Nonneoplastic intramedullary spinal cord lesions mimicking tumors

It Looks Like a Spinal Cord Tumor but It Is Not

Differentiating neoplastic from non-neoplastic spinal cord pathologies may be challenging due to overlapping clinical and radiological features. Spinal cord tumors, which comprise only 2-4% of central nervous system tumors, are rarer than non-tumoral myelopathies of inflammatory, vascular, or infectious origins. The risk of neurological deterioration and the high rate of false negatives or misdiagnoses associated with spinal cord biopsies require a cautious approach. Facing a spinal cord lesion, prioritizing more common non-surgical myelopathies in differential diagnoses is essential. A comprehensive radiological diagnostic approach is mandatory to identify spinal cord tumor mimics. The diagnostic process involves a multi-step approach: detecting lesions primarily using MRI techniques, precise localization of lesions, assessing lesion signal intensity characteristics, and searching for potentially associated anomalies at spinal cord and cerebral MRI. This review aims to delineate the radiological diagnostic approach for spinal cord lesions that may mimic tumors and briefly highlight the primary pathologies behind these lesions.

Cervical Schwannoma camouflaged by cervical intervertebral disc prolapse-A case report

INTRODUCTION

Cervical prolapsed intervertebral disc is one of the common conditions causing cervical myeloradiculopathy. Anterior Cervical Discectomy and Fusion (ACDF) is the standard line of management for the same. Intradural neurogenic origin tumors are relatively rare and can present with features of myeloradiculopathy. Radiological imaging plays important role in diagnosis of such pathologies.

CASE REPORT

We report a patient with C5-6 cervical disc prolapse that presented with radiculopathy symptoms in the right upper limb, which was refractory to conservative care. He underwent a C5-6 ACDF and reported complete relief from symptoms at 4 weeks. He developed deteriorating symptoms over the next 10 weeks and presented at 14 weeks follow-up with severe myeloradiculopathy symptoms on the left upper limb with upper limb weakness. A fresh MRI identified an intradural extramedullary tumor with cystic changes at the index surgery level. This was treated with tumor excision and histopathology confirmed a diagnosis of schwannoma. Simultaneous presence of cord signal changes with disc herniation obscured the cystic schwannoma which became apparent later on contrast enhanced MRI imaging.

CONCLUSION

Careful review of preoperative imaging and contrast MRI study may help in diagnosing cystic schwannomas with concomitant cervical disc herniations that have cord signal changes.

Diffusion Weighted Imaging in Spine Tumors

Diffusion weighted imaging (DWI) has developed into a powerful tool for the evaluation of spine tumors, particularly for the assessment of vertebral marrow lesions and intramedullary tumors. Advances in magnetic resonance techniques have improved the quality of spine DWI and diffusion tensor imaging (DTI) in recent years, with increased reproducibility and utilization. DTI, with quantitative parameters such as fractional anisotropy and qualitative visual assessment of nerve fiber tracts, can play a valuable role in the evaluation and surgical planning of spinal cord tumors. These widely available techniques can be used to enhance the diagnostic evaluation of spinal tumors.

Clinical and Imaging Characteristics of Non-Neoplastic Spinal Lesions: A Comparative Study with Intramedullary Tumors

The features of non-neoplastic lesions are often similar to those of intramedullary tumors, and a differential diagnosis is challenging to obtain in some cases. A surgical biopsy, which is performed on highly invasive tumors, should be avoided in cases of non-neoplastic lesions. Therefore, an accurate diagnosis is important prior to treatment. We evaluated 43 patients suspected of having spinal cord tumors and, finally, were diagnosed with non-neoplastic intramedullary lesions via magnetic resonance imaging. The patients commonly presented with myelitis. The patients with non-neoplastic neurological diseases had a significantly shorter symptom duration than those with intramedullary astrocytomas. The proportion of patients with non-neoplastic neurological diseases who presented with lesions at the cervical spinal level and focal lesions on axial imaging but without a spinal cord enlargement was significantly higher than that of patients with intramedullary astrocytomas. The current study aimed to distinguish spinal cord tumors from non-neoplastic intramedullary lesions based on their distinct features.

Diffusion tensor imaging in unclear intramedullary tumor-suspected lesions allows separating tumors from inflammation

DESIGN

Prospective diagnostic study.

OBJECTIVES

Primary imaging-based diagnosis of spinal cord tumor-suspected lesions is often challenging. The identification of the definite entity is crucial for dedicated treatment and therefore reduction of morbidity. The aim of this trial was to investigate specific quantitative signal patterns to differentiate unclear intramedullary tumor-suspected lesions based on diffusion tensor imaging (DTI).

SETTING

Medical Center - University of Freiburg, Germany.

METHODS

Forty patients with an unclear tumor-suspected lesion of the spinal cord prospectively underwent DTI. Primary diagnosis was determined by histological or clinical work-up or remained indeterminate with follow-up. DTI metrics (FA/ADC) were evaluated at the central lesion area, lesion margin, edema, and normal spinal cord and compared between different diagnostic groups (ependymomas, other spinal cord tumors, inflammations).

RESULTS

Mean DTI metrics for all spinal cord tumors (n = 18) showed significantly reduced FA and increased ADC values compared to inflammatory lesions (n = 8) at the lesion margin (p < 0.001, p = 0.001) and reduced FA at the central lesion area (p < 0.001). There were no significant differences comparing the neoplastic subgroups of ependymomas (n = 10) and other spinal cord tumors (n = 8), but remaining differences for both compared to the inflammation subgroup. We found significant higher ADC (p = 0.040) and a trend to decreased FA (p = 0.081) for ependymomas compared to inflammations at the edema.

CONCLUSION

Even if distinct differentiation of ependymomas from other spinal cord neoplasms was not possible based on quantitative DTI metrics, FA and ADC were feasible to separate inflammatory lesions. This may avoid unnecessary surgery in patients with unclear intramedullary tumor-suspected lesions.

Surgical Treatment of Intramedullary Hemangioblastomas: Current State of Problem (Review)

Intramedullary hemangioblastomas (HAB) refer to very rare highly vascularized vascular spinal cord tumors associated with various neurological disorders. Effective HAB therapy to a greater extent depends on diagnostic accuracy and the absence of intra- and postoperative complications.

The present study is a review of publications concerned with modern diagnostic and therapeutic techniques to control spinal HAB. The authors showed that perfusion computed tomography, computed tomographic angiography, and magnetic resonance angiography can be reasonably used for diagnosis and differentiation in a number of HAB due to their high vascularization. Preoperative embolization significantly reducing intraoperative bleeding risks is highly efficient. Some authors recommend this procedure in case of large lesions and high risks of intraoperative bleeding. The review also considered intraoperative imaging of a tumor and its feeding vessels using indocyanine green providing inspectability over the total tumor resection and clear imaging of tumor vascular architecture. The advantages and restrictions of the mentioned procedures were described.

Intramedullary tumours and tumour mimics

Spinal cord lesions are traditionally classified as either extradural or intradural extramedullary or of intramedullary origin. Intramedullary spinal cord tumours are histopathologically similar to cranial tumours with a diverse range of pathologies. Astrocytomas and ependymomas account for approximately 80% of all intramedullary tumours, with other primary and secondary lesions accounting for the remaining 20%. Magnetic resonance imaging is the preferred imaging modality for diagnosing and characterising spinal cord lesions; however, accurate characterisation of tumour histology can be challenging, and is further confounded by intramedullary non-neoplastic lesions, such as demyelinating vascular, inflammatory, infectious, or traumatic lesions. This review illustrates the spectrum of intramedullary tumours and tumour mimics with emphasis on the imaging findings.

Magnetic-Resonance Diffusion-Tensor Tractography in the Diagnosis of Tumefactive Spinal-Cord Lesions in Neuromyelitis Optica

Magnetic-resonance (MR) imaging is the modality of choice for the evaluation of spinal-cord lesions. However, challenges persist in discriminating demyelinating processes from neoplastic lesions using conventional MR sequences. Consequently, an invasive spinal-cord biopsy is likely for most patients. MR diffusion-tensor imaging is an emerging noninvasive and powerful method for characterizing changes in tissue microstructure associated with spinal disorders. We currently present the case of a middle-aged woman suffering from neuromyelitis optica, and highlight that MR diffusion-tensor tractography can be helpful in the identification of tumefactive spinal-cord lesions.

Imaging and pathological findings of intramedullary inflammatory pseudotumour in a miniature dachshund: a case report

Background

Inflammatory pseudotumours (IPTs) are distinctive lesions consisting of myofibroblastic spindle cells and a variety of inflammatory cells. The aetiology of IPTs is unknown. Reports of IPTs in veterinary medicine have been scarse. Moreover, only one case of intradural extramedullary IPT has been previously reported. In this report, we introduce the first known case of canine IPT, which occurred in the parenchyma of the spinal cord.

Case presentation

A 10-year-old female Miniature Dachshund presented with a 2-month-long history of progressively worsening ataxia and tetraparesis. Neurological examination was consistent with a lesion involving the cervical spinal cord. Magnetic resonance imaging revealed an intradural space-occupying lesion in the region of the fourth cervical vertebra. Dorsal laminectomy and resection of the mass were performed. Histopathological examination revealed the proliferation of immature spindle cells (fibroblasts/myofibroblasts and glial cells) and a highly cellular mixture of neutrophils, macrophages and lymphocytic cells. The mass was located in the parenchyma of the spinal cord and was diagnosed as an IPT occurring in the parenchyma of the spinal cord. No causative pathogen was detected. The dog’s symptoms improved, during the first month after surgery. However, neurological symptoms, such as laboured breathing and dysuria, subsequently worsened and the dog died 42 days after surgery.

Conclusions

The present study describes a canine case of IPT occurring in the parenchyma of the spinal cord. The diagnosis and determination of the site of the mass was difficult solely based on preoperative imaging in the present case. The outcome of this case was poorer than that observed in cases of canine extramedullary IPT and human intramedullary IPT, in which the patients exhibited recovery. The prognosis after surgical resection cannot be decided from the present case alone. However, patients should be monitored for potential serious complications and recurrence.

Pediatric spinal cord biopsy: A case series from a high-volume referral center

Pediatric patients presenting with intramedullary spinal cord lesions often require specific diagnoses to guide their treatment plans. Though results from magnetic resonance imaging and lumbar puncture may narrow the differential diagnosis, these tests cannot always provide a definitive diagnosis. In such cases, spinal cord biopsy may be undertaken to provide a specific histopathologic diagnosis for guiding treatment. Data from the adult population show 24% of spinal cord biopsies can be nondiagnostic and the procedure may carry a 21% complication rate. Therefore, spinal cord biopsy may portend a similar high risk-to-benefit ratio in the pediatric population. Here, we review spinal cord biopsy cases scheduled for diagnosis, and not debulking, at a high volume pediatric referral center during a seventeen-year period. We report our experience with five patients who met our inclusion criteria. Due to the rarity of the procedure, statistically significant factors associated with improved diagnostic yield or peri-operative complication could not be identified. A definitive diagnosis which guided the post-operative treatment plan was obtained in four of our five patients. None of our patients developed post-operative motor deficits. However, these patients were susceptible to the same risks of open spine surgery, such as wound infections and spinal deformities. Our case series shows that intramedullary spinal cord biopsies may provide tissue for obtaining histopatholgic diagnoses. However, the potential risks of complication, and the possibility of obtaining nondiagnostic tissue, should be discussed with patients, families and their medical treatment teams.

A practical approach to the diagnosis of spinal cord lesions

Every neurologist will be familiar with the patient with atypical spinal cord disease and the challenges of taking the diagnosis forward. This is predominantly because of the limited range of possible clinical and investigation findings making most individual features non-specific. The difficulty in obtaining a tissue diagnosis further contributes and patients are often treated empirically based on local prevalence and potential for reversibility. This article focuses on improving the diagnosis of adult non-traumatic, non-compressive spinal cord disorders. It is structured to start with the clinical presentation in order to be of practical use to the clinician. We aim, by combining the onset phenotype with the subsequent course, along with imaging and laboratory features, to improve the diagnostic process.

Spinal diffusion tensor tractography for differentiation of intramedullary tumor-suspected lesions

BACKGROUND AND PURPOSE

Primary MRI diagnosis of spinal intramedullary tumor-suspected lesions can be challenging and often requires spinal biopsy or resection with a substantial risk of neurological deficits. We evaluated whether Diffusion Tensor Imaging (DTI) tractography can facilitate the differential diagnosis.

MATERIALS AND METHODS

Twenty-five consecutive patients with an intramedullary tumor-suspected lesion considered for spinal surgery were studied with a Diffusion-weighted multi-shot read out segmented EPI sequence (RESOLVE). White matter tracts ("streamlines") were calculated using the FACT algorithm and visually co-registered to a T2-weighted 3D sequence. The fused images were assessed concerning spinal streamline appearance as normal, displaced or terminated. Definite diagnosis was verified by histological analysis or further clinical work-up.

RESULTS

All patients with normal appearing streamlines (n=6) showed an acute inflammatory demyelinating pathology in the further clinical work-up. In 10 patients streamline displacing lesions were found from which 5 patients underwent a surgical treatment with histologically confirmed low-grade tumors like ependymomas and pilocytic astrocytomas. In nine patients streamlines were terminated, from which 6 patients received a histology proven diagnoses with a more heterogenous spectrum (3 cases of high grade tumor, 1 case of low grade tumor with intralesional hemorrhage and 2 cases with gliosis but no tumor cells).

CONCLUSION

Using multi-shot DTI spinal tractography acute inflammatory lesions can be differentiated from other tumorous intramedullary lesions. The entity diagnosis of spinal tumors seems to be more challenging, primarily due to the variety of factors like invasivity, expansion or intralesional hemorrhage.

Spontaneous Regression of Inflammatory Pseudotumor in the Cauda Equina: A Case Report

Spinal intradural extramedullary inflammatory pseudotumor (IPT) is an extremely rare entity. Spontaneous shrinking of a spinal IPT has never been reported. A case of an IPT of the cauda equina that regressed spontaneously is presented. A 78-year-old woman presented with hypoesthesia of both lower legs in the L4 nerve root distribution and motor weakness of the right leg. Preoperative CT myelography and MRI showed two tumor-like lesions located at T12-L1 and L2-3. The lesion at the T12-L1 level appeared to encase several nerve roots. The preoperative diagnosis was ependymoma, schwannoma, or malignant lymphoma. The tumors were biopsied. In the operation, the lesion turned out to consist of swollen and adherent nerve roots. On histopathological examination of the biopsied nerve roots, they were diagnosed as IPT. The patient's symptoms improved gradually without any treatment after the operation. The IPTs regressed on the postoperative MR images and disappeared at one year. This is the first report of spontaneous regression of an IPT in the spinal region. IPT should be considered in the differential diagnosis of a tumor that appears to involve several nerve roots on preoperative imaging, but surgery is necessary for diagnosis. Complete resection is not absolutely required if an intraoperative pathological diagnosis of the frozen section reveals IPT.

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.

Imaging and clinical properties of inflammatory demyelinating pseudotumor in the spinal cord

Inflammatory demyelinating pseudotumor usually occurs in the brain and rarely occurs in the spinal cord. On imaging, inflammatory demyelinating pseudotumor appears very similar to intramedullary tumors such as gliomas. It is often misdiagnosed as intramedullary tumor and surgically resected. In view of this, the clinical and magnetic resonance imaging manifestations and the pathological fea-tures of 36 cases of inflammatory demyelinating pseudotumor in the spinal cord were retrospec-tively analyzed and summarized. Most of these cases suffered from acute or subacute onset and exhibited a sensorimotor disorder. Among them, six cases were misdiagnosed as having intra-dullary gliomas, and inflammatory demyelinating pseudotumor was only identified and pathologi-cally confirmed after surgical resection. Lesions in the cervical and thoracic spinal cord were com-mon. Magnetic resonance imaging revealed edema and space-occupying lesions to varying grees at the cervical-thoracic junction, with a predominant feature of non-closed rosette-like forcement (open-loop sign). Pathological examination showed perivascular cuffing of predominantly dense lymphocytes, and demyelination was observed in six of the misdiagnosed cases. These re-sults suggest that tumor-like inflammatory demyelinating disease in the spinal cord is a kind of special demyelinating disease that can be categorized as inflammatory pseudotumor. These solitary lesions are easily confused with intramedullary neoplasms. Patchy or non-closed reinforcement (open-ring sign) on magnetic resonance imaging is the predominant property of inflammatory myelinating pseudotumor, and inflammatory cell infiltration and demyelination are additional pa-logical properties.

Isolated spinal neurosarcoidosis: An enigmatic intramedullary spinal cord pathology-case report and review of the literature

Isolated spinal cord neurosarcoidosis (NS) in the absence of systemic disease or intracranial involvement is exceptionally rare. Adjunctive laboratory tests though useful may not be reliable and the absence of any pathognomonic radiological features makes the diagnosis difficult. As spinal cord NS may be a presenting feature of systemic sarcoidosis which may be occult on routine workup, (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET) may be of value in unraveling this systemic involvement avoiding biopsying the spinal cord. A case of truly isolated NS is described with review of literature on this enigmatic pathology. Long segment intramedullary signal changes with focal parenchymal along with dural/meningeal enhancement in the absence of significant cervical stenosis in a young patient of northern European or African-American decent is very suggestive of NS and although may be presumably treated with steroids; there should be a low threshold for spinal cord biopsy especially in the absence of response to steroids to confirm isolated spinal cord NS in a patient with clinical neurological deterioration.

Neuromyelitis optica mimicking intramedullary tumor

Neuromyelitis optica (NMO) is considered to be a rarer autoimmune disease than multiple sclerosis. It is very difficult to make a diagnosis of MNO for doctors who are not familiar with its clinical features and diagnostic criteria. We report a case of a young female patient who had been suffering motor weakness and radiating pain in both upper extremities. Cervical MRI showed tumorous lesion in spinal cord and performed surgery to remove lesion. We could not find a tumor mass in operation field and final diagnosis was NMO. NMO must be included in the differential diagnosis of lesions to rescue the patient from invasive surgical interventions. More specific diagnostic tools may be necessary for early diagnosis and proper treatment.

Intradural extramedullary spinal inflammatory myofibroblastic tumor: case report and literature review

The authors present the case of an inflammatory myofibroblastic tumor that involves the cervical spinal cord meninges, presenting in a manner mimicking en plaque meningioma, which has never been previously reported. During the first surgical procedure, which did not involve exploration of the intradural space, inflammatory epidural tissue was found. We performed a second operation to remove the tumor that was finally intradural, dural-based and very tough. Imaging studies, surgical findings, and histopathological examinations were used to support the diagnosis. Intradural extramedullary inflammatory myofibroblastic tumor is a rare entity that has only been described nine times in the literature. Surgery remains the treatment of choice. Although histologically benign, spinal inflammatory myofibroblastic tumor can be aggressive and requires a large resection and long-term follow-up of the entire central nervous system with magnetic resonance imaging.

Inflammatory myofibroblastic tumor in the intradural extramedullary space of the lumbar spine with spondylolisthesis: case report and review of the literature

An inflammatory myofibroblastic tumor (IMT) is a rare disease entity reported to arise in various organs but still thought to be a neoplastic or reactive inflammatory condition controversially. The author reports an extremely rare case of intradural extramedullary IMT of lumbar spine which was presenting radiculopathy and neurogenic intermittent claudication due to concomitant spondylolisthesis.

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.

Intramedullary lumbar lesion mimicking spinal cord tumor: a case of non-neoplastic intramedullary spinal cord lesion

Non-neoplastic intramedullary spinal lesion cases are rarely seen in the literature. We would like to present this case for differential diagnosis of intramedullary spinal tumors. The aim of this case report is to attract attention on the MRI findings with lack of contrast enhancement and long syrinx formation which differs these types of lesions from the intramedullary spinal tumors. Intraoperative, pathological and immunohistochemical findings of non-neoplastic intramedullary spinal lesion were discussed.

Demyelinating disease masquerading as a surgical problem: a case series

INTRODUCTION

We report three cases of demyelinating disease with tumor-like presentation. This information is particularly important to both neurosurgeons and neurologists who should be aware that inflammatory demyelinating diseases can present as a mass lesion, which is indistinguishable from a tumor, both clinically and radiologically, especially when there is no evidence of temporal dissemination of this disease.

CASE PRESENTATION

The first patient was a 42-year-old Malay woman who developed subacute onset of progressive quadriparesis with urinary incontinence. Magnetic resonance imaging of her spine showed an intramedullary lesion at the C5-C7 level. She was operated on and biopsy was suggestive of a demyelinating disease. Retrospective history discovered two episodes of acute onset of neurological deficits with partial recovery and magnetic resonance imaging of her brain revealed demyelinating plaques in the centrum semiovale. The second patient was a 16-year-old Malay boy who presented with symptoms of raised intracranial pressure. A computed tomography brain scan revealed obstructive hydrocephalus with a lesion adjacent to the fourth ventricle. An external ventricular drainage was inserted. Subsequently, a stereotactic biopsy was taken and histopathology was reported as demyelination. Retrospective history revealed similar episodes with full recovery in between episodes. The third case was a 28-year-old Malay man who presented with acute bilateral visual loss and confusion. Magnetic resonance imaging of his brain showed a large mass lesion in the right temporoparietal region. Biopsy was consistent with demyelinating disease. Reexamination of the patient revealed bilateral papillitis and not papilledema. Visual evoked potential was prolonged bilaterally. In all three cases, lumbar puncture for cerebrospinal fluid study was not carried out due to lack of patient consent.

CONCLUSIONS

These cases illustrate the importance of considering a demyelinating disease in the differential diagnosis of a mass lesion. Critical analyses of clinical presentations coupled with good physical examination are vital in assisting clinicians to reach the correct diagnosis.

Surgery for movement disorders

Movement disorders, such as Parkinson's disease, tremor, and dystonia, are among the most common neurological conditions and affect millions of patients. Although medications are the mainstay of therapy for movement disorders, neurosurgery has played an important role in their management for the past 50 years. Surgery is now a viable and safe option for patients with medically intractable Parkinson's disease, essential tremor, and dystonia. In this article, we provide a review of the history, neurocircuitry, indication, technical aspects, outcomes, complications, and emerging neurosurgical approaches for the treatment of movement disorders.

Intramedullary lesions of the conus medullaris: differential diagnosis and surgical management

The medullary conus represents a distinct entity of the spinal cord regarding its anatomical, clinical and microsurgical features. An overview of the pathologic processes of this region is provided. Epidemiological, clinical and neuroradiological characteristics of neoplastic (glial tumors, non-glial tumors, metastasis, primary melanomas) and non-neoplastic lesions (granulomatous lesions, abscess, parasitic infections, vascular, demyelinating and dysembryogenetic lesions) are discussed. Main MR imaging characteristics used to differentiate neoplastic from non-neoplastic lesions consist in pathological spinal cord expansion, gadolinium-enhancement and tumoural cyst formation. Management strategies differ substantially, depending on the kind of lesion. According to the suspected pathological entity radical resection, biopsy or conservative treatments are reasonable options. Intraoperative electrophysiological monitoring is a fundamental part of the surgical setting.

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.

Part I: Spinal-cord neoplasms—intradural neoplasms

Intradural spinal-cord tumours are an uncommon but important consideration in the differential diagnosis of patients with back pain, radicular pain, sensorimotor deficits, or sphincter dysfunction. Intradural spinal tumours can be divided into intramedullary and extramedullary spinal-cord tumours on the basis of their anatomical relation to the spinal parenchyma. The heterogeneous cell composition of the intradural compartment allows the formation of neoplasms, arising from glial cells, neurons, and cells of spinal vasculature. Additionally, developmental tumours, metastases, and intradural extension of extradural tumours are represented. In this Review, we discuss the published work on intradural spinal-cord tumours in terms of epidemiological, radiographic, and histological characteristics. Surgical and adjuvant treatment strategies are also reviewed.

Neurosarcoïdose : état des connaissances

The origins of neurosarcoidosis, a multisystemic granulomatous disease, remain unknown. Nervous system localizations remain rare, but severe. Lymphocytic meningitis, psychiatric disorders, diabetes insipidus and cranial nerve palsy are the most frequent signs. Cerebral fluid test and cervical medullar and cerebral MRI with gadolinium have to be performed first. In some cases, histological evidence of granuloma have to be obtained with neuromuscular, meningeal or cerebral biopsies. Functional impairment and life-threatening conditions require early corticosteroid therapy. In worsening cases or in the event of no therapeutic response or poor tolerance to corticosteroids, other immunosuppressive agents should be associated. Maintenance therapy and most often life long maintenance therapy allow a continuous success while avoiding relapse.

Recurrent intramedullary sarcoidosis

We present a 47-year-old man with recurrent intramedullary sarcoidosis. This condition, without any other manifestations of the disease, is rare, with less than 20 reports in the literature. Further, to our knowledge our presentation is the only reported case of intramedullary sarcoidosis recurring in a separate, distant region of the cord after a period of treatment with steroids, to which the patient had initially responded.

Enlargement of the spinal cord: inflammation or neoplasm?

Intramedullary spinal tumours are uncommon lesions that can cause significant difficulties in the differential diagnosis between inflammatory diseases such as multiple sclerosis and acute disseminated encephalomyelitis, and vascular malformations or neoplasms. We report five cases in which the history and the clinical symptoms suggested an inflammatory process of the spinal cord but the MRI characteristics were those of neoplastic lesions. Both non-neoplastic and neoplastic intramedullary lesion may have very similar symptoms, and even CSF abnormalities, but in every one of our cases, a more detailed history and longer observation of the clinical course would have led to the correct diagnosis; in such problem cases, empirical treatment and a follow-up MRI after a month's observation would be a more prudent approach providing that the patient is not rapidly deteriorating.

Intramedullary inflammatory mass dorsal to the Klippel-Feil deformity: error in development or response to an abnormal motion segment?

STUDY DESIGN

Case study on a 45-year-old female with progressive weakness and paresthesias in her lower extremities and a magnetic resonance image of an intramedullary mass at the level of C5-6 and a Klippel-Feil (KF) deformity ventral to the lesion.

OBJECTIVE

Present an interesting case of an intramedullary mass coexisting with a ventral KF deformity with review of the medical literature on intramedullary masses and cervical spine biomechanics.

SETTING

New York city, New York, USA.

METHODS

Case study with discussion of neurosurgical and neuropathological findings and review of the literature.

RESULTS

The patient underwent open neurosurgical excisional biopsy of the intramedullary mass which revealed a non-neoplastic inflammatory mass that slowly resolved with medical management.

CONCLUSIONS

While no definitive etiology was found in this case we offer two interesting mechanisms: (1) maldevelopment of the cervical spine or (2) this inflammatory mass is in response to an abnormal motion at the level of the Klippel-Feil.

Intramedullary neurosarcoidosis in the medulla oblongata: a case report

OBJECTIVE

We present a rare case of neurosarcoidosis mimicking an intramedullary tumor in the medulla oblongata. The features of the clinical presentation, magnetic resonance (MRI) appearances, and management strategy are discussed.

CASE PRESENTATION

A 59-year-old man without evidence of systemic sarcoidosis was presented with a history of progressive numbness and deep sensation disturbance in bilateral lower extremities. MR imaging revealed an enhanced intra-axial mass lesion on the dorsal side of medulla. Under neurophysiological monitoring, tumor biopsy was performed. Pathologic evaluation revealed noncaseating granuloma composed of large epithelioid cells with multinucleated giant cells, suggesting sarcoidosis. Findings of comprehensive hematologic laboratory studies; cerebrospinal fluid examination; and examinations for bacteria, fungi, and acid fast bacilli were all negative. This mass lesion was diagnosed as medullary neurosarcoidosis, and then high-dose steroid therapy was tried. On follow-up, nearly complete resolution of the neurosarcoidosis on MRI was revealed.

CONCLUSION

To our knowledge, this is the first reported case of neurosarcoidosis manifested in the medulla oblongata. A biopsy is sufficient for a diagnosis and high-dose steroid is recommended.

Inflammatory myofibroblastic tumour of the spinal cord: case report and review of the literature

Inflammatory myofibroblastic tumours (IMT), also called inflammatory pseudotumours, nodular lymphoid hyperplasia, plasma-cell granuloma and fibrous xanthoma, are rare soft-tissue lesions characterised by inflammatory cells and a fibrous stroma. Clinically and radiologically, they may look like malignant tumours. They rarely affect the central nervous system and are very rare in the spinal cord. We report an IMT of the spinal cord in a 22-year-old woman presenting with spinal cord compression and a cauda equina syndrome. MRI showed a lesion at T9 with extramedullary and intramedullary components giving low signal on T2-weighted images and enhancing homogeneously. Pial lesions on the lumbar enlargement and thoracic spinal were present 11 months after surgery, when the lesion recurred. We present the radiological, operative and pathological findings and review the literature.

Intramedullary Spinal Cord Tumors

The three most common types of intramedullary spinal cord tumors are low-grade astrocytomas, ependymomas, and high-grade astrocytomas. Surgical extirpation is the necessary and sufficient primary treatment for most intramedullary spinal cord tumors. Radiation therapy may also have a role in the management of persistent, recurrent, or progressive low-grade astrocytomas and ependymomas. The current treatment of spinal cord high-grade astrocytomas, which includes surgical debulking, radiation therapy, and possibly chemotherapy, is clearly inadequate. Chemotherapy may have a potential role for certain progressive spinal cord tumors, but the role is undefined at present. Recent reports have described the use of stereotactic radiosurgery for extramedullary spinal tumors, and stereotactic radiosurgery may someday be useful in the management of intramedullary spinal cord tumors. Rehabilitation programs are an important component of the multidisciplinary care of patients with spinal cord tumors. Finally, more work, especially the inclusion of adults and children with intramedullary spinal cord tumors into prospective clinical trials, is needed to improve the therapy of intramedullary spinal cord tumors and rehabilitation after diagnosis of a spinal cord tumor.

Spinal cord biopsy: a review of 38 cases

OBJECTIVE

Neurosurgeons are frequently asked to evaluate patients for spinal cord biopsies when preoperative magnetic resonance imaging studies demonstrate nonspecific features. These lesions often appear unresectable, but surgeons must decide whether a biopsy is warranted. To determine the best approach to these cases, we evaluated the clinicopathological findings for patients with unknown spinal cord lesions who underwent spinal cord biopsies.

METHODS

Thirty-eight consecutive patients who underwent spinal cord biopsies at the Mayo Clinic (Rochester, MN) between August 1988 and July 1998 were studied. A detailed review of the case histories, radiological results, surgical notes, histological findings, and outcomes was performed.

RESULTS

Spinal cord biopsies were performed for 21 male and 17 female patients (mean age, 42.1 yr) with progressive neurological deficits related to spinal cord lesions. All patients underwent preoperative magnetic resonance imaging evaluations. High T2-weighted signal intensity and spinal cord expansion were identified in 92 and 87% of cases, respectively. After gadolinium infusion, the majority (94%) of the inflammatory lesions demonstrated patchy and often peripherally situated enhancement. This neuroradiological pattern was less common for neoplasms (50%) and benign lesions (40%). The most common pathological findings were inflammatory changes of demyelination or sarcoidosis, which together accounted for 13 cases (34%). Nonspecific changes or benign lesions were observed in 10 cases (26%). Neoplasms were identified in eight cases (21%). One case of tuberculosis and one of schistosomiasis were found. Overall, 47% of the preoperative diagnoses made by the attending surgeon were correct. For 26% of the patients, specific treatment was based on the biopsy results. The average follow-up period was 12 months (standard deviation, 14 mo; range, 0-50 mo).

CONCLUSION

Preoperative laboratory and imaging studies are often diagnostically inconclusive in cases of spinal cord lesions with nonspecific features. Biopsies should be considered for patients with progressive symptomatic lesions.

Spinal Intramedullary Tuberculoma Requiring Surgical Treatment-Case Report-

A 71-year-old male presented with multiple central nervous system tuberculomas including spinal intramedullary tuberculoma manifesting as occipitalgia and left hemiparesis. He had received medical treatment for lung and testis tuberculosis. Magnetic resonance imaging revealed an intramedullary lesion at the C-2 level as well as multiple small extramedullary and intracranial lesions. His neurological symptoms gradually worsened despite intensive antituberculous therapy. The C-2 intramedullary lesion responsible for left hemiparesis was surgically extirpated. Postoperatively, his neurological symptoms improved gradually, and no recurrence was evident at the resected site. Surgical intervention is mandatory in patients with intramedullary tuberculoma if neurological symptoms deteriorate or lesions enlarge despite continuous antituberculous therapy.

Extramedullary sarcoid lesion mimicking intraspinal tumor

BACKGROUND CONTEXT

Spinal sarcoidosis is rare. Most spinal sarcoid lesions are intramedullary, and only three cases of extramedullary sarcoid lesions have been reported.

PURPOSE

To describe a case of an extramedullary sarcoid lesion in a patient that did not have systemic involvement and to review the literature of spinal sarcoidosis.

STUDY DESIGN/SETTING

Case report and review of the literature.

PATIENT SAMPLE

Case report.

OUTCOME MEASURES

Report of resolution of symptoms.

METHODS/DESCRIPTION

The patient was a 33-year-old woman who had neck pain and pain radiating to the right scapula area and down the right arm into her hand and wrist. She also complained of numbness, tingling, muscle spasms and tremors, and had difficulty with writing. Magnetic resonance imaging showed a mass that was extramedullary in the right lateral aspect of the spinal canal at the level of C5 and extending into the right C5-6 neuroforamen. Admitting diagnosis of neurofibroma was made. The patient underwent C4, C5 and C6 laminoplasty and gross total resection of an intradural extramedullary tumor. The lesion encroached on the neuroforamen on the right side involving the C6 nerve root, was grossly adherent to some of the rootlets and looked like a Schwannoma. Gross total resection of the tumor was performed. Pathological examination of the specimen showed a noncaseating granulomatosis consistent with sarcoid. Postoperative testing did not reveal systemic involvement of sarcoidosis. The patient was treated with corticosteroids.

RESULTS

The patient made a satisfactory recovery, returned to work full-time, and had no complaints of neurological symptoms.

CONCLUSIONS

An extramedullary sarcoid lesion is rare. Unlike intramedullary sarcoid lesions, it can be totally removed. If no systemic sarcoidosis is present, the patient can have a satisfactory recovery.

Intramedullary plasma cell granuloma in the cervicothoracic spine

✓ Intraspinal plasma cell granuloma, which is a nonneoplastic entity, is extremely rare. To date, only four cases have been documented in the spinal meninges. The authors report the first case of a C7—T1 intramedullary plasma cell granuloma. After excision of the lesion, the patient's gait and bladder dysfunction improved. This plasma cell granuloma initially showed no delineated mass on T1-weighted magnetic resonance (MR) images, low signal intensity on T2-weighted images, and was well enhanced after administration of gadolinium diethylenetriamine pentaacetic acid. The latter MR imaging modality should help to detect this tumorous lesion. Histologically, the granuloma needs to be distinguished from lymphoplasmacyte-rich meningioma and plasmacytoma.

Intrinsic spinal cord tumor resection

SPINAL CORD TUMORS are more frequently detected than in the past, because of progress in neuroradiology. Many neurosurgeons must now decide how to treat such lesions. The recent neurosurgical literature contains many case reports, few series, and different strategies. This article describes the surgical method I have developed in a period of 15 years, with Georges Fischer in Lyon, on the basis of experience with more than 260 patients and 300 operations. The standard treatment is complete resection whenever possible, but we must learn when and where to stop to preserve the quality of life. I have several useful strategies, which are explained in this report. For gliomas (ependymomas and astrocytomas), I favor a midline approach; for most vascular tumors (such as hemangioblastomas and cavernomas), however, I prefer to proceed from the point at which the lesion is observed through the microscope and to dissect the lesion in one piece. Meticulous nonbleeding surgery and experience are the keys to success.

Multiple plasma cell granuloma of the central nervous system: a unique case with brain and spinal cord involvement. Case report and review of literature

STUDY DESIGN

Single subject (male, 34 years-of-age) case report.

OBJECTIVES

To describe a unique case of plasma cell granuloma (PCG) with simultaneous brain and spinal cord involvement.

SETTING

Private hospital, capital city, Turkey.

METHODS

The patient presented with headache and paraplega. T2 weighted MR images showed multiple hyperintense cerebral, cerebellar, brainstem and spinal cord lesions that enhanced homogeneously with contrast medium. The patient was operated on, and the two intramedullary spinal cord lesions at T11 and T12 were totally excised.

RESULTS

After 3 months of an intense physiotherapy programme the patient was able to walk with help.

CONCLUSION

We report for the first time, the occurrence of multiple, simultaneous brain and intramedullary spinal cord plasma cell granulomas.

[Schistosomiasis of the spinal cord. Case report]

The authors report a case of a 34 year-old woman who, in the last four years, had travelled to Africa frequently, and developed a progressive clinical (about three months) dysfunction of the conus medullaris mainly consisting in sensitive disturbances. The MRI showed an intramedullary spinal cord lesion, and specific laboratory tests were negative. A biopsy for histologic diagnosis, showed a granulomatous tissue with eggs of S. Hematobium. After this diagnosis she was treated with praziquantel. We emphasize the relative frequency of the spinal cord location of schistosomiasis in endemic countries, and the importance of the laboratory diagnosis to start an early and effective antischistosomal treatment. Spinal cord schistosomiasis is uncommon but we must bear in mind this possibility in patients with a progressive spinal cord afectation.