Intradural Extramedullary Spinal Neoplasms: Radiologic-Pathologic Correlation

Imaging of intraspinal cystic lesions: A review

Several distinct conditions present as cystic or pseudocystic lesions within the spinal canal. Some of the most common spinal cystic lesions include spinal meningeal cysts, juxtafacet cysts, dermoid/epidermoid cysts, nerve sheath tumors, and syringohydromyelia. Clinical presentation is usually nonspecific and imaging characteristics are frequently overlapping, which may pose a challenging presurgical diagnosis. We provide a pictorial review of cystic intraspinal lesions and discuss the main imaging features that can aid the neuroradiologist in the differential diagnosis. First, we propose a categorization of the lesions according to their location as extradural, intradural extramedullary, and intramedullary. This is a crucial initial step in the diagnostic workup and surgical planning. Second, for each of these locations, we organize the lesions according to their etiology: congenital and developmental disorders, degenerative disorders, traumatic or postsurgical collections, infectious conditions, neoplastic lesions, and other miscellaneous disorders. Finally, we summarize the clinical highlights and MR features that provide important insights for the differential diagnosis. MR is the technique of choice in presurgical evaluation and postsurgery follow-up. It provides accurate lesion localization and characterization and, most of the times, it will allow a confident differential diagnosis. High-resolution three-dimensional T2-weighted sequences and diffusion-weighted imaging can provide important hints in specific cases. Signal correlation with T1-weighted and fat-saturated sequences allows to differentiate true cystic lesions from hemorrhage or fat tissue.

Magnetic Resonance Imaging for Spine Emergencies

This article is devoted to the MR imaging evaluation of spine emergencies, defined as spinal pathologic conditions that pose an immediate risk of significant morbidity or mortality to the patient if not diagnosed and treated in a timely manner. MR imaging plays a central role in the timely diagnosis of spine emergencies. A summary of MR imaging indications and MR imaging protocols tailored for a variety of spinal emergencies will be presented followed by a review of key imaging findings for the most-encountered emergent spine pathologic conditions. Pathologic conditions will be broadly grouped into traumatic and atraumatic pathologic conditions. For traumatic injuries, a practical and algorithmic diagnostic approach based on the AO Spine injury classification system will be presented focused on subaxial spine trauma. Atraumatic spinal emergencies will be dichotomized into compressive and noncompressive subtypes. The location of external compressive disease with respect to the thecal sac is fundamental to establishing a differential diagnosis for compressive emergencies, whereas specific patterns of spinal cord involvement on MR imaging will guide the discussion of inflammatory and noninflammatory causes of noncompressive myelopathy.

Imaging characteristics of orbital peripheral nerve sheath tumors: Analysis of 34 cases

BACKGROUND

Peripheral nerve sheath tumors (PNSTs), a rare group of neoplasms in the orbit, comprise only 4% of all orbital tumors. At present, there are very few studies detailing the features of these tumors identified using imaging technology.

AIM

To compare the differences in location, morphology, magnetic resonance imaging (MRI) signal intensity/computed tomography (CT) value, and enhancement degree of tumors of different pathological PNSTs types.

METHODS

Clinical, pathological, CT, and MRI data were analyzed retrospectively in 34 patients with periorbital sheath tumors diagnosed using histopathology from January 2013 to August 2021.

RESULTS

Among 34 cases of orbital peripheral nerve sheath tumors, 21 were schwannomas, 12 were neurofibromas, and 1 was a plexiform neurofibroma. Common clinical symptoms presented by patients with these types of tumors include eyelid swelling, exophthalmos, and limited eye movement. Schwannomas mostly occur in the intramuscular space with small tumor volume and rare bone involvement. Neurofibromas develop in the extrapyramidal space with larger tumor volume and more bone involvement. Radiologically, schwannomas and neurofibromas are characterized by regular morphology and uneven density and signal. One case of plexiform neurofibroma showed tortuous and diffuse growth along the nerve, with a worm-like appearance on imaging.

CONCLUSION

Different pathological types of orbital peripheral nerve sheath tumors have unique imaging characteristics. Comprehensive consideration of the patient's clinical and imaging manifestations is of great value in the diagnosis of orbital peripheral nerve sheath tumors.

Epidemiology, Characteristic, and Prognostic Factors of Primary Sporadic Intradural Malignant Peripheral Nerve Sheath Tumor in the Spinal Canal: A Systematic Literature Review

Purpose

Primary sporadic intradural malignant peripheral nerve sheath tumor (MPNST) in the spinal canal is a type of rare neoplasm with challenging diagnosis and therapy. The overall prognosis of this tumor is markedly different from that of the usual spinal intradural tumors. The purpose of this systematic review is to reduce the misdiagnosis and enhance the prognosis of the disease by reviewing the literature.

Methods

PubMed, Medline, and Embase databases were searched for articles in English language published from 1980 to May 2021, yielding 500 potentially relevant articles. The keywords were as follows: “spinal”, “malignant peripheral nerve sheath tumor”, “neurosarcoma”, “malignant schwannoma”, and “malignant neurofibroma”. Thirteen papers met the eligibility criteria, including 55 cases with spinal intradural primary sporadic MPNSTs, which were confirmed by post-operation pathology. We further analyzed the clinical manifestations, radiological manifestations, pathological features, comprehensive treatment strategies, and prognosis.

Results

Fifty-five spinal intradural primary sporadic MPNSTs from 30 (54.5%) male and 25 (45.5%) female patients with an average age at diagnosis of 40 years (range, 3–70 years) were included in the study. The most common clinical manifestations were local or radicular pain and motor disturbance. All tumors had significant enhancement and heterogeneous enhancement was more common. Out of 18 lesions, 14 were diagnosed as high grade and the remaining 4 were diagnosed as low grade. The ki-67 labeling index ranged from 5% to 60%. The median recurrence and survival time were 36 and 72 months, respectively. The log-rank tests indicated that significant predictors of OS were patient age (≤30 vs. >30 years) at the time of diagnosis and the presence of metastatic disease, and similar analyses for RFS demonstrated that the presence of metastatic disease was the only significant predictor (60 vs. 10 months). The multivariate Cox proportional hazards regression analysis revealed that absence of metastasis was an independent factor for predicting a favorable prognosis.

Conclusions

Spinal intradural primary sporadic MPNSTs are challenging malignant tumors without a systematic treatment plan. The factors affecting its prognosis are not clear. Even after surgical treatment and adjuvant treatment, the recurrence rate and mortality rate are still high. Clinicians should be alert to the possibility of this disease and achieve early detection and treatment.

Validity of magnetic resonance imaging (MRI) in the primary spinal cord tumors in routine clinical setting

MRI is the primary diagnostic modality for spinal cord tumors. However, its validity has never been vigorously scrutinized in daily routine clinical practice, where MRI tissue diagnosis is usually not a single one but multiple ones with several differential diagnoses. Here, we aimed to assess the validity of MRI in terms of predicting the pathology and location of the tumor in routine clinical settings. We analyzed 820 patients with primary spinal cord tumors, who have a pathological diagnosis and location in the operation record which were confirmed. We modified traditional measures for validity based upon a set of diagnoses instead of a single diagnosis. Sensitivity and specificity and positive and negative predictabilities were evaluated for the tumor location and pathology. For tumor location, 456 were intradural extramedullary; 165 were intramedullary, and 156 were extradural. The overall sensitivity and specificity were over 90.0%. However, the sensitivity became lower when the tumor resided simultaneously in two spaces such as in the intradural-and-extradural or intramedullary-and-extramedullary space (54.6% and 30.0%, respectively). Most common pathology was schwannoma (n = 416), followed by meningioma (114) and ependymoma (87). Sensitivities were 93.3%, 90.4%, and 89.7%, respectively. Specificities were 70.8%, 82.9%, and 76.0%. In rare tumors such as neurofibromas, and diffuse midline gliomas, the sensitivity was much lower (less than 30%). For common locations and pathologies, the validity of MRI is generally acceptable. However, for rare locations and pathologies, MRI diagnosis still needs some improvement.

Symptomatic mature teratoma of the lumbar spine: A case report

Background:

Teratomas are a unique family of tumors derived from two or more of the three embryonic layers: endoderm, mesoderm, and ectoderm. Mature teratomas are comprised the most well-differentiated tissue types and may contain skin, hair, teeth, smooth muscle, respiratory tissues, etc. Infrequently, mature teratomas may be found within the central nervous system and, in exceedingly rare cases, may be occur within the spinal cord itself (i.e., intramedullary/intradural).

Case Description:

A 78-year-old female presented with a subacute progressive lower extremity paraparesis. The MR revealed a cystic 81 × 30 × 25 mm intradural/intramedullary spinal mass involving the distal conus with exophytic extension into the L1-L4 spinal canal. Following surgical intervention consisting of a L1-L4 laminectomy, the lesion was largely removed. Pathology of the mass confirmed a large mature teratoma containing a multilobulated cyst that intraoperatively compressed the conus and cauda equina. Immediately postoperatively, the patient significantly improved neurologically. However, on postoperative day 2, she acutely developed a change in mental status with the left gaze preference and hemiparesis. CT brain in the acute setting showed no evidence of causative pathology and subsequent MR brain was unremarkable. The patient’s neurologic deficits progressively improved leading to eventual discharge.

Conclusion:

Intrathecal intramedullary/extramedullary mature teratomas of the conus that results in subacute cauda equina syndromes are rare. The differential diagnosis for such lesions exophytic to the conus must include mature teratomas which, though rare, may be readily resected resulting in generally favorable outcomes.

False-Positive 123I-Uptake Mimics Metastatic Lung Disease in a Patient With Interstitial Lung Disease Secondary to Scleroderma

ABSTRACT

A 59-year-old woman with a history of papillary thyroid cancer status post total thyroidectomy and 131I ablation therapy presented with lower back pain and leg weakness. MRI of the lumbar spine revealed homogenously enhancing lesions at L1-L2 and L3-L4. Subsequent whole-body 123I-Na scan demonstrated significant 123I retention in the mid to distal esophagus, as well as diffuse uptake in basal segments of the lungs bilaterally. SPECT/CT of the lumbar vertebra was unremarkable. Although 123I-Na uptake often indicates metastatic recurrence, these findings were better explained by nonspecific radioiodine uptake secondary to systemic complications of the patient's underlying scleroderma.

[Benign extramedullary spinal cord tumors at the level of craniovertebral junction: a systematic review]

Extramedullary spinal cord tumors at the level of craniovertebral junction are a rare group of neoplasms with their own characteristics. Taking into account the peculiarities of clinical course and complex anatomy of craniovertebral complex, these tumors present a complex diagnostic and surgical problem. A systematic review of literature data on epidemiology, clinical picture, diagnostic methods and dorsal minimally invasive methods of surgical treatment of patients with extramedullary spinal cord tumors of craniovertebral junction was performed.

Clinical Reasoning: Longitudinally Extensive Spinal Cord Lesions in a Middle-aged Man

An immunocompetent 47-year-old man presented with a five-month history of progressive lower limb weakness, back pain, sphincter dysfunction, and intermittent fever, suggesting myelopathy in a chronic deteriorating course. A comprehensive analysis comprising of blood tests, neuroimaging, CSF profiling, molecular analysis, and histopathology was performed. Notably, enhanced spinal cord MRI revealed longitudinally extensive intradural-extramedullary lesions involving the cervical, thoracic, and lumbosacral spinal cord, with homogeneous enhancement and spinal cord compression. Serum TPHA and RPR tests were positive. CSF profiling showed pleocytosis, significant protein elevations, hypoglycorrhachia, and positive TPHA test. 18F-FDG-PET/CT indicated slightly increased intraspinal FDG uptake. Spinal cord biopsy further showed small round blue cells in poorly differentiated tissues. Immunostaining was positive for NKX2.2, CD56, CD99, Synaptophysin, and Ki67 (50%). Molecular analysis detected a novel MALAT-CYSLTR1 fusion protein and variants in oncogenic genes including PTCH1, TERT, CREBBP, SPEN, and STK11 The diagnosis of intraspinal extraosseous Ewing's sarcoma (ES) was confirmed. Briefly, our case details the diagnosis of a patient with intradural-extramedullary ES and highlights the value of spinal cord biopsy in progressive myelopathy of unknown causes.

Recurrent Solitary Fibrous Tumor in Intradural Extramedullary Space: Case Report and Review of the Literature

Solitary fibrous tumor/hemangiopericytoma (SFT/HPC) is a rare neoplasm arising from spindle cells and most commonly arising from pleura. Spinal SFT/HPC is a rare entity; hence, it is not on the top of the differential diagnosis list when a clinician faces a spinal lesion. In the review of the literature, there exist less than 50 case reports of intradural extramedullary SFT/HPC. Here, we present a 54-year-old female patient who underwent subtotal surgical excision of an intradural extramedullary spinal mass pathologically reported to be SFT/HPC and had symptomatic recurrence in the 3^rd year of follow-up. Surgical intervention was unachievable and the patient was given 45 Gy to the surgical cavity followed by a 5.4 Gy boost to visible tumor with external radiotherapy. Patient reported significant relief of her symptoms. We aim to contribute to the formation of a treatment algorithm for this rare entity.

Approach to Myelopathy and Myelitis

Myelopathy can present acutely or more insidiously and has a broad differential diagnosis. In addition to the clinical history and neurologic examination, diagnostic testing, including MRI and cerebrospinal fluid analysis, as well as thorough review of patient comorbidities, risk factors, and potential toxic exposures, can help neurohospitalists distinguish between various causes and potentially start appropriate empiric therapy while awaiting definitive testing. This article focuses on how imaging can help in determining the most likely cause of myelopathy and highlights a range of causes, including compressive, vascular, metabolic and toxic, infectious, autoimmune, neoplastic, and paraneoplastic causes of spinal cord dysfunction.

Cervical solitary fibrous tumor: case report and literature review

Solitary fibrous tumors (SFTs) are rare neoplasms in the spinal canal. There are few studies addressing SFT/hemangiopericytomas with no distinctive clinical characteristics, no conclusive radiological findings or even a well-defined best treatment strategy. We described a rare case of cervical SFT/hemangiopericytomas in a young patient with spinal cord compression. There are many differential diagnoses for spinal dural-based masses of which meningiomas are the most common. Surgeons and oncologists should be aware of differentials of dural-based masses in the spinal cord for surgical decision making and to guide treatment.

[Spinal neoplasms]

Spinal neoplasms are generally rare disorders but play an important role in the differential diagnosis of space-occupying masses of the spinal axis. Although there are several different classification criteria (histological origin, dignity, positional relationship to the spine), the standard classification of spinal neoplasms based on the relationship to the dura mater into extraspinal, intraspinal extramedullary and intraspinal intramedullary is used. Magnetic resonance imaging is the gold standard for the morphological imaging of spinal neoplasms, followed by computed tomography. In addition to localization and symptoms, the patient's age is essential with respect to the diagnosis of the possible tumor entity.

Cauda equina ependymomas: surgical treatment and long-term outcomes in a series of 125 patients

OBJECTIVE

Cauda equina ependymoma (CEE) is a rare tumor for which little information is available on the oncological and clinical outcomes of patients. In this study the authors aimed to address functional, oncological, and quality-of-life (QOL) outcomes in a large series of consecutive patients operated on at their institution during the past 20 years.

METHODS

The records of 125 patients who underwent surgery between January 1998 and September 2018 were reviewed. Analyzed variables included demographic, clinical, radiological, surgical, and histopathological features. Neurological outcomes were graded according to the McCormick and Kesselring scales. The QOL at follow-up was evaluated by administering the EQ-5DL questionnaire.

RESULTS

On admission, 84% of patients had a McCormick grade of I and 76.8% had a Kesselring score of 0. At follow-up (clinical 8.13 years; radiological 5.87 years) most scores were unchanged. Sacral level involvement (p = 0.029) and tumor size (p = 0.002) were predictors of poor functional outcome at discharge. Tumor size (p = 0.019) and repeated surgery (p < 0.001) were predictors of poor outcome. A preoperative McCormick grade ≥ III and Kesselring grade ≥ 2 were associated with worse outcomes (p = 0.035 and p = 0.002, respectively). Myxopapillary ependymoma (MPE) was more frequent than grade II ependymoma (EII). The overall rate of gross-total resection (GTR) was 91.2% and rates were significantly higher for patients with EII (98%) than for those with MPE (84%) (p = 0.0074). On multivariate analysis, the only factor associated with GTR was the presence of a capsule (p = 0.011). Seventeen patients (13.7%) had recurrences (13 MPE, 4 EII; 76.4% vs 23.6%; p = 0.032). The extent of resection was the only factor associated with recurrence (p = 0.0023) and number of surgeries (p = 0.006). Differences in progression-free survival (PFS) were seen depending on the extent of resection at first operation (p < 0.001), subarachnoid seeding (p = 0.041), piecemeal resection (p = 0.004), and number of spine levels involved (3 [p = 0.016], 4 [p = 0.011], or ≥ 5 [p = 0.013]). At follow-up a higher proportion of EII than MPE patients were disease free (94.7% vs 77.7%; p = 0.007). The QOL results were inferior in almost all areas compared to a control group of subjects from the Italian general population. A McCormick grade ≥ 3 and repeated surgeries were associated with a worse QOL (p = 0.006 and p = 0.017).

CONCLUSIONS

An early diagnosis of CEE is important because larger tumors are associated with recurrences and worse functional neurological outcomes. Surgery should be performed with the aim of achieving an en bloc GTR. The histological subtype was not directly associated with recurrences, but some of the features more commonly encountered in MPEs were. The outcomes are in most cases favorable, but the mean QOL perception is inferior to that of the general population.

Magnetic Resonance Image under Variable Model Algorithm in Diagnosis of Patients with Spinal Metastatic Tumors

The aim of this study was to explore the adoption of the variable model algorithm in magnetic resonance imaging (MRI) image analysis and evaluate the effect of the algorithm-based MRI in the diagnosis of spinal metastatic tumor diseases. 100 patients with spinal metastatic tumors who were treated in hospital were recruited as the research objects. All patients were randomly divided into the experimental group (MRI image analysis based on variable model) and the control group (conventional MRI image diagnosis), and the MRI of the experimental group was segmented using the conventional algorithm with variable model and the improved algorithm with GVF force field. The accuracy index (Dice coefficient D) values were used to evaluate the vertebral segmentation effect of the improved variable model algorithm with the introduction of GVF force field, and the recognition rate, sensitivity, and specificity indexes were used to evaluate the effects of the two algorithms on the recognition of MRI image features of spinal metastatic tumors. The results showed that the mean D value of the variable model improvement algorithm for the segmentation of five vertebrae of spinal metastatic tumors was significantly improved relative to the conventional variable model algorithm, and the difference was statistically significant (P < 0.05). At the number of 80 iterations, the recognition rate, sensitivity, and specificity of MRI image segmentation of the traditional variable model algorithm processing group were 89.32%, 74.88%, and 86.27%, respectively, while the recognition rate, sensitivity, and specificity of MRI image segmentation of the variable model improvement algorithm processing group were 97.89%, 96.75%, and 96.45%, respectively. The results of the latter were significantly better than those of the former, and the differences were statistically significant (P < 0.05); and the comparison of MRI images showed that the variable model improvement algorithm was more rapid and accurate in identifying the focal sites of patients with spinal metastases. The accuracy of MRI images based on the variable model algorithm increased from 69.5% to 92%, and the difference was statistically significant (P < 0.05). In short, MRI image analysis based on the variable model algorithm had great adoption potential in the clinical diagnosis of spinal metastatic tumors and was worthy of clinical promotion.

Giant lumbar spinal schwannoma: a case report and literature review

We report a case of a 40-year-old female patient admitted to the hospital due to lumbar pain that spread to both legs and was associated with weakness of the lower extremities. Magnetic resonance imaging revealed an intradural - extramedullary tumor at the level of the T12 - L2 vertebra. The lesion was over 7 cm in greatest diameter and compressed the conus medullaris. The patient underwent surgery to remove the entire tumor. Postoperative pathology confirmed the diagnosis of schwannoma. The symptoms resolved almost completely without significant complications.

Malignant peripheral nerve sheath tumor in an elderly patient with superficial spreading melanoma: A case report

BACKGROUND

Malignant peripheral nerve sheath tumor (MPNST) is a type of spindle cell sarcoma originating from the peripheral nerve, which usually results in the corresponding nerve sign on magnetic resonance imaging (MRI). Patients with MPNST may also have neurofibromatosis type 1.

CASE SUMMARY

A 78-year-old male was admitted to the hospital due to a tumor in his left knee. He had a previous history of superficial spreading melanoma on the left thigh. Color Doppler ultrasonography showed a hypoechoic mass in the subcutaneous soft tissues of the medial left knee with an abundant rich blood flow. Computed tomography scanning did not show obvious signs of bone destruction, but the skin adjacent to the tumor was slightly thickened. MRI examination revealed that the hypervascular lesion was well-circumscribed, lobulated, invaded the surrounding soft tissues and demonstrated heterogeneous enhancement but lacked an entering and exiting nerve sign. The MRI result indicated the invasiveness of the tumor. The patient underwent a left knee joint mass expanded resection and the first histopathological examination showed a MPNST with positive surgical margins. Therefore, the second extended resection was performed, and the patient had a good outcome in the short term.

CONCLUSION

MRI is a useful technique for revealing the biological characteristics of MPNST and provides clinical support for evaluation of the surgical area before operation.

Long-Term Follow-Up and Predictors of Functional Outcome after Surgery for Spinal Meningiomas: A Population-Based Cohort Study

Simple Summary

Spinal meningiomas are the most common adult primary intradural spinal tumors. While mostly benign, they may give rise to spinal cord compression with acute or chronic neurologic dysfunction. The primary treatment is surgical resection. Previous studies, limited by small sample sizes and short follow-up times, report that histopathological grade, tumor localization and size affect outcomes following surgery. In this population-based cohort study, we retrospectively reviewed 129 cases of surgically treated spinal meningiomas to assess postoperative complications, long-term clinical and radiological outcomes, predictors of neurological improvement and potential differences between elderly and non-elderly patients. Our median follow-up time was 8.2 years. We found that surgery was associated with significant neurological improvement. There was no significant difference in postoperative complications, tumor control or neurological improvement between elderly and non-elderly. Shorter time from diagnosis to surgery, larger tumor size and spinal cord compression predicted postoperative outcomes.

Abstract

Spinal meningiomas are the most common adult primary spinal tumor, constituting 24–45% of spinal intradural tumors and 2% of all meningiomas. The aim of this study was to assess postoperative complications, long-term outcomes, predictors of functional improvement and differences between elderly (≥70 years) and non-elderly (18–69 years) patients surgically treated for spinal meningiomas. Variables were retrospectively collected from patient charts and magnetic resonance images. Baseline comparisons, paired testing and regression analyses were used. In conclusion, 129 patients were included, with a median follow-up time of 8.2 years. Motor deficit was the most common presenting symptom (66%). The median time between diagnosis and surgery was 1.3 months. A postoperative complication occurred in 10 (7.8%) and tumor growth or recurrence in 6 (4.7%) patients. Surgery was associated with significant improvement of motor and sensory deficit, gait disturbance, bladder dysfunction and pain. Time to surgery, tumor area and the degree of spinal cord compression significantly predicted postoperative improvement in a modified McCormick scale (mMCs) in the univariable regression analysis, and spinal cord compression showed independent risk association in multivariable analysis. There was no difference in improvement, complications or tumor control between elderly and non-elderly patients. We concluded that surgery of spinal meningiomas was associated with significant long-term neurological improvement, which could be predicted by time to surgery, tumor size and spinal cord compression.

Case report: An epidural cavernous hemangioma mimicking a dumbbell-shaped neuroma

Introduction and importance

Spinal epidural cavernous hemangiomas are a rare occurrence. This particular case is made even more distinctive by the fact that the lesion mimicked a dumbbell-shaped neuroma. Moreover, it had a very unique localization (wholly epidural, at cervical-thoracic -C7-D1- level). The importance of this case is linked not only to its remarkable rarity, but also to the diagnostic avenues explored.

The surgery was carried out by Prof. Riccardo Caruso, Head of the Neurosurgical Department of the Military Hospital of Rome and Professor of Neurosurgery of Sapienza University of Rome, assisted by Dr. Luigi Marrocco, Senior Neurosurgeon of the Military Hospital of Rome. Postsurgical recovery was managed by Dr. Venceslao Wierzbicki, Senior Neurosurgeon of the Military Hospital of Rome.

Case presentation

In 2020, a 71 year-old man, suffering from intense pain in the left scapular region and in the ulnar area of the left forearm, underwent surgery for the removal of a spinal epidural cavernous hemangioma involving the left C7-D1 foramen. Prior to surgery, the lesion had been misdiagnosed as a neuroma by a radiologist.

Clinical discussion

In the Literature there are other, rare cases of hemangiomas partly located in the spinal canal, and partly located intra and extra foramen. In the case here presented, differential diagnosis as well as a potential Schwannoma, suggested by the dumbbell shape of the lesion, should have considered also the possibility of a meningioma. Two teams of radiologists examined the images, the radiologists of our team, Dr. Valentina Martines and Dr. Emanuele Piccione, thanks to a close inspection of the features of the lesion, postulated the extra-dural position. Other aspects of the scans were then analyzed to help guide future diagnosis of similar lesions.

Conclusion

With a spinal tumor affecting the foramen, a close examination of the images allows for accurate presurgical differential diagnosis, differentiating between the more frequent neuroma and other rarer tumors, such as a hemangioma.

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Close examination of images is key to an accurate pre-surgical differential diagnosis for spinal tumors.

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A very rare spinal hemangioma mimicked in shape a dumbbell-shaped neuroma

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Considerations to be made when facing spinal lesions

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How to tell apart a neuroma, a meningioma, and a hemangioma of the spine from scans

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Rare case of spinal hemangioma in unique localization and presenting remarkable features

Thoracic spine schwannoma presenting with traumatic spinal cord injury: A case report

Background:

The presentation of a thoracic spinal tumor due to high-impact trauma is quite rare and we found no other case reported.

Case Description:

This is a case report and literature review. A patient presented with severe paraparesis on day 4 after trauma. Thoracic MRI showed an oval image centered to T4-T5 suggestive of hemorrhage. The patient underwent a bilateral T4 and T5 laminectomy and microsurgically assisted intradural exploration. After laminectomy, we found no extradural lesions, so we proceeded to dural opening, after which we found a large extramedullary lesion which was completely removed. Pathology revealed a schwannoma. The patient had a very good recovery after surgery and motor rehabilitation. At 6 months after surgery, inferior limbs muscle strength was completely normal. We found no other case reported.

Conclusion:

Thoracic spine schwannomas are difficult to early diagnose unless there is a clinical suspicion. Initial presentation as bleeding after trauma was not described before. This presentation should be kept in the differential diagnosis of any patient with an acute neurological deficit without trauma signs on admission imaging.

Clinical characteristics and management differences for grade II and III spinal meningiomas

PURPOSE

The majority of spinal meningiomas are grade I tumors, as defined by World Health Organization (WHO) classification making atypical (grade II) or anaplastic (grade III) tumors extremely rare lesions to encounter in clinical practice. Here, we present our institutional experience of management of grade II and III spinal meningiomas.

METHODS

Following IRB approval, we queried all available institutional electronic medical records for patients undergoing surgical resection of pathology-proven spinal meningiomas, with further review of patients with grade II and III. Variables of interest included age, sex, histological type, tumor size, symptoms at baseline, treatment characteristics, symptom resolution at the last follow-up, recurrence, NF-2 status, concurrent intracranial meningioma, and mortality. Kaplan Meier curves were constructed to study time to progression/recurrence.

RESULTS

A total of 188 patients undergoing surgical resection of spinal meningioma between 1988 and 2018 were identified. Among those, 172 (91.5%) patients had grade I meningioma and 16 (8.5%) patients had high grade meningiomas [grade II (15) and III (1)]. Over a median (IQR) follow-up of 8.0 years (5.1-13.0), mortality and recurrence rates were 18.8% (n = 3) and 47.1% (n = 8), respectively. In univariate analysis, adjuvant radiotherapy and thoracic segment involvement were associated with lower rates of recurrence while male sex was associated with a higher rate of recurrence.

CONCLUSIONS

Results showed variations in clinical outcomes for patients with high grade spinal meningiomas, especially the recurrence. Adjuvant radiotherapy and thoracic segment involvement was associated with lower rates of recurrence while recurrence ocurred at a higher rate in males.

Rare presentation of intradural calcium pyrophosphate dihydrate crystal deposition

Calcium pyrophosphate dihydrate crystal deposition (CPPD), also known as pseudogout, can have spinal manifestations in roughly one quarter of patients. We present a rare, intradural manifestation of CPPD requiring surgical intervention, with a review of pertinent differential diagnoses on imaging. A 48-year-old male presented with urinary retention, and was found to have an intradural lesion with peripheral enhancement on gadolinium T1-weighted magnetic resonance imaging. Due to the patient's progressive neurological deterioration, he was taken for a minimally invasive approach for resection of the lesion. Histopathological analysis revealed crystal deposits with rhomboidal birefringence consistent with CPPD. The imaging features of this lesion were atypical for any of the traditional intradural extramedullary lesions. Typically seen extradurally, recognizing CPPD as a potential culprit for intradural compression is helpful to recognize for providers.

Sporadic cauda equina hemangioblastoma: surgical management in a pregnant woman

Hemangioblastoma is a rare benign vascular tumour of the central nervous system that occurs either sporadically or in association with Von Hippel-Lindau syndrome. Hemangioblastoma can be found throughout the central nervous system and usually present with late manifestations due to their slow growth rate. Cauda equina hemangioblastomas are extremely rare, and in the literature, no cases are reported on the surgical management of pregnant patients with this condition. We report the case of a young woman with back pain and sphincter dysfunctions in whom an L1-L2 hemangioblastoma was diagnosed. We describe the perioperative and surgical strategies we adopted to successfully treat the patient and preserve the fetus well-being.

Hemorrhagic spinal melanotic schwannoma presenting as acute chest pain: A case report and literature review

Background:

Melanotic schwannoma (MS) is a rare variant of peripheral nerve sheath tumor. MS commonly arises along the spinal nerve sheath. Patients most often experience pain along the dermatome of the affected nerve root. Symptoms development is usually insidious. About half of MS cases are associated with Carney complex, a multi-neoplastic disorder. The remaining cases arise spontaneously. About 10–44% of these tumors undergo malignant transformation.

Case Description:

We describe a case of hemorrhagic MS presenting as acute chest pain mimicking myocardial infarction, a presentation which has not yet been described in the literature. Neurologic examination did not reveal any abnormalities. Myocardial infarction was ruled out in the ER, and a chest CT angiogram was ordered for evaluation of PE or aortic dissection which revealed an intradural extramedullary dumbbell-shaped mass extending through the left vertebral foramen at the level of T8. MRI revealed a heterogenous mass that was hyperintense with T2 and hypointense with T1-weighted imaging. The patient underwent an open laminectomy of the left T8 and T9 vertebrae and gross total resection (GTR) of a hemorrhagic black tumor. Microscopic examination showed fascicles and nests of plump spindle cells with variable intracellular melanin. Immunohistochemistry showed the cells to be positive for S100, SOX10, HMB-45, and MART-1, confirming diagnosis of MS. Two months after the operation, the patient was doing well and is free of recurrence.

Conclusion:

GTR is considered the optimal treatment for MS; radiotherapy and chemotherapy may be considered but have not been shown to improve patient outcomes.

[Spinal tumors]

Spinal tumors are often classified into three anatomical compartments on the basis of their relationship to the dural space and myelon. The most common primary spinal neoplasms are glial tumors (ependymoma, astrocytoma), nerve sheath tumors (schwannoma, neurofibroma) and meningioma. Metastases represent another common tumor entity and can occur in every spinal compartment. Magnetic resonance imaging (MRI) is the most important noninvasive method for spinal tumor imaging.

Rare Case of Multiple Intradural Extramedullary Spinal Schwannomas With Intramedullary Extension

Spinal schwannomas are benign WHO grade I nerve sheath tumors that account for nearly 30% of all spinal neoplasm. Typically, these lesions are intradural extramedullary in location and are composed entirely of well-differentiated eosinophilic Schwann cells. Intramedullary schwannomas, however, are extremely rare due to the lack of Schwan cells in the normal spinal cord and represent 1% of all the spinal schwannoma population. The presence of such an intramedullary component makes diagnosis challenging as imaging features may resemble other intramedullary neoplastic entities.

Here, we describe a case of a 56-year-old male patient who presented with an 18-month history of intermittent right-sided mid-thoracic pain secondary to multiple intradural extramedullary spinal schwannoma with intramedullary extensions. We also review the literature pertaining to the condition.

Neuroimaging of Spinal Cord and Cauda Equina Disorders

PURPOSE OF REVIEW

This article reviews the neuroimaging of disorders of the spinal cord and cauda equina, with a focus on MRI. An anatomic approach is used; diseases of the extradural, intradural-extramedullary, and intramedullary (parenchymal) compartments are considered, and both neoplastic and non-neoplastic conditions are covered. Differentiating imaging features are highlighted.

RECENT FINDINGS

Although T2-hyperintense signal abnormality of the spinal cord can have myriad etiologies, neuroimaging can provide specific diagnoses or considerably narrow the differential diagnosis in many cases. Intradural-extramedullary lesions compressing the spinal cord have a limited differential diagnosis and are usually benign; meningiomas and schwannomas are most common. Extradural lesions can often be specifically diagnosed. Disk herniations are the most commonly encountered mass of the epidural space. Cervical spondylotic myelopathy can cause a characteristic pattern of enhancement, which may be mistaken for an intrinsic myelopathy. A do-not-miss diagnosis of the extradural compartment is idiopathic spinal cord herniation, the appearance of which can overlap with arachnoid cysts and webs. Regarding intrinsic causes of myelopathy, the lesions of multiple sclerosis are characteristically short segment but can be confluent when multiple. Postcontrast MRI can be particularly helpful, including when attempting to differentiate the long-segment myelopathy of neurosarcoidosis and aquaporin-4 (AQP4)-IgG-seropositive neuromyelitis optica spectrum disorder (NMOSD) and when characterizing spinal cord tumors such as primary neoplasms and metastases. Spinal dural arteriovenous fistula is another do-not-miss diagnosis, with characteristic MRI features both precontrast and postcontrast. Tract-specific white matter involvement can be a clue for diseases such as subacute combined degeneration, paraneoplastic myelopathy, and radiation myelitis, whereas gray matter-specific involvement can suggest conditions such as cord infarct, viral myelitis, or myelin oligodendrocyte glycoprotein (MOG)-IgG associated disorder.

SUMMARY

Knowledge of the neuroimaging findings of the many causes of spinal cord and cauda equina dysfunction is critical for both neurologists and neuroradiologists. A structured approach to lesion compartmental location and imaging feature characterization is recommended.

MR Imaging Characteristics of Primary T-Cell Lymphoma of the Cauda Equina: A Case Report and Literature Review

Primary central nervous system lymphoma is a rare form of extranodal non-Hodgkin lymphoma, and primary T-cell lymphoma of the cauda equina is extremely rare. We describe a case involving a 56-year-old female who presented with low back pain and radiating leg pain for 4 months. MRI of the lumbar spine revealed an elongated, multinodular intradural lesion of approximately 10 cm from the L4 body to the S2 body level with iso-signal intensity on T1-weighted imaging, heterogeneous iso- and high-signal intensity on T2-weighted imaging, and a heterogeneous intense enhancement on gadolinium contrast-enhanced T1-weighted imaging. A peripheral T-cell lymphoma of the cauda equina was diagnosed on the basis of immunohistochemical and T-cell receptor gamma gene rearrangement analysis after intradural biopsy of the mass.

Schwannoma of the lumbar spine, presenting with pain of the knee, like an osteoid osteoma, in a 10-year-old girl

Localized pain in the absence of local lesion may represent referred pain from the spine, in a child, arising from a benign spinal schwannoma. It can be diagnosed by MRI. Surgical excision of the tumor relieves the symptoms.

Long-term outcomes of spinal meningioma resection with outer layer of dura preservation technique

Spinal meningioma is a common benign intradural spinal tumor. It has been reported that the local recurrence rate after surgical resection increases with longer follow-up duration. Simpson grade 1 resection could reduce the risk of recurrence, but this procedure needs dural reconstruction, which would cause cerebrospinal fluid (CSF) leakage or iatrogenic spinal cord injury. Saito et al. reported dura preservation technique to reduce the risk of CSF leakage, in which the meningioma together with the inner layer of the dura is removed and the outer layer is preserved for simple dural closure. The long-term outcomes with this technique have never been investigated. In this study, we retrospectively analyzed the data of 38 surgically treated patients (dura preservation technique, 12 patients; Simpson grade 2 resection, 26 patients) to assess the long-term recurrence rate (mean, 121.5 months; range, 60-228 months). The local recurrence rate in the dura preservation group was 8.3% (1 of 12 cases), which was similar to that in Simpson grade 2 resection group (2 of 26 cases [7.7%]). Although this case series did not indicate the significant difference in the recurrence rates between the dura preservation group and Simpson grade 2 group, we consider that this technique still has advantages for surgically less invasiveness in terms of dural reconstruction which is necessary for Simpson grade 1 and higher possibility of complete resection of tumors compared with Simpson grade 2 resection.

An overview of the tumors affecting the spine-inside to out

Spine tumors may arise within or surrounding the spinal cord and/or vertebral column. Spinal tumors can be benign or malignant. Based on their epicenter, they may be classified as intradural-intramedullary, intradural-extramedullary, or extradural. Of these, extradural lesions are the most common, and are typically metastatic. Primary bone tumors of the spinal column comprise 5% of all primary skeletal tumors. The majority of primary spinal column tumors are benign, with malignant tumors comprising only 20%. Overall, spine metastases are the most common malignant spine tumor, and these usually arise from primaries such as lung, breast, and prostate cancers. The advent of improved systemic therapies leading to improved survival and the frequent use of imaging has positioned metastatic spine disease as the new epidemic in oncology. For spine tumors, establishing the correct diagnosis is heavily reliant on magnetic resonance imaging and histological confirmation. In this review, we will provide an overview of the epidemiology, radiological and histopathological features, and the natural history of key primary (benign and malignant) spinal cord and column tumors and metastatic spine tumors. Treatment principles for primary spinal cord or column tumors are aimed toward curative resection, whereas palliative resection forms the treatment principle for most metastatic tumors.

Ependymomas of Filum Terminale: Clinical Characteristics and Surgical Management of 5 Patients

OBJECTIVE

To retrospective review a series of patients with ependymomas of filum terminale (FTEs) who underwent microsurgical resection and had long-term follow-up.

METHODS

Five adults with FTEs were surgically treated and enrolled in the study. Clinical manifestations, imaging data, intraoperative findings, and postoperative outcome were recorded.

RESULTS

Six FTEs were discovered on preoperative lumbar magnetic resonance imaging, with 1 rare case of a single FTE accompanied by a neurofibroma. Gross total resection was achieved in all patients; en bloc excision was carried out in 2 patients for 2 FTEs and 1 neurofibroma, while piecemeal resection was done in 3 patients for 4 FTEs. Most preoperative symptoms were relieved soon after surgery; 1 patient with urination difficulty achieved complete recovery 1 year postoperatively. Tumor recurrence was found in 1 patient 54 months after her first surgery.

CONCLUSIONS

FTEs are rare subdural extramedullary tumors. Patients usually present initially with back and leg pain. Elaborate microsurgical manipulations and intraoperative electrophysiologic monitoring are helpful in ensuring satisfactory excision and neurological prognosis. Regular long-term follow-up is recommended for all postoperative patients.

Atypical Imaging of Hemorrhagic Lumbosacral Myxopapillary Ependymoma with Histopathological Correlation: A Case Report

Patient: Male, 16-year-old

Final Diagnosis: Hemorrhagic myxopapillary ependymoma • myxopapillary ependymoma

Symptoms: Gait abnormality • pain in lumbar region

Medication: —

Clinical Procedure: Resection of intraspinal mass

Specialty: Neurosurgery • Radiology

A Rare Presentation of Spinal Schwannoma Causing Conus Medullaris Syndrome: A Case Series on Surgical Outcome

Introduction

Spinal schwannoma can occur anywhere along the spinal cord but is predominantly seen in the cervical and thoracic region.It composes mainly of well-differentiated schwann cell and is benign in nature. It is typically seen in the peripheral nerves and is commonly associated with neurofibromatosis. Up to 80% of cases, spinal schwannoma is reported to be intradural in location and 15% of cases have both intradural and extradural components. Spinal schwannoma rarely causes conus medullaris syndrome.

Case Report

In this case series, all three female patients in their 4th and 5th decades of life presented with conus medullaris syndrome. Lower back pain, radiculopathy, lower limb weakness, and urinary incontinence are their main clinical presentation. Magnetic resonance imaging shows a well-defined intradural, extramedullary mass compressing onto the conus medullary region. These patients undergone microscopic assisted excision of the tumor and had remarkably good early outcome despite the advanced presentation of neurological deficit.

Conclusion

Despite the late presentation with significant neurological deficit, surgical excision of spinal schwannomas carries a good prognosis postoperatively due to their benign nature and extramedullary location.

Lumbar Intradural Neurenteric Cyst: A Rare Pathology in an Unusual Location

A previously healthy 48-year-old female presented to the emergency department with a 2-week history of low back pain, progressive lower extremities weakness, and right leg numbness. There were no bowel or bladder dysfunction symptoms. Spine magnetic resonance imaging (MRI) showed an intradural cystic lesion dorsal to the spinal cord at the level of L1 measuring 1.6 × 2.1 × 4.1 cm, which was T1 hypointense and T2 hyperintense, with a small soft tissue component and no gadolinium enhancement (Figure 1). A small lipomatous component was also noted. There were no associated vertebral anomalies. The patient underwent a T12-L2 laminectomy and cyst resection, which was subtotal due to the cyst adherence to the conus medullaris. Histopathology showed characteristic features of a neurenteric cyst, with respiratory-type epithelium in the cyst wall (Figure 2). Eight months later, follow-up MRI showed no evidence of recurrence. The patient reported improved sensation in the lower extremities; however, there was some residual weakness predominantly in the proximal hip flexors bilaterally.

Intramedullary Masses of the Spinal Cord: Radiologic-Pathologic Correlation

Spinal cord tumors are a challenge for patients and neurosurgeons because of the high risk of neurologic deficits from the disease process and surgical interventions. Spinal cord tumors are uncommon, and approximately 2%-3% of primary intra-axial tumors of the central nervous system occur in the spinal cord. Primary intra-axial tumors are usually derived from neuroepithelial tissue, especially glial cells. This often leads to a classic intramedullary mass differential diagnosis of ependymoma or astrocytoma, which together constitute up to 70% of spinal cord tumors. For example, ependymomas occur predominantly in adults, and astrocytomas (specifically pilocytic astrocytomas) occur predominantly in children. While that is an excellent starting point, in order to refine the differential diagnosis, the authors review the radiologic-pathologic features of specific neoplastic categories and entities recognized by the World Health Organization (WHO) in the 2016 WHO Classification of Tumours of the Central Nervous System and a few additional congenital-developmental entities. Radiologists can add value by providing a reasonable preoperative differential diagnosis for the patient and neurosurgeon, in many cases by favoring the most common conditions, and in other cases by identifying radiologic features that may point toward a less common entity. Some of the less common entities include intramedullary myxopapillary ependymoma, spinal subependymoma, and spinal hemangioblastoma. Whenever possible, the characteristic imaging features and locations of these tumors are explained or traced back to the underlying cell of origin and findings seen at histopathologic examination.See discussion on this article by Buch.

Spinal paraganglioma as unusual finding in von Hippel-Lindau disease

A 20-year-old patient with a history of von Hippel-Lindau disease reported on thoracic back pain radiating to the left shoulder for 10 weeks. Magnetic resonance imaging revealed a progressive contrast-enhancing tumor (14 × 21 × 28 mm) compressing the spinal cord and extending into the left neural foramen at T5/6. After embolization of supplying vessels, the tumor was completely resected via hemilaminectomy of T5. The postoperative course was uneventful without surgery related morbidity. The pathological examination disclosed a paraganglioma WHO grade I. We discuss the differential diagnoses and pitfalls of this unexpected finding in this patient with von Hippel-Lindau disease.

New Insights into Expression of Hormonal Receptors by Meningiomas

OBJECTIVE

Meningiomas have a female predilection, which is even stronger for spinal than for intracranial meningiomas. The relationship between meningiomas and endogenous or exogenous sex hormones such as cyproterone acetate (CPA) is well documented, yet their underlying mechanism remains unknown. Clarification of the expression profile of hormonal receptors by meningiomas would help us to better understand their hormonal susceptibility.

METHODS

We used tissue microarray and immunohistochemistry to determine the receptor status of the 3 main sex hormones: androgen (AR), estrogen, and progesterone (PR) in 30 intracranial meningiomas, 30 spinal meningiomas, and 30 meningiomas developed on CPA.

RESULTS

AR status was positive in 73% of meningiomas in the intracranial group, 87% of meningiomas in the CPA group, and in all meningiomas in the spinal group. Estrogen status was positive in only 7% of meningiomas in the intracranial group and in only 3% of meningiomas in the CPA group but in 30% of meningiomas in the spinal group. PR status was positive in 90% of meningiomas in the intracranial group, in 97% of meningiomas in the CPA group, and in 87% of meningiomas in the spinal group. These specific hormonal receptor statuses based on immunoreactive score were reflected on staining intensities. Furthermore, AR and PR expression was correlated in each group.

CONCLUSIONS

Our study shows that intracranial meningiomas, spinal meningiomas, and meningiomas developed on CPA express specific hormonal receptor patterns. This result invites the scientific community to review the potential role of AR in the unbalanced sex ratio of meningiomas.

Giant Melanotic Malignant Peripheral Nerve Sheath Tumor in the Pelvis: Contrast-Enhanced CT and 18F-FDG PET/CT Finding

Melanotic malignant peripheral nerve sheath tumor is an extremely rare tumor, which originates from the neural crest, and more than half the cases are associated with Carney complex (myxomas, spotty pigmentation, and endocrine abnormalities). Herein, we have presented a case of a melanotic malignant peripheral nerve sheath tumor, which is not associated with Carney complex. The patient underwent preoperative nonenhanced CT, contrast-enhanced CT, and F-FDG PET/CT scans, which showed a large pelvic tumor with heterogeneous enhancement and increased F-FDG uptake. Subsequently, the patient underwent complete resection of the tumor.

Invasive myxopapillary ependymoma of the lumbar spine: A case report

BACKGROUND

Myxopapillary ependymomas are rare spinal tumours. Although histologically benign, they have a tendency for local recurrence.

CASE SUMMARY

We describe a patient suffering from extra- and intradural myxopapillary ependymoma with perisacral spreading. He was treated with subtotal resection and postoperative radiation therapy. After treatment, he experienced slight sphincter disorders and lumboischialgic pain with no motor or sensory disturbances. Eight months later, a tumour regression was documented. The patient is still followed-up regularly.

CONCLUSION

Lumbar myxopapillary ependymomas may present with lumbar or radicular pain, similar to more trivial lesions. Magnetic resonance imaging (MRI) is the primary modality for diagnosis. The treatment aim is to minimize both tumour and therapy-related morbidity and to involve different treatment modalities.