see very well defined super-bright cord lesion, which is significantly smaller than the whole region of distortion that it creates
When you treat it surgically, what part of cord do you remove?: Just the enhancing tumor nidus (and any associated cyst). Not the edematous cord.
What does edema look like in the cord?: Looks flame-shaped on T2, extending up or down the central part of the cord, sparing the periphery of the cord
What type of edema is this?: Vasogenic edema, of course. It does not involve the cord periphery (i.e. where the gray matter is). The flame-shape is the cord equivalent of vasogenic edema.
What is a more typical appearance of hemangioblastoma in VHL?: They get multiple small hemangioblastoma nodules, which are up against the pial surface, not so much central in the cord.
Does hemangioblastoma have tumor associated cysts?: Yes. The tumor assd cysts are just collections of edema. They are not sensitive or specific
What is age dist'n of cord astrocytoma?: Mainly 20s to 40s, but also occur in kiddies.
What is true of size of astrocytomas?: Fusiform expansion, usually greater than 2 segments.
How big are demyelinating plaques in the cord?: Small. 2 segments or less!
What percent of astrocytomas enhance?: For my purposes all do. Only 10% dont
What do they look like?: Basically just like they would in brain. They enhance. They can have central areas of necrosis. Nothing really specific about em.
Where do astrocytomas not occur?: Filum
What is the most common primary cord tumor?: Ependymoma
What tumor feature is suggestive of ependymoma?: Certain locations
What tumor locations make ependymoma much more likely?: Lower cord, conus, and filum
What is another feature of ependymoma that is somewhat specific?: Hemorrhage
How does this manifest?: Dark hemosiderin cap above and below lesion
What is another very typical finding of ependymoma?: Tumor associated cysts above and below lesion
How do you differentiate tumor associated cysts with intratumoral cysts?: No enhancement on outer sides of tumor assd cysts
What does ependymoma do to bones?: Remodels vertebrae
Why is this important to know?: Because you cant just assume that something remodeling the spine is benign. It is not always so. It is a slow growing tumor though.
What percent of ependymomas enhance?: For my purposes, all cord tumors will enhance. But if you must know, 80% of ependymomas do enhance.
What if you see a cord tumor which is extensive, involving many segments, but which demostrates lots of areas of dark signal?: C/W hemosiderin deposition, which represents old hemorrhage, as is suspicious for ependymoma.
What is classic appearance of cord mets?: Lots of separate foci of enhancement throughout the cord in patient with known primary
What are the 4 most common mets to cord?: Lung

Breast

Melanoma

RCCA
What are vascular malformations of cord?: Cavernous hemangioma

AV Malformation
What does cord cavernoma look like?: Look up. Looks same as brain I guess. But I don't know that either!
What is the classic presentation for a particular vascular malformation of the cord?: Young patient presenting with subarachnoid hemorrhage
What malformation is this a classic presentation for?: AVM of the cord
What does ill defined cord enhancement in an expanded segment of cord suggest?: Cord infection
What should you consider in all cases that look atypical (poor enhancement, multiple segments, indistinct margins of enhancement)?: Sarcoid

Lymphoma
What is the differential for intradural extramedullary lesions?: 1) Schwannoma

2) Meningioma

3) Mets
What are the characteristics of intradural extramedullary lesions?: Displace cord

AND

Widen adjacent CSF space
What is a classic characteristic of meningioma on MRI (nice when you see it to clinch diagnosis, but don't always see): Dark on T2
What is the appearance of schwannoma?: Enhancing with unenhancing cystic component. May be mostly cystic with just peripheral enhancement.
What is the most classic finding of schwannoma?: Dumbell lesion extending through and expanding the neural foramen
What patients get dural dysplasia?: NF-1
What patients get frequent spinal tumors.: NF-2
What spinal tumors do they get in NF-2?: Meningiomas

Schwannomas (can have schwannomas at multiple levels, classic appearance)

Ependymomas
What type of metastatic disease is intradural extramedullary?: Drop mets
What tumors give drop mets?: Medulloblastoma

Ependymoma

Oligodendroglioma

Pinealoma

Astrocytoma
What other type of tumor can give drop mets?: Metastatic disease near CSF:

Breast

Lun

Melanoma

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