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