INTRADURAL HYPOINTENSE CYSTIC MASS
7yrs/M boy presented with three week history of torticollis and weakness of the left upper extremity His neurological exam showed paresis of the left upper extremity, all reflexes were hyperactive and plater reflex was extensor on the left side.DIAGNOSIS AND SUGGEST MANAGEMENT PLAN?
D/D Syringohydromelia Arachnoid cyst Ependymoma Schwanomma Astrocytoma Meningioma Treatment- Neurosurgical consultation regarding plan for surgery
Intradural extramedularry compression at c3-c4 region which is hypo in T1 and hyper at T2, seems same signal intensity as CSF with significant cord compression ? Arachnoid cyst Need surgical removal, NSX opinion
T1 hypointense,T2 hyperintense intradural extramedullary lesion compressing displacing and thinning of the spinal cord at C2-3 region. Spinal congenital arachnoid cyst. DD : Spinal epidermoid cyst Dermoid cyst NEURENTRIC CYST. CHILD IS SYMPTOMATIC ,NEEDS SURGICAL REMOVAL. Ref to neurosurgeon
Possibly meningioma. Neurosurgeon's reference. Surgery Biopsy HPE to conclude.
this can be a neurenteric cyst..second possibility is arachnoid cyst.. a micro neurosurgery is essential
Intradural extramedullary tumor menigioma as there is neurodeficit surgeryhas to bedone.
Intradural spinal mass lesions are relatively uncommon, compared to intracranial or extradural masses, and can be challenging to diagnose. Additionally, the need for a pre-operative/non-operative diagnosis is in many ways greater as biopsy of lesions within the cord has the potential of devastating neurological impairment. As such, a systematic approach to these lesions is required. MRI is the modality of choice for the assessment of lesions within the spinal canal as it has exquisite anatomical contrast and structural resolution, is able to image all compartments, and affords assessment for the presence of enhancement, cystic change, and blood products. Myelography historically was of prime importance but is now done only in patients for whom an MRI is contraindicated (e.g. those fitted with a non-MRI-compatible/conditional pacemaker) or who could potentially have too much artefact from spinal instrumentation, or occasionally as a problem-solving technique (e.g. spinal arachnoid cyst vs ventral cord herniation). This is usually combined with CT (i.e. CT myelography). CT remains the best modality to assess the osseous structures and is especially important in planning instrumentation, although this is usually not required for intradural tumours as the vertebral bodies are essentially unaffected in virtually all cases. Angiography is useful in a select group of patients who have vascular lesions (for both vascular malformations and vascular tumours). Endovascular treatment may be useful in some instances. Ultrasound, except in the infant, does not have a role in diagnosis, as it is unable to image the intradural compartment due to the overlying posterior spinal elements. As such, the rest of this article focuses on MRI. MRI protocol A standard approach to imaging an intradural mass consists of: T1 sagittal and axial T2 sagittal and axial T1 C+ sagittal and axial, with one or both planes fat-saturated (especially when there is foraminal extension or when there is concern for an extradural process) Additional sequences may also be useful, including: CSF flow studies gradient echo sequences (for blood products/calcification) high resolution diffusion-weighted imaging tractography As with all studies, having a systematic approach to intradural lesions is essential if subtle lesions are to be detected and the differential adequately narrowed. There is no single correct way to do this, and what is presented is merely a personal approach The relationship of the mass to the cord is of prime importance and typically two compartments are considered: intramedullary (i.e. within the cord), intradural extramedullary (i.e. within the theca but outside of the cord). Additionally, the cauda equina region is often considered separately as a number of lesions are particular to it. The vast majority of cases will then fall into a relatively small number of more common entities for each region (for a more complete list please refer to neoplasms of the spinal canal): intramedullary spinal ependymoma spinal astrocytoma (diffuse) spinal pilocytic astrocytoma spinal haemangioblastoma spinal cord metastasis (intramedullary) primary spinal glioblastoma multiforme 2 intradural extramedullary spinal meningioma spinal nerve sheath tumours spinal schwannoma spinal neurofibroma spinal leptomeningeal metastases cauda equina region myxopapillary ependymoma spinal nerve sheath tumours spinal schwannoma spinal neurofibroma Although in most cases which compartment a lesion is in is obvious, sometimes larger lesions can be challenging, and typically the questions which arise are: is this a large extramedullary mass compressing the cord or an exophytic intramedullary mass? is this a conus lesion or a lesion just below the conus? In most cases a careful assessment not so much of the mass but of the cord immediately above or below the mass is helpful. An extramedullary mass will push the cord away from it whereas an intramedullary lesion will expand and thin the cord around it (this is known elsewhere as the claw sign). Sometimes one must also consider whether a mass is actually extradural, and again examination of the dura above and below the mass is useful. Other than extension into the foramen as is seen in nerve sheath tumours and sometimes meningiomas (so-called dumbbell lesions), it is rare for intradural masses to extend into the extradural compartment, and thus vertebral body or clear epidural involvement usually means that the mass is extradural. Contrast enhancement Most spinal neoplasm demonstrate contrast enhancement, although the pattern of enhancement is highly variable. Lack of enhancement, however, certainly does not exclude a neoplasm as a minority of tumours do not enhance at all. Conversely, intradural lesions that mimic spinal neoplasms may demonstrate variable contrast enhancement. Such lesions include cavernous malformations, dural arteriovenous fistulas, spinal cord infarction, demyelinating lesions, transverse myelitis, and spinal cord abscesses. Blood products Depending on age, blood products have a variable appearance on MRI (see ageing blood on MRI). Chronic blood appears hypointense on T1 and T2 weighted images and demonstrates blooming on susceptibility-weighted images. Haemorrhage within a spinal tumour suggests ependymoma, haemangioblastoma, paraganglioma, or a haemorrhagic metastasis (thyroid, melanoma). Cavernomas and cord contusions also demonstrate blood products of varying ages.
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