Intramedullary Spinal Cord Lesion
Bernadette L. Koch, MD
DIFFERENTIAL DIAGNOSIS
Common
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Syringomyelia
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ADEM
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Idiopathic Acute Transverse Myelitis
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Acute Transverse Myelopathy
Less Common
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Contusion-Hematoma
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Multiple Sclerosis
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Astrocytoma
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Cellular Ependymoma
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Abscess
Rare but Important
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Dermoid and Epidermoid Tumors
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Cavernous Malformation
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Infarction
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Hemangioblastoma
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
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Tumor vs. demyelinating disease
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Tumors tend to be ovoid in shape, frequently enlarge cord ± cyst
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Demyelinating disease tends to be flame-shaped without cord enlargement or cyst
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Differentiation may require follow-up
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Adult vs. child spinal cord tumors
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Intramedullary tumors tend to be more rostral in children than adults; 50% are cervical or cervicothoracic in children
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Astrocytoma is most common spinal cord tumor in children; ependymoma is most common spinal cord tumor in adults
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Hemorrhage: Ependymoma, cavernoma, hemangioblastoma, cord contusion
Helpful Clues for Common Diagnoses
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Syringomyelia
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Key facts
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Hydromyelia = cystic central canal
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Syringomyelia = cystic cord cavity, not contiguous with central canal
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Syringohydromyelia = features of both syringomyelia and hydromyelia
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Imaging findings: Expanded cord + nonenhancing cyst or dilated central canal
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Tubular, beaded, or sacculated
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± widened canal, vertebral scalloping
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± hydrocephalus, Chiari 1, Chiari 2, dysraphism, tethered cord, or scoliosis
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ADEM
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Key facts: Self-limiting, para-/postinfectious or postimmunization illness
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Typically monophasic
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Brain > spinal cord involvement
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Imaging findings: ↑ T2 SI ± enhancement
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Idiopathic Acute Transverse Myelitis
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Key facts: No etiology found
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Imaging findings: Normal in up to 50%
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↑ T2 SI with variable enhancement
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Mild fusiform cord enlargement
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Usually central in location, > 2/3 cross-sectional area of cord
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Usually 3-4 vertebral segments in length
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Lacks associated intracranial lesions
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Acute Transverse Myelopathy
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Key facts: Secondary to collagen vascular disease, viral infection, post-vaccination or post-irradiation, paraneoplastic syndrome; chronic ischemia/venous stasis secondary to AVM
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Imaging findings: Same as idiopathic ATM
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Helpful Clues for Less Common Diagnoses
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Contusion-Hematoma
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Key facts: Post-traumatic
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Imaging findings
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Acute contusion = edema or hematoma
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Transection: Best identified on T1WI
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Chronic: Gliosis, atrophy ± cyst, hemosiderin scar
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± associated fracture, subluxation, traumatic disc herniation
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Multiple Sclerosis
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Key facts: Multiphasic demyelinating disease of central nervous system
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Imaging findings
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↑ T2 SI ± patchy or confluent CE
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Multiple lesions of variable enhancement
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Cervical cord most common site
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Usually < 2 vertebral segments in length; < 1/2 cross-sectional area of spinal cord
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Cord enlargement uncommon
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Majority of patients have associated brain lesions: Periventricular, subcallosal, brain stem, or cerebellar white matter
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Astrocytoma
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Key facts: Most common spinal cord tumor in children (60%)
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Tumor margins frequently extend beyond enhancing tissue
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Imaging findings
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Fusiform enlargement of cord, infiltrative margins of T2 hyperintensity
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More eccentric and less enhancing than ependymomas
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Peritumoral cysts in up to 40%
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± expansion of canal, scoliosis
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Cellular Ependymoma
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Key facts: 2nd most common cord tumor in children (30%)
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Tumor margins usually = margin of enhancing tissue
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Imaging findings: Circumscribed and enhancing, usually central in cord
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Peritumoral cysts in up to 80%
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Hemosiderin (“cap” sign) at superior and inferior borders, present in 20%
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± widened canal, scoliosis, scalloping
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Abscess
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Key facts: Direct extension from dysraphism in children; idiopathic or hematogenous spread in adults
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Imaging findings: Irregular ring enhancement + cord expansion; ± restricted diffusion
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Helpful Clues for Rare Diagnoses
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Dermoid and Epidermoid Tumors
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Key facts: Benign tumor
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Intramedullary (40%), extramedullary (60%), extradural (rare)
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From cells that produce skin, hair follicles, sweat, and sebaceous glands
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Imaging findings
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Similar to CSF on T1 and T2WI ± hyperintense T1 fat in dermoid
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Epidermoid may be hyperintense on DWI, slightly hyperintense on FLAIR
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± mild ring enhancement
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↑ ↑ enhancement, suspect infection
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Cavernous Malformation
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Key facts: 3-5% in spinal cord
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