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Top 10 Mass Top 10 Mass

Lesions Lesions - - Spine Spine
Alice Boyd Smith, Lt. Col., USAF MC Alice Boyd Smith, Lt. Col., USAF MC
Chief, Neuroradiology Chief, Neuroradiology
Department of Radiologic Pathology Department of Radiologic Pathology
Armed Forces Institute of Pathology Armed Forces Institute of Pathology
Washington, DC Washington, DC
& &
Assistant Professor of Radiology & Radiological Sciences Assistant Professor of Radiology & Radiological Sciences
Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences
Bethesda, MD Bethesda, MD
Objectives Objectives
Be able to identify lesions of the spinal Be able to identify lesions of the spinal
column in relation to their location. ( column in relation to their location. ( ie ie. .
intramedullary, extramedullary intradural, intramedullary, extramedullary intradural,
extradural) extradural)
Be able to identify imaging Be able to identify imaging
characteristics of spinal lesions that allow characteristics of spinal lesions that allow
for narrowing of the differential diagnosis. for narrowing of the differential diagnosis.
Spinal Lesions Spinal Lesions
Intramedullary: Intramedullary:
Ependymoma Ependymoma
Astrocytoma Astrocytoma
Hemangioblastoma Hemangioblastoma
Intradural/Extramedullary: Intradural/Extramedullary:
Nerve sheath tumor: Schwannoma, Nerve sheath tumor: Schwannoma,
neurofibroma neurofibroma
Meningioma Meningioma
Myxopapillary ependymoma Myxopapillary ependymoma
Lipoma/Dermoid/Epidermoid Lipoma/Dermoid/Epidermoid
Extradural: Extradural:
Degenerative: Synovial cyst, disc Degenerative: Synovial cyst, disc
Infection/abscess Infection/abscess
Metastasis
Intramedullary Intramedullary
Intramedullary Neoplasms Intramedullary Neoplasms
Account for 4 Account for 4- -10% of CNS 10% of CNS
tumors tumors
Most malignant: 90 Most malignant: 90- -95% 95%
gliomas gliomas
Expand cord Expand cord
Majority enhance Majority enhance
Biopsy Biopsy
Cysts a common finding Cysts a common finding
Tumoral Tumoral
Non Non- -tumoral tumoral
Astrocytoma
Ependymoma Ependymoma
Most common Most common
intramedullary spinal intramedullary spinal
neoplasm in adults neoplasm in adults
Arises from ependymal Arises from ependymal
cells of central canal cells of central canal
Most WHO grade II Most WHO grade II
Slow growing Slow growing
Compress rather than Compress rather than
infiltrate cord infiltrate cord
Grade II Ependymoma
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Ependymoma Ependymoma
CT: Canal widening & CT: Canal widening &
vertebral body scalloping vertebral body scalloping
Calcification not common Calcification not common
MR: MR:
T1: Iso T1: Iso- - or hypointense or hypointense
Enhance Enhance
T2: Iso T2: Iso- - or hyperintense or hyperintense
Cystic degeneration common Cystic degeneration common
Cap sign Cap sign
Average number vertebral Average number vertebral
segments involved: 3 segments involved: 3- -4 4
Ependymoma Ependymoma
Ependymoma Ependymoma Astrocytoma Astrocytoma
1/3 of spinal cord 1/3 of spinal cord
gliomas gliomas
Most common Most common
intramedullary tumor intramedullary tumor
in children in children
Holocord Holocord
involvement common involvement common
in children in children
Astrocytoma Astrocytoma
WHO: WHO:
Grade I: 75% Grade I: 75%
Grade IV: Uncommon (0.2 Grade IV: Uncommon (0.2- -
1.5%) 1.5%)
Imaging: CT Imaging: CT
Canal widening & vertebral Canal widening & vertebral
body scalloping body scalloping
Grade IV
Astrocytoma Astrocytoma
MR: MR:
Poorly defined margins Poorly defined margins
T1: Iso T1: Iso- - to hypointense to hypointense
T2: Hyperintense T2: Hyperintense
Enhancement Enhancement
Cysts common Cysts common
Average length of Average length of
involvement: 7 vertebral involvement: 7 vertebral
segments segments
Courtesy Steven Goldstein, MD
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Pilocytic Astrocytoma Pilocytic Astrocytoma Grade IV Grade IV
Ependymoma vs. Astrocytoma
No No Yes Yes Conus or filum Conus or filum
Patchy, irregular Patchy, irregular Focal, intense Focal, intense
homogeneous homogeneous
Enhancement Enhancement
Uncommon Uncommon Common Common Hemorrhage Hemorrhage
Ill Ill- -defined defined Well Well- -circumscribed circumscribed Morphology Morphology
Eccentric Eccentric Central Central Location Location
Pediatric Pediatric Adult Adult Population Population
Astrocytoma Astrocytoma Ependymoma Ependymoma
Koeller et al, RadioGraphics 2000;20:1721-1749.
Hemangioblastoma Hemangioblastoma
1 1- -7% of spinal cord 7% of spinal cord
neoplasms neoplasms
Cell of origin Cell of origin unknown unknown
WHO grade I WHO grade I
Most solitary Most solitary
Multiple Multiple think VHL think VHL
(approximately 1/3) (approximately 1/3)
Associated syrinx common Associated syrinx common
Hemangioblastoma Hemangioblastoma
Most intramedullary Most intramedullary
10 10- -15% along nerve 15% along nerve
roots roots
Occasionally exophytic Occasionally exophytic
Diffuse cord Diffuse cord
expansion expansion
Highly vascular Highly vascular
Rarely may be a source Rarely may be a source
of hematomyelia or of hematomyelia or
SAH SAH
Hemangioblastoma Hemangioblastoma
T1: Variable, most common T1: Variable, most common
isointense isointense
T2: Hyperintense T2: Hyperintense
May see flow voids May see flow voids
Intense enhancement Intense enhancement
May have surrounding May have surrounding
edema edema
Cyst formation common Cyst formation common
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Hemangioblastoma Hemangioblastoma Intramedullary Metastasis Intramedullary Metastasis
Rare Rare
Usually round/oval Usually round/oval
Fairly well Fairly well- -circumscribed circumscribed
Extensive edema Extensive edema
Enhance Enhance
Full craniospinal imaging Full craniospinal imaging
Intradural Extramedullary Intradural Extramedullary Intradural Extramedullary Intradural Extramedullary
Expansion of ipsilateral Expansion of ipsilateral
subarachnoid space subarachnoid space
Displacement of cord to Displacement of cord to
opposite side opposite side
Meningiomas & nerve Meningiomas & nerve
sheath tumors account sheath tumors account
for up to 90% for up to 90%
Meningioma
Nerve Sheath Tumor Nerve Sheath Tumor
2 histopathologic 2 histopathologic
types: types:
Schwannoma Schwannoma
Neurofibroma Neurofibroma
Neurofibromatosis Neurofibromatosis
type 1 type 1
Neurofibroma Neurofibroma
Neurofibromatosis Neurofibromatosis
type 2 Schwannoma type 2 Schwannoma
NF-2
Nerve Sheath Tumor: Imaging Nerve Sheath Tumor: Imaging
Difficult to separate by Difficult to separate by
imaging imaging
Tend to erode bone Tend to erode bone
T1: Isointense T1: Isointense
T2: Hyperintense T2: Hyperintense
Enhance Enhance
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Schwannoma Schwannoma vs vs Neurofibroma Neurofibroma
May hemorrhage May hemorrhage
Fatty degeneration Fatty degeneration
Rarely undergo Rarely undergo
malignant change malignant change
Noninfiltrative Noninfiltrative
Encapsulated Encapsulated
Hemorrhage Hemorrhage
uncommon uncommon
Rare fatty Rare fatty
degeneration degeneration
May progress from May progress from
benign to malignant benign to malignant
Tumor & nerve Tumor & nerve
fascicles intermixed fascicles intermixed
May be plexiform May be plexiform
Not Encapsulated Not Encapsulated
Courtesy of Tarik Tihan, MD PhD
Schwannoma Schwannoma
Neurofibroma Neurofibroma
Schwannoma Schwannoma
Schwannoma Schwannoma Neurofibromatosis Type 1 Neurofibromatosis Type 1
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Neurofibromatosis Type I Neurofibromatosis Type I
Other spinal Other spinal
findings: findings:
Dural ectasia Dural ectasia
Lateral meningocele Lateral meningocele
Arachnoid cyst Arachnoid cyst
Kyphoscoliosis Kyphoscoliosis
Intramedullary Intramedullary
astrocytomas astrocytomas
Lateral Meningocele Lateral Meningocele
Neurofibromatosis Type II Neurofibromatosis Type II
Other spinal findings Other spinal findings
Meningiomas Meningiomas
Ependymomas Ependymomas
Meningioma Meningioma
Majority in thoracic level Majority in thoracic level
Most common in middle Most common in middle- -
aged women aged women
>95% WHO grade I >95% WHO grade I
Majority intradural Majority intradural
3.5 3.5- -7% epidural 7% epidural
Lack of foraminal Lack of foraminal
extension extension
Meningioma Meningioma
CT: Hyperattenuation; avidly enhances CT: Hyperattenuation; avidly enhances
MR: MR:
T1 & T2: Isointense to spinal cord T1 & T2: Isointense to spinal cord
Avidly enhances post contrast Avidly enhances post contrast
Meningioma: Psammomatous Meningioma: Psammomatous
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Myxopapillary Ependymoma Myxopapillary Ependymoma
WHO grade I WHO grade I
Predilection for conus or Predilection for conus or
filum filum
Thought to arise from Thought to arise from
ependymal ependymal glia glia
Lobulated soft mass often Lobulated soft mass often
ecapsulated ecapsulated
Slow growing Slow growing
Occasionally extradural Occasionally extradural
Myxopapillary Ependymoma Myxopapillary Ependymoma
Subcutaneous Sacrococcygeal Subcutaneous Sacrococcygeal
Myxopapillary Ependymoma Myxopapillary Ependymoma
Myxopapillary Ependymoma Myxopapillary Ependymoma
Most common Most common
ependymoma subtype to ependymoma subtype to
hemorrhage hemorrhage
Superficial siderosis Superficial siderosis
Subarachnoid hemorrhage Subarachnoid hemorrhage
May have subarachnoid May have subarachnoid
dissemination dissemination
Intradural Lipoma Intradural Lipoma
Any portion of Any portion of
spinal cord can be spinal cord can be
involved involved
May have localized May have localized
dysraphism dysraphism
Etiology: Thought Etiology: Thought
to be premature to be premature
separation of separation of
cutaneous ectoderm cutaneous ectoderm
from from neuroectoderm neuroectoderm
during neurulation during neurulation
Intradural Lipoma Intradural Lipoma
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Epidermoid & Dermoid Epidermoid & Dermoid
Epidermoid: Epidermoid:
Squamous epithelium Squamous epithelium
only ectoderm only ectoderm
Symptoms typically 3 Symptoms typically 3
rd rd
to 5 to 5
th th
decade decade
Dermoid: Dermoid:
Squamous epithelium + Squamous epithelium +
dermal dermal adnexa adnexa only only
ectoderm ectoderm
Symptoms typically Symptoms typically
before age 20 before age 20
Epidermoid
Epidermoid & Dermoid Epidermoid & Dermoid
( (Epi)dermoids Epi)dermoids comprise 0.5 comprise 0.5- -
2% of spinal tumors 2% of spinal tumors
40% intramedullary 40% intramedullary
20% dermal sinus 20% dermal sinus
Dermoid 100% congenital Dermoid 100% congenital
Epidermoid 60% congenital Epidermoid 60% congenital
Epidermoid/Dermoid Epidermoid/Dermoid
CT: CT:
Epidermoid: Hypodense Epidermoid: Hypodense
Dermoid: Isodense +/ Dermoid: Isodense +/- -
calcification, fat calcification, fat
MRI: MRI:
Epidermoid: T1 isointense Epidermoid: T1 isointense
to CSF to CSF
Dermoid: T1 Hypo Dermoid: T1 Hypo- - to to
hyperintense hyperintense
Both T2 hyperintense Both T2 hyperintense
DWI: epidermoid DWI: epidermoid
hyperintense hyperintense
Epidermoid: Intramedullary Epidermoid: Intramedullary
Epidermoid Epidermoid Dermoid Dermoid
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Metastasis Metastasis
Any point along CSF pathway Any point along CSF pathway
Enhance Enhance
Patterns: Patterns:
Sugar coating Sugar coating
Single/multiple nodules Single/multiple nodules
Image entire neuroaxis Image entire neuroaxis
Zuckerguss Zuckerguss
Metastasis: Etiology Metastasis: Etiology
Hematogenous Hematogenous
Lung & breast Lung & breast
Drop metastasis Drop metastasis
Adults: Anaplastic Adults: Anaplastic
astrocytoma, GBM, astrocytoma, GBM,
ependymoma ependymoma
Children: Medulloblastoma, Children: Medulloblastoma,
germinoma, CPP/CPC germinoma, CPP/CPC
Extradural Extradural
Metastasis Metastasis
Vertebral body & Vertebral body &
posterior elements posterior elements
Solitary or multiple Solitary or multiple
Intervertebral Intervertebral discs discs
spared spared
May have May have
paraspinal paraspinal/epidural /epidural
mass mass
Lung Cancer
Metastasis Metastasis
Pancreatic Adenocarcinoma
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Lymphoma Lymphoma
Primary or Primary or
secondary secondary
B cell NHL most B cell NHL most
common common
Most common Most common
malignancy of malignancy of
epidural space epidural space
Degenerative: Synovial Cyst Degenerative: Synovial Cyst
Posterolateral to thecal sac Posterolateral to thecal sac
Adjacent to facet joint Adjacent to facet joint
90% lumbar spine 90% lumbar spine
Wall enhancement Wall enhancement
Synovial Cyst Synovial Cyst Hemorrhagic synovial cyst Hemorrhagic synovial cyst
Degenerative: Disk Degenerative: Disk
Protrusion Protrusion
Extrusion Extrusion
Sequestered Sequestered
Migrated Migrated
Disc Herniation Disc Herniation
Most common Most common
location: L4 location: L4- -5 or L5 5 or L5- -S1 S1
Sagittal imaging best Sagittal imaging best
at discriminating at discriminating
extrusion from extrusion from
protrusion protrusion
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Extruded Disc Extruded Disc Epidural Abscess Epidural Abscess
Adjacent infection, Adjacent infection,
bacteremia bacteremia, or direct , or direct
inoculation inoculation
S. S. aureus aureus most most
common common
Surgical Surgical
decompression decompression
Pyogenic Pyogenic Osteomyelitis Osteomyelitis
Peak incidence older Peak incidence older
patients patients
Lower lumbar spine Lower lumbar spine
most frequent most frequent
Initial: Subchondral Initial: Subchondral
bone adjacent to bone adjacent to
endplate endplate
Vertebral height loss Vertebral height loss
HIV: Osteomyelitis HIV: Osteomyelitis
Infectious: Tuberculous Infectious: Tuberculous
Osteomyelitis Osteomyelitis
Multiple vertebral Multiple vertebral
bodies bodies
Thoracic most Thoracic most
common common
Paravertebral Paravertebral
abscesses abscesses
Relatively intact Relatively intact
intervertebral intervertebral disc disc
Gibbus Gibbus deformity deformity
Tuberculosis Tuberculosis
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Fungal Spondylitis Fungal Spondylitis
May be May be
indistinguishable from indistinguishable from
TB TB
Lesser degree of Lesser degree of
paraspinal paraspinal involvement involvement
Disc space may be Disc space may be
spared spared
Vertebral deformity Vertebral deformity
less common less common
Spinal Lesions Spinal Lesions
Intramedullary: Intramedullary:
Ependymoma Ependymoma
Astrocytoma Astrocytoma
Hemangioblastoma Hemangioblastoma
Intradural/Extramedullary: Intradural/Extramedullary:
Nerve sheath tumor: Schwannoma, Nerve sheath tumor: Schwannoma,
neurofibroma neurofibroma
Meningioma Meningioma
Myxopapillary ependymoma Myxopapillary ependymoma
Lipoma/Dermoid/Epidermoid Lipoma/Dermoid/Epidermoid
Extradural: Extradural:
Degenerative: Synovial cyst, disc Degenerative: Synovial cyst, disc
Infection/abscess Infection/abscess
Metastasis
Summary Summary
Identification of the lesion as Identification of the lesion as
intramedullary, extramedullary intradural, or intramedullary, extramedullary intradural, or
extradural helps to narrow the differential extradural helps to narrow the differential
diagnosis. diagnosis.