Radiological imaging of spinal cord tumour.

Dr/ ABD ALLAH NAZEER. MD.

Spinal Cord Tumours:Extra-dural.Intra-dural extra-medullary Intra-medullary.

Spinal Cord Tumors are classified into:

Benign tumours.Cysts, and other benign tumour like masses.Malignant tumors.Metastasis.

Extra-dural tumors:. Occurs outside the spinal dura.. Typically arises from the osseous spine, intervertebral discs and adjacent soft tissues.. Imaging criteria. Focal displacement of the theca away from the mass.

Diagnosis: A thorough medical examination with emphasis on back pain and neurological deficits is the first step to diagnosing a spinal tumor. Radiological tests are required for an accurate and positive diagnosis.X-ray: Application of radiation to produce a film or picture of a part of the body can show the structure of the vertebrae and the outline of the joints. X-rays of the spine are obtained to search for other potential causes of pain, i.e. tumors, infections, fractures, etc. X-rays are not very reliable in diagnosing tumors.Computed tomography scan (CT or CAT scan): A diagnostic image created after a computer reads X-rays, a CT/CAT scan can show the shape and size of the spinal canal, its contents, and the structures around it. It also is very good at visualizing bony structures.Magnetic resonance imaging (MRI): A diagnostic test that produces three-dimensional images of body structures using powerful magnets and computer technology. An MRI can show the spinal cord, nerve roots and surrounding areas, as well as enlargement, degeneration, and tumors.

Extra-dural benign tumors:-Hemangioma.-Osteoid osteoma.-Osteochondroma.

Slowly growing benign tumour of capillary, cavernous or venous origin.Most common benign spinal neoplasm and approximately 50% of osseous hemangiomas are found in the vertebral bodies (thoracic especially). Most epidural hemangiomas occur secondarily as extension of expanding intra-osseous lesions.Most hemangioma are asymptomatic and discovered accidentally.

Hemangioma.

Radiological imaging of hemangiomas. Plain film:Findings include: prominent trabecular pattern, sclerotic vertebra with vertical trabeculae: Corduroy sign lytic calvarial lesions with spoke-wheel appearance irregular and lytic in long bones, with a honeycomb appearance.CT: Usually as an incidental finding, especially in the vertebrae.Better visualization of thickened vertical trabeculation (polka-dot appearance).MRI: Signal intensity is somewhat variable, depending largely on the amount of fat content.T1: high is more common (fat rich).intermediate to low signal intensity is seen in fat poor hemangioma.T2: high.T1 C+ (Gd): enhancement is often present.

Hemangioma.

Hemangioma.

Hemangioma.

MRI: An epidural component of hemangioma of the LI vertebra with a lesion of its arch pedicle (А); hemangioma of ThXI vertebra, spreading paravertebrally and to the right pedicle of its arch (B).

Sagittal T2-weighted image showing a T3 haemangioma with epidural extension compressing the spinal cord.

Osteoid osteoma is a small, benign osteoblastic tumor consisting of a highly vascularized nidus of connective tissue surrounded by sclerotic bone. The nidus is usually < 1.5 cm. 10% occur in the spine, usually at the site of neural arch. The classical clinical presentation of spinal osteoid osteoma is that of painful scoliosis. Other clinical features include nerve root irritation and night pain. Osteoid osteoma has characteristic computed tomography (CT) findings( dense sclerosis surrounding a lytic lesion that has a central calcific nidus). Because magnetic resonance imaging (MRI) findings of the osteoid osteomas causing intense perinidal edema can be confusing, these patients should be evaluated with clinical findings and other imaging techniques. Nidus typically low to intermediate signal at T1 and T2WI.Bone Scan. Focal activity on both intermediate and delayed images.

osteoid osteoma.

osteoid osteoma.

Osteochondromas are among the most frequent of benign bone tumors. They occur either as solitary lesions or as multiple osteochondromatosis, they arises through lateral displacement of the epiphyseal growth cartilage, results in a bony excrescence with cartilaginous –covered cortex and a medullary cavity. However, the spine is affected by these tumors in only 2% to 7%. Osteochondromas are commonly seen in the second or the third decade of life. Spinal osteochondromas present as asymptomatic palpable masses or more unusually, with neurological deficit, because the majority of the lesions grow out of the spinal canal and usually do not cause symptoms. But nerve root compression is an uncommon manifestation of exostosis developed within the intra-spinal canal. Neurological compromise is more common in the patient.

Radiological imaging of osteochondroma.

X-Ray films: A sessile or pedunculated bone like projection.CT Scan: The cortex of the parent bone flares into the cortex of the osteochondroma with which it is contiguous. The cartilaginous cap often contains calcification.MRI: Show mixed signal on both T1 and T2WI. Cartilage in the cap has high signal intensity on T2-weighted, spin-echo MRI scans. This characteristic allows measurement of the cap, which is an important consideration in malignant transformation.

Osteochondroma at upper cervical cord in a patient with multiple exostoses.

Osteochondroma of rib with neural foraminal extension and cord compression

T2W MRI cervical spine showing the C3 osteochondroma compressing the cord, (b) CT axial section showing the pedunculated osteochondroma, (c) Post op MRI T2WI showing the cord contusion, (d) Histopathological examination showing cartilaginous cap with underlying irregular bony trabeculae.

Uncommon extra-dural masses.

Cysts, and other benign tumour like masses.-Eosinophilic granuloma.-Epidural lipomatosis.-Non-neoplastic cysts. Synovial and arachnoid cyst.

Eosinophilic granuloma(EG) Langerhans Cell Histiocytosis.A benign non-neoplastic disorder, self limiting process of well demarcated bone resorption. 1st- 2nd decade, Male to female ratio 2:1 Spine involvement in 10-15% of EG.A classic cause of a single collapsed vertebral body as a lytic lesion without surrounding sclerosis.Associated with 2 systemic diseases:-Hand-Schuller-Christian disease.- Letterer-Siwe disease.

Radiological imaging finding:

X-Ray: Vertebral plana.CT Scan: Lytic lesions or collapse of the vertebral bodies(Vertebra plana).MRI: decreased signal intensity on T1-weighted images and high signal intensity on T2-weighted sequences. The lesion may enhance after the administration of a gadolinium-based contrast agent.

Eosinophilic granuloma.

Eosinophilic granuloma.

Thoracic vertebral eosinophilic granuloma.

Epidural lipomatosis.Epidural lipomatosis refers to excessive accumulation of fat within the epidural space, such that the thecal sac is compressed.Clinical presentationPatients may present with back pain resembling that of a disc herniation. In severe cases, symptoms of canal stenosis are produced.

Radiographic featuresMRI spineThere is a often generalized excess of fat seen in the extradural space. As a result the dural sac can appear narrowed or even resemble a "Y" shaped configuration.Signal characteristics follow fat on all sequences:T1 - high signalT1 (FS) - shows fat suppressionT2 - high signal

Epidural lipomatosis.

spinal epidural lipomatosis. The thecal sac has the typical "Y" configuration on axial section at the L5 level.

Epidural dorsal angiolipoma.

SYNOVIAL CYST.A synovial cyst is a relatively uncommon cause of spinal stenosis in the spine. It is a benign (noncancerous) condition and the symptoms and level of pain and discomfort can remain stable for many years. A synovial cyst is a fluid-filled sac that develops as a result of degeneration of the joints in the spine. Since it developsas a result of the aging process, it is rarely seen in an individual less than 45 years of age and is most commonly seen in a person over the age of 65. The cyst causes compression of the nerves in the spinal canal and this causes the patient to experience symptoms of spinal stenosis. Spinal stenosis is defined as narrowing of the space for the spinal nerves.

A synovial cyst is best visualized on an MRI scan of the spine. It shows up as a bright signal on the T2 portion of the scan. It often has the same appearance as the cerebrospinal fluid that surrounds the nerves in your spinal canal.Plain X-rays of the spine, including flexion/extension (bending) X-rays of the spine, are also performed to rule out any associated instability of the spine. It is very important to check for spinal instability as the involved joint often has an accompanying degenerative spondylolithesis. A spondylolithesis is defined as a slippage of one vertebrae over another and it indicates that the joint is unstable or incompetent.CT Scan: Show hypo to hyperdense area compared to the ligamentum flavum and these changes are associated with facet joint degeneration.

Radiological imaging finding:

Retrodental Cervical Synovial Cyst MRI.

Extradural arachnoid cyst.CSF-filled outpouching of arachnoid that protrude through a dural defect.Spinal extradural arachnoid cysts are uncommon expanding lesions. Idiopathic arachnoid cysts are not associated with trauma or other inflammatory insults. If they enlarge, they usually present with progressive signs and symptoms of neural compression. Spinal extradural arachnoid cysts are a rare cause of spinal cord compression. These cysts most commonly occur in the middle to lower thoracic spine (65%) but also have been reported in the lumbar and lumbosacral (13%), thoracolumbar (12%), sacral (7%), and cervical regions (3%). Cyst enlargement can result in symptomatic spinal cord compression.

CT scan is another examination method often used for the diagnosis of Tarlov cyst. Unenhanced CT scans may show widened interpedicular distance, scalloping of vertebral bodies or pedicle thinning and cystic masses that are have the same density with CSF. CT Myelogram is minimally invasive, and could be employed when MRI cannot be performed on patient.

MRI is considered the imaging study of choice in identifying arachnoid cysts which appears CSF-equivalent extra-dural mass that cause spinal cord compression. MRI provides better resolution of tissue intensity, absence of bone interference, multiplanar capabilities, and is noninvasive. Plain films may show bony erosion of the spinal canal. If MRI made with a contrast medium:The signal in the cyst is the same as in the dural bag.

Radiological imaging finding:

Spinal extradural arachnoid cyst.

Spinal extradural arachnoid cyst

Primary malignant tumour:Chordoma.Lymphoma.Sarcoma.Osteogenic sarcoma.Chondrosarcoma.Ewing sarcoma.Plasmacytoma.Multiple Myeloma.Malignant Schwannoma.Metastasis.

Primary Extradural Tumours and metastasis of the Spine.

ChordomaChordoma is a rare slow-growing neoplasm thought to arise from cellular remnants of the notochord. Grossly, locally invasive lobulated gelatinous –appearing masses. Typically, arise in the midline of the spinal column at any location from the clivus to the coccyx.

Radiographic features:CT: Centrally located, well-circumscribed destructive lytic lesion, sometimes with marginal sclerosis expansile soft-tissue mass (usually hyper-attenuating relative to the adjacent brain, however inhomogeneous areas may be seen due to cystic necrosis or hemorrhage; the soft-tissue mass is often disproportionately large relative to the bony destruction)MRI: T1 intermediate to low signal intensity, small foci of hyperintensity (Intratumoral hemorrhage or a mucus pool).T2: most exhibit very high signal.T1 C+ (Gd): heterogeneous enhancement with a honeycomb appearance corresponding to low T1 signal areas within the tumour.GE (gradient echo): confirms hemorrhage if present with blooming.

Sacrococcygeal Chordoma.

Sacral Chordoma.

Sacrococcygeal chordoma.

Lymphoma of the spinal cord:Lymphoma of the spinal cord is an uncommon manifestation of lymphoma. Although lymphoma more commonly involves the vertebral body (vertebral body tumours) or epidural compartment, intramedullary lymphoma does rarely occur.

Radiographic features:The most common intramedullary location is the cervical cord, followed by the thoracic cord then the lumbar cord . Most are solitary lesions, however there may be multiple lesions throughout the spinal cord.MRI: Although spinal cord expansion is usually present, in some patients there is relatively minimal enlargement of the cord. The lesions are generally poorly defined and tumoural cysts are generally not a feature and secondary syringomyelia is rare. Lymphoma usually does not have a hemorrhagic component Reported signal characteristics include:T1: isointense to spinal cordT2: hyperintense (this is in contrast to the characteristic low T2 signal intensity that is seen in intracranial lesions)T1 C+ (Gd): usually solid and homogeneous enhancement.CT: Non specific bone destruction and hyperostosis.

Lymphoma of the spine

Arrows point to lymphoma causing epidural compression. Lymphoma of the spines.

Osteosarcoma:

Osteosarcomas are malignant bone forming tumours and the second most common primary bone tumour after multiple myeloma. They account for ~20% of all primary bone tumours.

primary osteosarcoma: typically occurs in young patients (10-20 years) with 75% occurring before the age of 20; which is logical because the growth centers of the bone are more active during the puberty to adolescence time period. Therefore the epidemiology can be easily understood. For less clear reasons, there is a slight male predominance.secondary osteosarcoma: occurs in the elderly, usually secondary to malignant degeneration of Paget's disease, extensive bone infarcts or post radiotherapy for other conditions.

Radiographic featuresPlain film: Conventional radiography continues to play an important role in diagnosis. Typical appearances of conventional high grade osteosarcoma include: medullary and cortical bone destruction wide zone of transition, permeative or moth-eaten appearance aggressive periosteal reaction, sunburst type .CT: The role of CT is predominantly in assisting biopsy and staging, but adds little to plain x-ray films.MRI:T1: soft tissue non-mineralized component: intermediate signal intensity

mineralized/ossified components: low signal intensity, peri-tumoural edema: intermediate signal intensity scattered regions of hemorrhage will have variable signal (see ageing blood on MRI) enhancement: solid components enhance

T2: soft tissue non-mineralized component: high signal intensity mineralized/ossified components: low signal intensity peri-tumoural edema: high signal intensity.

Telangiectatic osteosarcoma.

Osteosarcoma of the Spine:

osteosarcoma of the sacrum.

Chondrosarcoma is a malignant tumor that produces cartilage matrix. Primary chondrosarcoma is very uncommon, arises centrally in the bone, and is found in children. Secondary chondrosarcoma arises from benign cartilage defects such as osteochondroma or enchondroma.Imaging show lytic lesions with sclerotic and variable matrix calcification occurring in rings and arc.CT scanning may be useful for detecting subtle calcifications in the matrix when the diagnosis is in doubt. MRI: The investigation of choice for assessing the extent of a chondrosarcoma Helps delineate the extent of soft-tissue involvement Important for preoperative planning and for confirming or diagnosing recurrence at a surgically treated site

Chondrosarcoma.

Chondrosarcoma along the left posterior paraspinal location.

Spinal Chondrosarcoma.

Chondrosarcoma of the lower cervical spine.

Plasmacytoma and multiple myeloma.Multiple myeloma is the most common primary malignant bone neoplasm in adults, and results in a wide range of radiographic abnormalities. Four main patterns are recognised:disseminated form: multiple defined lesions: predominantly affecting the axial skeletondisseminated form: diffuse skeletal osteopenia solitary plasmacytoma: single large/expansile lesion most commonly in a vertebral body or in the pelvisosteosclerosing myeloma.The spine is the most common location.

X-Ray Films: The vast majority of lesions are purely lytic, sharply defined/punched out with endosteal scalloping when abutting cortex. In only 3% of patients are the lesions sclerotic.CT: CT does not have a great role in the diagnosis of disseminated multiple myeloma, however it may be useful to determine the extent of extra-osseous soft tissue component in patients with a large disease burden. MRI: MRI is generally more sensitive in detecting multiple lesions compared to the standard plain film skeletal survey. Infiltration and replacement of bone marrow is exquisitely visualized, and newer scanners are able to perform whole body scans for this purpose which has been shown to be superior to both CT and skeletal surveys.

Radiographic features:

Multiple myeloma.

Two cases of multiple myeloma.

Spinal metastases:Spinal metastases is by far the most common extra-dural malignant neoplasm. Metastatic disease have any of the following: vertebral metastases (94%)

may have epidural extensionintradural extramedullary metastases(5%)intramedually metastases (1%).In adults, the initial site is the vertebral body, usually the posterior aspect.Most metastasis arises from the, breast: 22%, lung: 15%, prostate: 10%, lymphoma: 10%, kidney: 7%, gastrointestinal tract: 5%, melanoma: 4%, unknown: 4%, others: 24%.

Plain radiography is used to show erosion of the pedicles or the vertebral body. Owl-eye erosion of the pedicles in the anteroposterior (AP) view of lumbar spine is characteristic of metastatic disease and is observed in 90% of symptomatic patients. However, radiologic findings become apparent only when bone destruction reaches 30-50%. Osteoblastic or osteosclerotic changes are common in prostate cancer and Hodgkin disease; they are occasionally seen in breast cancer and lymphoma. CT scanning is useful in determining the integrity of the vertebral column.MRI- Is very sensitive in detecting vertebral metastasis. The most common pattern is multifocal lytic lesions characterized by low signal at the T1WI and of high signal at the T2WI.Scintigraphy- Very sensitive although non-specific in detecting bone metastasis.

Radiographic features.

Spine metastasis.

Spinal metastases.

C2 metastasis in a 60-year-old male patient with renal cell carcinoma.

Intradural extramedullary spinal tumours.Intradural extramedullary neoplasms are located outside the spinal cord but within the dural sheath.Schwannomas are the most common intradural extramedullary spinal lesions (30% cases), followed by meningiomas (25% cases).In the pediatric population, the most common intradural extramedullary neoplasms are leptomeningeal metastases resulting from primary brain tumours.

Benign tumours: spinal schwannoma, spinal meningioma, spinal neurofibroma spinal paraganglioma and myxopapillary ependymomaCysts and other benign tumourlike masses:

spinal lipoma, intradural spinal lipoma, spinal epidermoid cyst, spinal dermoid cyst spinal neurenteric cyst and spinal arachnoid cyst.

Malignant tumours: spinal leptomeningeal metastases.

Spinal schwannoma and neurofibroma:Spinal schwannomas are schwannomas arising from nerves within the spinal canal. They are the most common intradural extramedullary spinal tumours, representing 30% of such lesions. They are most frequently seen in the cervical and lumbar regions, far more frequently than in the thoracic spine.

In general schwannomas appear as rounded lesions, often with associated adjacent bony remodelling. when large they may either align themselves with the long axis of the cord, forming sausage shaped masses which can extend over several levels, or may protrude out of the neural exit foramen, forming a dumb-bell shaped mass. Plain X-Ray film: Show erosions of the pedicle with enlarged neural foramina.CT Scan: Shows bone erosion, and the density is hypo to slightly hyperdense.MRI: T1 - 75% are isointense, 25% are hypointense.T2 - more than 95% are hyperintense, often with mixed signal. T1 C+ (Gd) - virtually 100% enhance.

Spinal schwannoma.

Cervical Spinal schwannoma.

Spinal neurofibroma.

Spinal neurofibroma.

Spinal meningioma.Meningiomas arising from the coverings of the spinal cord represent a minority of all meningiomas (approximately 12%5) but are the second most common intradural extramedullary spinal tumour representing 25% of all such tumours. Despite usually being small, due to the confines of the spinal canal they can result in significant neurologic dysfunction. spinal meningiomas are also not distributed evenly along the canal: cervical spine - 15% thoracic spine - 80% lumbosacral spine: uncommon. Meningiomas are often located posterolaterally in the thoracic region and anteriorly in the cervical region. Most meningiomas are solitary lesions (98%). Multiple meningiomas are most often associated with NF2.

Plain film: usually normal, rarely bone erosion or calcificationCT (non-contrast)Isodense or moderately hyperdense mass hyperostosis may be seen but is not as common as in the intracranial forms.calcification may be presentMRI: well-circumscribed, broad-based dural attachment dural tail signsThey share similar signal characteristics to intracranial meningiomas:T1

isointense to slightly hypointense.may have a heterogenous texture.

T2 - isointense to slightly hyperintense.T1 C+ (Gd) - moderate homogeneous enhancement.Occasionally, densely calcified meningiomas are hypointense on T1 and T2, and show only minimal contrast enhancement.

Radiographic features.

Spinal meningioma.

Upper cervical spinal meningioma.

Spinal paraganglioma.

Spinal myxopapillary ependymoma.

Intradural spinal lipoma.

Spinal epidermoid cyst.Spinal epidermoid cysts are cystic tumours lined by squamous epithelium. Unlike dermoid cysts, they do not contain skin appendages (hair follicles, sweat glands, sebaceous glands).They are usually extramedullary but rarely can be intramedullary . They may be congenital or acquired. Plain film: In advanced cases, there may be scalloping of the vertebral bodies or a scoliosis.CT: well circumscribed mass hypodense (similar to CSF), minimal to no enhancement calcification is rareMRI: well-defined lesion, generally no perilesional edema, Although variable, typical signal characteristics include:T1: hypointentse (similar to CSF)T2: hyperintense (similar to CSF)FLAIR: hyperintense compared to CSFT1 C+ (Gd): no enhancement or a thin rim of capsular enhancementDWI: bright (with corresponding low intensity on ADC map).

Spinal dermoid cyst.Spinal dermoid cysts are uni or multilocular cystic tumours lined by squamous epithelium containing skin appendages (hair follicles, sweat glands, sebaceous glands) . They are congenital in origin.Forty percent are intramedullary, and 60% are extramedullary .Radiographic features: Spinal dermoid cysts are most often located in the lumbosacral region (60%) and cauda equina (20%) . They are rarely found in the cervical or thoracic spine. They have variable imaging appearances, but commonly appear as a mass of CSF density/intensity with fat density/intensity components .CT: well defined mass, isodense to CSF, often with hypodense components (fat)calcification may be present minimal enhancement may be demonstrated widening of the spinal canal, flattening of the pedicles and laminae and osseous erosions may be demonstratedMRI: Signal intensity may be homogeneous or heterogeneous. Typical signal characteristics include:T1: hypo or hyperintense

hypointense: water contenthyperintense: due to the presence of fatty secretions of sebaceous glands

T2: hyperintenseFLAIR: hyperintense compared to surrounding CSFT1 C+ (Gd): no enhancement or mild rim enhancementDWI: less likely to show diffusion restriction than epidermoid.

Spinal dermoid cyst.

Spinal arachnoid cyst:Spinal arachnoid cysts are relatively uncommon and may be either intra-dural (type III meningeal cyst) or extra-dural (type IA meningeal cyst). Radiographic featuresGeneral: Most primary intradural spinal arachnoid cysts are dorsal to the cord. They occur at the following locations: thoracic: 80%, cervical: 15%, lumbar: 5%Secondary spinal arachnoid cysts can be located anywhere. MRI: As the cysts follow the intensity of CSF and their walls are generally not visible, they may not be identified unless the cord is displaced.T1: CSF intensityT2: CSF intensity, may even be brighter than CSF on account of no signal loss from pulsation/flowT1 C+ (Gd): no contrast enhancement phase-contrast imaging: decreased CSF flow within the cyst. DWI: No evidence of restricted diffusion

Intra-dural Spinal arachnoid cyst.

Intra-dural Spinal arachnoid cyst.

Intradural lymphoma.

Intradural extramedullary metastases:Intradural extramedullary metastases are rare and only accounts for approximately 5% of spinal metastases. Presentation is highly variable. As the most commonly affected site is the lumbosacral spine symptoms and signs include back or radicular pain, weakness, paresthesia, gait disturbance, cauda equina syndrome and symptoms/signs of meningeal irritation. Radiographic features:Plain films and CT are inadequate for the assessment of possible leptomeningeal metastatic disease, and in these cases, MRI is required. MRIMRI without contrast may be normal, and thus when suspected contrast should be administered. Typical signal characteristics include:T1: thickened nerve roots or nodular lesions that are isointense with the spinal cord may be seen.T2: cord edema may be seen with more extensive disease, especially if there is an intramedullary component.T1 C+ (Gd)

enhancing tumour nodules on the spinal cord, nerve roots or cauda equina.“sugar coating” of the spinal cord and nerve roots.

Multiple intramedullary extradural spinal cord metastases.

Multiple intramedullary extramedullary spinal cord metastases.

Intramedullary spinal tumours.Intramedullary spinal tumours are rare, representing 4-10% of all CNS tumours. They account for 20% of all intraspinal tumours in adults and 35% of all intraspinal tumours in children .Classification: They can be classified according to many ways:intramedullary neoplastic lesion:

glial neoplasms: 90-95% of all intramedullary tumours spinal ependymoma: 60% of all glial spinal cord tumours spinal astrocytoma: 33% of all glial spinal cord tumoursspinal ganglioglioma: 1% of all glial spinal cord tumours

non-glial neoplasms:highly vascular lesions

spinal hemangioblastoma and spinal paragangliomaother rare lesions

intramedullary metastasisprimary lymphoma of the spinal cordspinal primitive neuroectodermal tumoursolitary fibrous tumour

intramedullary benign masses: Syringohydromyelia, MS , transverse myelitis arachnoid and ependymal cyst.

Syringohydromyelia.Syringohydromyelia refer to any pathologic CSF-containing cord cavity and can mimic spinal cord tumour.Imaging shows focal or diffuse cord expansion.CT Scan: Show distinct area of low density within the cord without enhancement at the post-contrast study.MRI: Cystic area within the cord which appears of low signal at the T1WI and of bright signal at the T2WI. No enhancement seen within the lesion at post-contrast study.

Two cases of Syringohydromyelia.

Multiple sclerosis.Spinal cord may be the earliest affected by MS plaques.Plaques occur preferentially in the dorsolateral cord and do not respect boundaries between grey and white matter.More predominant on the female.Early there is a predilection for the cervical cord.MRI: The most common finding on T2WI of one or more elongated, poorly marginated, hyperintense intramedullary lesions. The foci may has mass effect and enhance at the post-contrast study. Focal or generalized mild cord atrophy may be present.

Multiple Sclerosis.

Multiple Sclerosis with disease activity.

Transverse Myelitis (TM).)

Focal inflammatory disorder of the spinal cord resulting in motor, sensory and autonomic dysfunction.Imaging findings:

More than 2/3 of the cross sectional area is involved.Focal enlargement.T2WI hyperintensityEnhancement + / -

Two forms of TM: Acute partial transverse myelitis - APTMLesions extending less than two Segments. These patients are at risk of developing MS.Acute complete transverse myelitis - ACTMLesions extending more than two Segments

ATM on T2WI, CE-T1WI and STIR.

Spinal Intramedullary Neuroepithelial (Ependymal) Cyst.

cystic intramedullary arachnoid cyst.

Spinal ependymoma.Spinal ependymomas are the most common intramedullary neoplasm in adults, comprising 60% of all glial spinal cord tumours. They are the second most common intramedullary neoplasm in the pediatric population, representing 30% of pediatric intramedullary spinal neoplasms.Peak incidence is in the fourth decade, with 39 years being the mean age at presentation. Males are more commonly affected than females.There is an increased incidence with neurofibromatosis type 2. 6 histological subtypes are recognised:cellular (the most common intramedullary type).Papillary.clear cell.Tanycytic.Myxopapillary.

virtually always located along the filum terminale with occasional extension into the conus medullaris

melanotic (the least common type).

CT:CT may demonstrate non-specific canal wideningisodense or slightly hyperdense compared with normal spinal cordintense enhancement with iodinated contrast.MRI: Typical signal characteristics:T1: most are isointense to hypointense; mixed signal lesions are seen if cyst formation, tumour necrosis or hemorrhage has occurredT2: hyperintense

peritumoural edema is seen in 60% of casesassociated hemorrhage leads to the “cap signs” (a hypointense hemosiderin rim on T2 weighed images) in 20-33% of cases. The cap sign is suggestive of but not pathognomonic for ependymoma as it may also be seen in hemangioblastomas & paragangliomas.

T1 C+ (Gd): virtually all enhance strongly, somewhat inhomogeneously.

Radiographic features:

An ependymoma of the cervical spine on MRI T2 image (left) and T1 with contrast (right). Note the associated syrinx seen on T2, contrast enhancing mass on T1, and overall expansion of the cord.

Large filum terminalis ependymoma (arrows).

Intramedullary cervical ependymoma (red arrows).

Spinal astrocytoma.

Spinal astrocytomas are the second most common spinal cord tumour overall, representing 40% of intramedullary tumours . They account for 60% of pediatric intramedullary tumours, making them the most common spinal cord tumour in children Spinal cord astrocytomas generally have a lower histologic grade than astrocytomas in the brain. In adults, 75% are low-grade neoplasms. Up to 25% are anaplastic astrocytomas. Glioblastoma multiforme represent only 0.2-1.5% of spinal cord astrocytomas. In children younger than 3, 80% are either grade I or II. All astrocytomas are characterised by hypercellularity and the absence of a surrounding capsule. In contrast to cord ependymomas, a cleavage plane is not present in most intramedullary spinal astrocytomas. Most common at cervical cord. High grade tumours are more likely to demonstrate extensive leptomeningeal spread seen in up to 60% of spinal cord glioblastomas.

A fibrillary astrocytoma of the cervical spine on T2 (left) and T1 with contrast (right). Note the indistinct cord edema, expansion and partial contrast enhancement

Spinal astrocytoma.

Spinal ganglioglioma are rare, comprising 1.1% of all spinal cord neoplasms . They are more frequent in children, representing 15% of intramedullary neoplasms in the pediatric age group.

Spinal hemangioblastoma.Spinal hemangioblastomas are the third most common intramedullary spinal neoplasm, representing 2-6% of all intramedullary tumours.

Angiography: A densely enhancing nidus with associated dilated arteries and prominent draining veins is characteristic for a hemangioblastoma.CT: On non-contrast CT They may be seen as a soft tissue nodule often with a prominent hypodense cyst-like component. Contrast administration results in vivid enhancement of the solid component. MRI: Although they usually appear as discrete nodules, there can be diffuse cord expansion. An associated tumour cyst or syrinx is common (50-100%) . T1: variable relative to normal spinal cord.

hypo-isointense most common, and difficult to identifyhyperintense (25%)

T2: iso-hyperintensefocal flow voids especially in larger lesionssurrounding edema and associated syrinx are usually seenhemosiderin capping may be present

T1 C+ (Gd): the tumour nodule enhances vividly.

A hemangioblastoma of the thoracic spine on T1 with contrast in sagittal (left) and axial sections (right). Note the enhancing tumour nodule with associated cyst.

Spinal cord hemangioblastoma is seen at L1-2 (arrowed).

Lymphoma of the spinal cord.Lymphoma of the spinal cord is an uncommon manifestation of lymphoma.

Radiographic featuresThe most common intramedullary location is the cervical cord, followed by the thoracic cord then the lumbar cord . Most are solitary lesions, however there may be multiple lesions throughout the spinal cord.MRI:Although spinal cord expansion is usually present, in some patients there is relatively minimal enlargement of the cord. The lesions are generally poorly defined and tumoural cysts are generally not a feature and secondary syringomyelia is rare. Lymphoma usually does not have a hemorrhagic component .Reported signal characteristics include:T1: isointense to spinal cordT2: hyperintense (this is in contrast to the characteristic low T2 signal intensity that is seen in intracranial lesions)T1 C+ (Gd): usually solid and homogeneous enhancement

Primary intramedullary spinal cord lymphoma.

Intramedullary spinal metastasis.Intramedullary spinal metastases are rare, occurring in 0.9-2.1% of autopsied cancer patients. They represent 8.5% of central nervous system metastases and account for 5% of all intramedullary lesions. They are less common than leptomeningeal metastases.

Radiographic features: CT (contrast enhanced)Hypervascular metastases may rarely be seen as enhancing intraspinal lesions.MRILesions are usually well-defined and typically produce cord expansion over several segments. In contrast to primary intramedullary neoplasms, associated cysts are rare.Typical MRI signal characteristics are:T1: hypointenseT2: hyperintense

prominent edema commonly surrounds the tumour noduleT1 C+ (Gd): avid homogeneous enhancement.

Intramedullary spinal metastasis.

Intramedullary spinal metastasis.

Thank You.