Enlargement of the spinal cord: inflammation or neoplasm?

Tumefactive Demyelinating Lesions: An Illustrative Pediatric Case With an Atypical Presentation and Literature Review

Tumefactive demyelinating lesions remain a rare entity and a source of diagnostic difficulty. Here, we report the case of a teenage girl who presented with a one-month history of progressive quadriparesis and symptoms of intracranial hypertension. Brain MRI showed multiple large subcortical white matter lesions with both open- and closed-rim enhancement on gadolinium injection. The patient subsequently underwent a brain biopsy which showed an inflammatory infiltrate and no signs of malignancy. She was treated with pulse intravenous methylprednisolone at a dose of 500mg per day for five days and had rapid improvement. Her symptoms fully resolved after three months. This case highlights the need for better recognition and diagnosis of tumefactive demyelination, potentially avoiding unnecessary invasive diagnostic procedures such as brain biopsies.

Clinical spectrum and prognosis of pathologically confirmed atypical tumefactive demyelinating lesions

To describe the clinical spectrum and prognosis of atypical tumefactive demyelinating lesions (TDLs), which were confirmed by pathology. A total of 11 patients were diagnosed with atypical TDLs confirmed by brain biopsy and surgery between January 2006 and December 2017. The clinical spectrum and prognosis in these patients were analyzed. The patients' ages ranged from 29 to 62 years, with a mean age of 48.9 years; 72.7% were males. The Expanded Disability Status Scale (EDSS) of the patients with first onset was 2.36. Most of the patients started with limb numbness and weakness (45.5%) or alalia (27.2%). The mean time from symptom onset to biopsy or surgery was 12.9 days (3-30 days). Most of the patients had solitary lesions (72.7%), supratentorial lesions (90.9%, particularly predominant in the frontal, temporal, and parietal lobes), moderate edema (63.6%), mild mass effect (54.5%), and patchy lesions (54.5%). Among them, three patients were positive for myelin basic protein (MBP) and one patient was positive for myelin oligodendrocyte glycoprotein (MOG). The patients were followed up for an average of 6.9 years (2-14 years), and recurrent TDLs were observed in 2 patients. Except for the 2 patients who relapsed, only 1 of the 9 patients died; the other 8 patients improved or maintained the status quo (the EDSS scores were lower or unchanged). The patients did not have any serious nervous system injury at onset, and the main presentation included extremity weakness, headache or dizziness, and alalia. The most common form was patchy on MRI enhancement. Cerebrospinal fluid and demyelination test can be an indicator of TDLs, and seizures may be a poor prognostic indicator. Most atypical TDLs have monophasic courses and good outcomes. The effect of neurosurgery alone was good in our group, and the effect of surgery on atypical TDLs can be further studied.

Idiopathic Transverse Myelitis Mimicking an Intramedullary Spinal Cord Tumor

The differential diagnoses for spinal cord lesions include spinal tumors and inflammatory processes. The distinction between these pathologies can be difficult if solely based on imaging. We report for the first time to our knowledge a case of idiopathic transverse myelitis (ITM) mimicking a discrete cervical spinal lesion in a 66-year-old man who presented with gait instability and neck pain. The patient's symptoms failed to resolve after an initial course of steroid therapy. Surgical biopsy confirmed the diagnosis of ITM. Subsequent treatment with dexamethasone resulted in complete resolution of the symptoms as well as the intramedullary enhancement. ITM is most common in the cervical and thoracic spine, spanning 3-4 spinal segments. It usually occupies more than 50% of the cross-sectional area of the spinal cord and tends to be central, uniform, and symmetric. It exhibits patchy and peripheral contrast enhancement. These criteria are useful guidelines that help distinguish ITM from neoplastic spinal lesions. A decision to perform biopsy must take into consideration the patient's clinical symptoms, the rate of progression of neurological deficits, and the imaging characteristics of the lesion. Surgical biopsy for questionable lesions should be reserved for patients with progressive neurological deficits refractory to empirical medical therapy.

Primary spinal oligoastrocytoma mimicking longitudinally extensive transverse myelitis

Longitudinally extensive transverse myelitis (LETM) is most commonly associated with neuromyelitis optica spectrum disorders (NMOSD). However, a wide range of etiologies may produce longitudinally extensive spinal cord lesions (LESCLs) on imaging. We highlight the case of a patient with a spinal cord tumor whose imaging showed LESCL and was diagnosed with LETM. He did not respond to immunosuppression and subsequently developed a progressive and protracted clinical course. Thoracic cord biopsy performed 6 years after symptom onset showed primary spinal oligoastrocytoma. We discuss the features that should raise suspicion of a neoplasm in the context of LESCL and serve a reminder that not all LESCLs are inflammatory.

[Contribution of spinal cord biopsy to the differential diagnosis of longitudinal extensive transverse myelitis]

BACKGROUND

Neuromyelitis optica spectrum disorders (NMOSD) are characterized by recurrent optic neuritis (ON) and longitudinally extensive transverse myelitis (LETM) as well as the serological detection of antibodies to aquaporin-4 (AQP4-ab). However, longitudinal extensive spinal cord lesions are not pathognomonic for NMOSD as they can also occur in systemic autoimmune diseases or mimic spinal cord tumors.

OBJECTIVES/METHODS

We report a female patient who initially presented with a subacute spinal syndrome and a longitudinal spinal cord lesion on magnetic resonance imaging (MRI). As the brain MRI showed only unspecific white matter lesions and the cerebrospinal fluid was normal, a spinal cord biopsy was performed to exclude malignancies and revealed inflammatory demyelinating changes. In addition, after several deep vein thromboses and the detection of antiphospholipid antibodies, an antiphospholipid syndrome (APS) was diagnosed. Many years after the spinal cord biopsy, AQP4-ab were tested and found to be positive. We discuss the important differential diagnoses of LETM, give an overview of previously reported NMOSD cases in which a spinal cord biopsy was performed and highlight the crucial role of AQP4-ab testing for the differential diagnosis of longitudinal spinal cord lesions.

RESULTS/CONCLUSIONS

Considering possible serious sequelae of spinal biopsy procedures, testing for AQP4-ab is mandatory in patients with unclear longitudinally extensive spinal cord lesions and should be performed preoperatively in all cases. In light of the heterogeneity of available assays, different detection methods should be used in doubtful cases. The relationship between NMO and APS needs further clarification; however, AQP4 IgG testing is recommended in patients presenting with APS and myelitis, optic neuritis or brainstem encephalitis.

Cervical myelopathy due to single level disc herniation presenting as intramedullary mass lesion: What to do first?

Cervical myelopathy (CM) is mostly a degenerative process ending in myelopathic and/or radiculopathic syndromes. On T2-weighted magnetic resonance imaging (MRI), CM appears as a hyperintense area near the spondylotic spine. This high intensity signal depends on the impact of outer forces and their duration. It also determines the prognosis of the surgical candidate. A 40-year-old male patient admitted to our clinic with right upper extremity weakness and hypoesthesia that had started 2 months earlier. On neurological examination there was 2/5 motor weakness of right biceps brachii, and hypoesthesia over right C6 dermatome. Right upper extremity deep tendon reflexes were hypoactive, but lower ones were hyperactive. After clinical and radiological work-up, preliminary diagnosis was directed to a spinal intramedullary tumor. Total resection of the herniated cervical disc fragment and the mass lesion was managed. Pathology of the mass lesion was compatible with subacute infarct tissue and inflammatory response. Final diagnosis was CM under effect of cervical disc herniation. Contrast-enhanced spinal cord myelopathic lesions are very rare and resemble much more tumors and inflammatory processes. However, the principal treatment approach totally differs depending on pathology. When there are both a disc herniation and a high clinical suspicion; biopsy should be delayed. The most probable solution will be surgery for the disc disease with thorough preoperative scanning of vascular malformations; clinical and radiological close follow-up after surgery. Biopsy or surgical resection can be performed if patient deteriorates despite the primary surgery.

Seropositive Neuromyelitis Optica imitating an Intramedullary Cervical Spinal Cord Tumor: Case Report and Brief Review of the Literature

A 44-year-old woman with progressive cervical myelopathy and central cord syndrome was noted to have an extensive cervical intramedullary contrast-enhancing lesion on magnetic resonance imaging (MRI). The lesion resembled a spinal astrocytoma or ependymoma that required surgical intervention. She was subsequently diagnosed to have neuromyelitis optica (NMO), a rare idiopathic inflammatory demyelinating disorder, when the clinical examination revealed left optic atrophy. This was confirmed by a test showing seropositivity for NMO-immunoglobulin (IgG). Disease control was achieved with corticosteroids and immunosuppressive therapy. We report a rare case of a patient with NMO who had MRI features that could have easily led to the condition being misdiagnosed as a spinal cord tumor. The importance of careful history taking, awareness of typical radiological findings and the usefulness of serum NMO-IgG as a diagnostic tool are emphasized.

Diagnostic approach of patients with longitudinally extensive transverse myelitis

The aim of this study is to present a diagnostic and therapeutic approach in patients with LETM. In a period between June 2008 and June 2010, all patients who fulfilled criteria for LETM were included in the study. All patients underwent a standardized protocol of investigations presented in this paper. Ten patients were included (5 male, 5 female, with the age distribution from 24 to 70 years). Four patients were diagnosed with NMO/spatially limited NMO spectrum disorder, three patients were diagnosed with spinal cord ADEM, two multiple sclerosis (MS) and one patient with copper deficiency myelopathy. Laboratory support for the diagnosis of NMO was positive NMO-IgG antibody; for the diagnosis of ADEM signs of peripheral nervous system involvement on electromyoneurography; and for the diagnosis of MS brain MRI lesions typical for MS, as well as positive oligoclonal bands (OCB) in the cerebrospinal fluid (CSF). All cases with inflammatory myelopathy were treated either with steroids or plasma exchange and copper replacement was started in the case of copper deficiency. The mean time from the first symptom until the final diagnosis was 16.3 months (range 1 month to 7 years). As each of idiopathic inflammatory demyelinating diseases that can present with LETM have specific therapy, the postponement in making the correct diagnosis can lead to a poor recovery. In patients with LETM, a standardized diagnostic approach can result in a correct diagnosis and appropriate treatment.

Spinal cord tumor versus transverse myelitis

BACKGROUND CONTEXT

Longitudinally extensive transverse myelitis (LETM) is one of the defining features of neuromyelitis optica (NMO). Despite the well-established criteria, clinical and paraclinical features, the disease is often misdiagnosed and erroneously treated.

PURPOSE

We report on a case of LETM in a patient with spatially limited NMO spectrum disorder that was misdiagnosed as spinal cord tumor and underwent spinal cord biopsy.

STUDY DESIGN

A 43-year-old female patient is described.

METHODS

The patient developed spastic tetraparesis over 1 week. Spinal cord magnetic resonance imaging (MRI) revealed LETM, and she was treated with steroids and recovered. Nine months later, her condition worsened and repeat spinal cord MRI was interpreted as a large intramedullary tumor in the cervical region with irregular postcontrast enhancement. Biopsy revealed demyelination. Cerebrospinal fluid (CSF) analysis revealed positive oligoclonal IgG bands, and serum was positive for NMO-IgG antibody.

RESULTS

The patient was diagnosed with spatially limited NMO spectrum disorder, treated with plasma exchange, high-dose corticosteroids, and cyclophosphamide, and with good recovery.

CONCLUSIONS

The factors favoring inflammatory LETM are acute or subacute onset of clinical symptoms, positive oligoclonal bands in the CSF, positive NMO-IgG or other antibodies, and brain MRI showing demyelinating lesions. Postcontrast axial MRI sequences of the spinal cord can also be helpful. In doubtful situations, a trial of therapy and follow-up MRI a month later might be a more prudent approach if the patient is not rapidly deteriorating.

Diagnostic imaging in acute disseminated encephalomyelitis

Acute disseminated encephalomyelitis is an idiopathic inflammatory demyelinating disease of the CNS that is particularly difficult to differentiate from the first episode of multiple sclerosis, so called clinically isolated syndrome. Currently, no diagnostic criteria exist that could reliably differentiate these two diseases. More importantly no single clinical, neuroimaging or cerebrospinal fluid feature defines a disorder with absolute certainty. This review will summarize clinical and paraclinical characteristics of acute disseminated encephalomyelitis in adults, with special emphasis on diagnostic imaging.

Intramedullary non-specific inflammatory lesion of thoracic spine: a case report

Background

There are several non-neoplastic lesions which mimick intramedullary spinal cord neoplasm in their radiographic and clinical presentation. These can be classified as either infectious (TB, fungal, bacterial, parasytic, syphilis, CMV, HSV) and non-infectious (sarcoid, MS, myelitis, ADEM, SLE) inflammatory lesions, idiopathic necrotizing myelopathy, unusual vascular lesions and radiation myelopathy. Although biopsy may be indicated in many cases, an erroneous diagnosis of intramedullary neoplasm can often be eliminated pre-operatively.

Case description

the authors report a very rare case of intramedullary non-specific inflammatory lesion of unknown origin, without signs of infection or demyelinization, in a woman who showed no other evidence of systemic disease.

Conclusions

Intramedullary lesions that mimick a tumor can be various and difficult to interpret. Preoperative MRI does not allow a certain diagnosis because these lesions have a very similar signal intensity pattern. Specific tests for infective pathologies are useful for diagnosis, but histological examination is essential for establishing a certain diagnosis. In our case the final histological examination and the specific tests that we performed have not cleared our doubts regarding the nature of the lesion that remains controversial.

Diagnostic and therapeutic strategy for confounding radiation myelitis

We report a case of confounding radiation myelitis to demonstrate the usefulness of surgical biopsy in ensuring the correct diagnosis and to avoid unnecessary treatment. The patient was a 40-year-old man with a history of epiglottis carcinoma and sarcoidosis. Six months after radiation therapy and chemotherapy for epiglottis carcinoma, he noticed paresthesia and dysesthesia in the left arm and leg. Two months after that, he complained of severe neck pain and rapidly progressing weakness in all extremities. MRI showed an enhanced intramedullary lesion with extensive edema in the cervical spinal cord. Radiation myelitis, intramedullary spinal tumor, and neurosarcoidosis were considered as differential diagnoses. Spinal cord biopsy with laminectomy was performed and radiation myelitis was diagnosed. After the surgery, the lesion was significantly decreased in size even though corticosteroid therapy was rapidly tapered. We emphasize that a spinal cord biopsy is indicated to obtain a pathological diagnosis and to make a clear treatment strategy for patients with associated diseases causing lesions of the spinal cord.

Tumefactive demyelinating lesions: nine cases and a review of the literature

Tumefactive demyelinating lesions (TDLs) are misdiagnosed frequently. To investigate the characteristics of TDLs, clinical and radiological data from nine cases with TDLs were analyzed after admission. All cases underwent surgery and pathological examination; some received postoperative steroid therapy. Onsets were mostly within 3 weeks and main presentation included intracranial hypertension, extremity weakness, epilepsy, and visual disturbance. Symptoms in children were acute and severe, frequently including headache, vomiting, and visual disturbance. Most intracephalic lesions were in cerebral hemispheres. All intraspinal lesions were in cervical segments. Radiological features included mass effect, perifocal edema and enhancement (of which open-ring enhancement was diagnostic), and decreased relative cerebral blood volume. Intraoperative frozen section did not confirm the diagnosis, while postoperative paraffin section did confirm it (by evidence of macrophage infiltration). The patients responded well to steroid therapy and no relapse was found during following up. Thus, intensive analysis of both clinical and radiological data may provide some clues for diagnosis. For suspected cases, it is advisable to take steroid therapy or undergo advanced radiological examinations, such as serial magnetic resonance spectroscopy. However, in difficult cases, pathological evidence is beneficial to a final diagnosis.

Atypical teratoid/rhabdoid tumor of the spine in a 4-year-old girl

Primary spinal atypical teratoid/rhabdoid tumor is extremely rare. The authors present a case of atypical teratoid/rhabdoid tumor occurring in a 4-year-old girl. Magnetic resonance imaging The authors showed an intramedullary mass extending from the bulbomedullary junction to T1 with leptomeningeal dissemination. The patient died 2 weeks after diagnosis.

Demyelinating plaque imitates an intramedullary tumour

An isolated spinal demyelinating lesion is very rare and almost always associated with multiple sclerosis. There are only a few reports of biopsy or resection of MS-associated lesions. Sometimes the radiological and the histopathological findings can lead to a false diagnosis of a tumour. A 15-year-old girl presented with a progressive spastic tetraparesis and various associated clinical symptoms. Magnetic resonance imaging (MRI) suggested a possible intramedullary tumour extending from C4 to C7 and the need for surgical intervention. There was no previous neurological or other history and the brain MRI was normal. The performing surgeons based their procedures on oncological criteria. The extracted lesion was finally diagnosed as a demyelinating plaque. The postoperative course was uneventful without deterioration of the neurological status and the young patient improved completely after 4-months of rehabilitation. After an 8-year follow-up, the patient remains in remission and free of neurological defects. Apart from the radiological findings, the CSF exam as well as the evoked potentials does not suggest a diagnosis of MS. A demyelinating plaque in the cervical spinal cord can occasionally imitate a cervical intramedullary tumour leading to an operation. Such lesions underscore the sensitivity of present-day lesion detection procedures. An addition of a MS work up could be beneficial in some cases of intramedullary tumours without a typical history, although in the case presented this type of workup was negative.

[Imaging of spinal tumors]

Spinal tumors are often categorized into extradural, intradural extramedullary, or intramedullary. Although this classification represents somewhat of an overgeneralization as a lesion may reside in two compartments, it still helps to characterize spinal tumors. In the intradural, extramedullary space, primary tumors, such as neurofibroma and meningioma, are relatively common. Secondary tumors or leptomeningeal enhancement also occur. In the intramedullary space, primary tumors are far more common than secondary tumors or metastases.