MRI Case DiscussionMacroadenoma, Neurogenic Spinal Tumors and

Spinal Ependymoma

Muhammad Bin Zulfiqar PGR IV SIMS/SHL Alnoor Diagnostic / New Radiology Department

Case 1

• H/O headache, forgetfulness, visual abnormalities.

• Known case of hypothyroidism.

• Snowman sign

Imaging Findings

• There is 3.4 x 3.3 x 2.8 cm sized sellar / suprasellar / right parasellar mass

• Showing intense enhancement on postgadolinium images.

• Mass is encasing intracavernosal part of both ICA.• Right parasellar mass is causing splaying of

interpeduncular cistern at midbrain level and• Compressing upon adjacent temporal lobe as well.

The mass is also compressing upon optic chiasma

Differentials

• Pituitary Macroadenoma• Meningioma• Craniopharyngioma• Chordoma / Chondrosarcoma• Pituitary Mets

Our Diagnosis

• Pituitary Macrodenoma

Pituitary Macroadenoma

• Tumor > 10 mm.• 25-60 years.• Extension– Sellar– Suprasellar– Parasellar

Classification of Pituitary Tumors

• ANATOMICAL SIZEMicroadenoma(<10 mm)Macroadenoma(>10 mm)

Classification of Pituitary Tumors

ACCORDING TO CLINICAL SYMPTOMSFunctionalNon functional

Classification of Pituitary Tumors

ACCORDING TO EXTENT OF EXPANSION OR EROSION OF SELLA

Grade 0: Intrapituitary microadenoma with normal sellar appearance

Grade I: Normal-sized sella with asymmetric floorGrade II: Enlarged sella with an intact floorGrade III: Localized erosion of sellar floorGrade IV: Diffuse destruction of floor

Classification of Pituitary Tumors

ACCORDING TO SUPRASELLAR EXTENSION

Type A: Tumor bulges into the chiasmatic cisternType B: Tumor reaches the floor of the 3rd ventricleType C: Tumor is more voluminous with extension

into the 3rd ventricle up to the foramen of MonroType D: Tumor extends into temporal or frontal

fossa

Case 2

• 23 years old lady with h/o of severe back pain radiating to right leg.

Imaging Findings

• There is 16 x 1.6 cm sized intradural extramedullary mass extending from T-11 down to L4-5 vertebra.

• Causing right posterolateral displacement• Compression upon lower thoracic cord /

conus medullaris. • Shows intense enhancement on

postgadolinium images.

Differentials

• Ependymoma• Astrocytoma• Dermoid • Infarct• Hematoma• Meningioma• Metastasis• Subdural empyema

Our Diagnosis

• Ependymoma

Spinal Tumors

• Extradural• Intradural extramedullary• Intramedullary

Case 3

• 35 years old lady with h/o backache, both lower limb weakness, and urinary incontinence.

• Dumbbell Sign

Imaging Findings• There is 7.2 x 5.3 cm size heterogeneous intensity right

paravertebral mass at T3-4 level showing intraspinal / intradural extension.

• Causing left anterior lateral displacement• Compression upon thoracic cord. • The described mass is causing significant expansion of right exiting

neural foramina • Shows heterogeneous enhancement on post gad images with

multiple areas of necrosis. • The mass is also involving the right paraspinal muscles• Marrow abnormality is seen in T3-4 level with sparing of

intervertebral discs.

Differentials

• Neurofibroma• Neuroblastoma• Ganglioneuroma• Meningioma• Schwannoma

Our Diagnosis

• Neurogenic tumor most probabally Malignant Peripheral Nerve Sheath Tumor with differential of Schwannoma.

Malignant Peripheral Nerve Sheath Tumors

• Malignant peripheral nerve sheath tumours (MPNSTs) are forms of peripheral nerve sheath tumours and comprise of malignant forms of neurofibromas andschwannomas.

• They can either arise de-novo or de-differentiate from an existing neurofibroma or schwannoma.

Imaging Features

• The larger the lesion, the more likely for it to be malignant

• Irregular borders (although most MPNSTs can have well defined margins)

• Rapid growth on interval imaging

Imaging Features

• T1: usually isointense to muscle heterogeneous signal on T1 (if present) may useful in differentiating from a neurofibroma 3

• T2: can have low signal due to high collagen content or high signal due to necrosis

• Heterogeneous contrast enhancement.

Schwannomas

• Schwannomas are benign tumours of Schwann cell origin

• Most common tumour of peripheral nerves.• Peak age is 5-6th decade.• Most commonly solitary• If Multiple---NF2

General Imaging Features

• Cystic and fatty degeneration are common • The larger a schwannoma is, the more likely it

is to show heterogeneity • Hemorrhage occurs in 5% of cases • calcification is rare• peripheral arachnoid cysts may be associated• peritumoural odema may be seen

MRI Features

• T1: isointense or hypointense• T2: hyperintense• T1 C+ (Gd): intense enhancement

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