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66 Cards in this Set

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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.
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?

Intradural extramedullary

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


Vascular lesions

Developmental lesions

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?
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?
Which ones?
1) Hemangioblastoma

2) Astrocytoma

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

Pancreatic cysts

Retinal angiomas
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?
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?
What is the most common primary cord tumor?
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?
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?



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)?

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

2) Meningioma

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


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?
What patients get frequent spinal tumors.
What spinal tumors do they get in NF-2?

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

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




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