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66 Cards in this Set
- Front
- Back
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.
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ok
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What is the first thing to do when seeing a lesion within the spinal cord?
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Determine what space you are in
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What are the choices?
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Intramedullary
Intradural extramedullary Extradural |
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Why do it this way?
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You only have to know three entities for each of those areas, simplifying your ddx greatly!
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What if you still aren't sure whether you have covered the full ddx for a given lesion?
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Just throw in Sarcoid and Lymphoma, and you are DONE!
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What are non-neoplastic categories that can cause intramedullary masses?
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Demyelinating dz
Inflammatory Vascular lesions Developmental lesions Trauma |
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What sequences are used for the cord?
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T1, T1 post, T2, proton density, STIR (or other fat suppressed fluid sens)
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Where in the cord are demyelinating lesions located?
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Posterior cord, since that is where the bulk of the white matter tracts is
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What is the hallmark of spinal neoplasm?
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Cord enlargement
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What are other features seen in spinal tumors?
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1) Hemorrhage
2) Cystic components 3) Enhancement |
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How many different types of cysts are seen with cord tumors?
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2
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What are they?
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Intratumoral cysts -- part of the tumor itself
Tumor associated cysts |
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Where are tumor associated cysts?
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They cap the lesion above and below
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What sequence is always done whenever cord tumor is suspected?
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T1 Postgado. Must evaluate enhancement
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How many intramedullary tumors do we need to remember for adults?
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3
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Which ones?
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1) Hemangioblastoma
2) Astrocytoma 3) Ependymoma |
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When does hemangioblastoma present?
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20s -- 40s
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What other lesions are seen in patients with cord hemangioblastomas?
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RCCA
Pancreatic cysts Retinal angiomas |
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Why?
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Because hemangioblastoma is assd with VHL, just like when it is seen in posterior fossa.
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What percent of patients with cord hemangioblastoma will have VHL?
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30%
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What is their general appearance?
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Variable, just like they are in posterior fossa.
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What are the variations?
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Can be large, can be small
Can be totally solid, can be primarily cystic with mural nodule. And anything in between |
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What are the CONSTANT findings in hemangioblastoma?
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1) LIGHT BULB enhancement of its cystic portions
2) Flow voids from large vessels feeding tumor 3) Edema within adjacent cord |
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What does the edema do to the cord?
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It causes cord expansion itself.
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Before giving contrast, how do you differentiate hemangioblastoma for holocord astrocytoma?
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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
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When you treat it surgically, what part of cord do you remove?
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Just the enhancing tumor nidus (and any associated cyst). Not the edematous cord.
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What does edema look like in the cord?
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Looks flame-shaped on T2, extending up or down the central part of the cord, sparing the periphery of the cord
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What type of edema is this?
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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.
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What is a more typical appearance of hemangioblastoma in VHL?
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They get multiple small hemangioblastoma nodules, which are up against the pial surface, not so much central in the cord.
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Does hemangioblastoma have tumor associated cysts?
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Yes. The tumor assd cysts are just collections of edema. They are not sensitive or specific
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What is age dist'n of cord astrocytoma?
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Mainly 20s to 40s, but also occur in kiddies.
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What is true of size of astrocytomas?
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Fusiform expansion, usually greater than 2 segments.
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How big are demyelinating plaques in the cord?
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Small. 2 segments or less!
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What percent of astrocytomas enhance?
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For my purposes all do. Only 10% dont
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What do they look like?
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Basically just like they would in brain. They enhance. They can have central areas of necrosis. Nothing really specific about em.
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Where do astrocytomas not occur?
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Filum
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What is the most common primary cord tumor?
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Ependymoma
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What tumor feature is suggestive of ependymoma?
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Certain locations
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What tumor locations make ependymoma much more likely?
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Lower cord, conus, and filum
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What is another feature of ependymoma that is somewhat specific?
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Hemorrhage
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How does this manifest?
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Dark hemosiderin cap above and below lesion
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What is another very typical finding of ependymoma?
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Tumor associated cysts above and below lesion
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How do you differentiate tumor associated cysts with intratumoral cysts?
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No enhancement on outer sides of tumor assd cysts
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What does ependymoma do to bones?
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Remodels vertebrae
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Why is this important to know?
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Because you cant just assume that something remodeling the spine is benign. It is not always so. It is a slow growing tumor though.
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What percent of ependymomas enhance?
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For my purposes, all cord tumors will enhance. But if you must know, 80% of ependymomas do enhance.
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What if you see a cord tumor which is extensive, involving many segments, but which demostrates lots of areas of dark signal?
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C/W hemosiderin deposition, which represents old hemorrhage, as is suspicious for ependymoma.
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What is classic appearance of cord mets?
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Lots of separate foci of enhancement throughout the cord in patient with known primary
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What are the 4 most common mets to cord?
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Lung
Breast Melanoma RCCA |
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What are vascular malformations of cord?
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Cavernous hemangioma
AV Malformation |
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What does cord cavernoma look like?
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Look up. Looks same as brain I guess. But I don't know that either!
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What is the classic presentation for a particular vascular malformation of the cord?
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Young patient presenting with subarachnoid hemorrhage
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What malformation is this a classic presentation for?
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AVM of the cord
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What does ill defined cord enhancement in an expanded segment of cord suggest?
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Cord infection
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What should you consider in all cases that look atypical (poor enhancement, multiple segments, indistinct margins of enhancement)?
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Sarcoid
Lymphoma |
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What is the differential for intradural extramedullary lesions?
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1) Schwannoma
2) Meningioma 3) Mets |
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What are the characteristics of intradural extramedullary lesions?
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Displace cord
AND Widen adjacent CSF space |
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What is a classic characteristic of meningioma on MRI (nice when you see it to clinch diagnosis, but don't always see)
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Dark on T2
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What is the appearance of schwannoma?
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Enhancing with unenhancing cystic component. May be mostly cystic with just peripheral enhancement.
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What is the most classic finding of schwannoma?
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Dumbell lesion extending through and expanding the neural foramen
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What patients get dural dysplasia?
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NF-1
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What patients get frequent spinal tumors.
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NF-2
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What spinal tumors do they get in NF-2?
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Meningiomas
Schwannomas (can have schwannomas at multiple levels, classic appearance) Ependymomas |
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What type of metastatic disease is intradural extramedullary?
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Drop mets
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What tumors give drop mets?
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Medulloblastoma
Ependymoma Oligodendroglioma Pinealoma Astrocytoma |
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What other type of tumor can give drop mets?
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Metastatic disease near CSF:
Breast Lun Melanoma |