PATOLOGIE TUMORALI
ENDOCANALARI
Dott.ssa Anna Pichiecchio
U.O. Neuroradiologia
Istituto Neurologico IRCCS Fondazione C. Mondino, Pavia
SPINAL TUMORS
Uncommon lesions
Classification based on their location
EXTRADURAL
INTRAMEDULLARY
(60% of all spinal tumors)
(5%-10% of all spinal tumors)
Metastasis
Extension of primary
bone tumors
INTRADURALEXTRAMEDULLARY
(30% of all spinal tumors)
Meningiomas and
neurinoma
Leptomeningeal
dissemination
gliomas
MRI gold standard!
TR
TE
FOV
Matrix
Sag T2-w
3500
120
275
304X225
Sag T1-w
400
10
275
304X225
Sag T2 STIR
2500
(TI=170)
70
275
256X190
Ax T2-w
4500
120
230
288X200
Ax T1-w
541
15
225
304X212
Sag T1-w fat
suppression
post contrast
400
10
275
304X212
Ax T1-w post
contrast
541
15
225
304X212
1. INTRAMEDULLARY TUMORS
DURA MATER
ARACHNOID
DURAL NERVE
ROOT SLEEVE
DENTICULATE
LIGAMENT
SPINAL CORD
AND PIA
EPIDURAL FAT
SUBDURAL SPACE
JUNCTION OF DURAL
SLEEVE AND SPINAL
NERVE PERINEURIUM
EPIDURAL FAT
SEPTUM POSTICUM
Summary
Three general characteristics:
1)they tend to enlarge the cord either focally or
diffusely
2) on T2-w they produce high signal intensity
3) They enhance
1.a. SPINAL CORD ASTROCYTOMA
From astrocytes
Most WHO I-II
Most common
in CHILDREN
•20% intraspinal
neoplasms
•60% primary spinal
cord tumors
80-90%
low grade
Pilocitic
Fibrillary
subarachnoid dissemination may occur!
Association with abnormalities of
chromosome 17p (TP53 gene)
General features
A) Age: two peaks: 10 - 30 ys
Demographic features:
BEST
DIAGNOSTIC
CLUE
LOCATION
SIZE
B) Gender: M > F (1,3:1);
no gender difference in children!
Enhancing infiltrating cord mass in child
No capsule or cleavage
Thoracic >Cervical > Lumbar
Usually 1-3 cm, less than 4 segments
MORPHOLOGY fusiform expansion of cord, eccentric , posterior
Risk in patients with Neurofibromatosis (NF1 and NF2)
MR Findings
T1-w: a) Cord expansion
Usually < 4
segments
Occasionally
multisegmental
(holocord more
common with
pilocytic
astrocytomas)
b) 40% cysts and
syringohydromyelia
c) Solid portion
(hypo-isointense)
CORD
EXPANSION
From Rossi et al 2007
MR Findings
T2-w:
a) Hyperintense
HYPERINTENSE
LESION
b) Not as hyperintense if
cysts/syrinx
T2* GRE:
a) Rarely hemorrhagic
CYSTS
From Rossi et al 2007
RARELY
HEMORRAGE
CYSTS
T1-w
post-contrast:
a) enhancement
MODERATE C.E.
ALWAYS!!
From Rossi et al 2007
DIFFERENTIAL DIAGNOSIS
SARCOIDOSIS
INTRAMEDULLARY
EPENDYMOMA
INTRAMEDULLARY
HEMANGIOBLASTOMA
From Baker et al 1999
ARNOLD-CHIARI I MALFORMATION
SYRINGOMYELIA
1.b. SPINAL CORD EPENDYMOMA
Cellular ependymomas
(lining spinal cord central canal)
Myxopapillary ependymomas
(from ependymal cells of filum
terminale)
CELLULAR EPENDYMOMA
Neoplasm of ependyma lining
spinal cord central canal
•Most common in ADULT
(60%) in lower spine
[ependymoma: 4% of all primary
CNS tumors]
•2nd most common
in CHILDREN
Associated with:
•ESA
•Superficial siderosis
•NF2
deletion or
traslocation chr 22
General features
A) Age: 40 yrs
Demographic features: B) Gender: M:F=3:1
C) Ethnicity: non racial predilection
BEST
DIAGNOSTIC
CLUE
LOCATION
SIZE
Circumscribed, enhancing cord mass with
hemorrhage
Conus> Cervico-Thoracic
Multisegmental (typically 3-4 segments)
Well-circumscribed, symmetric cord expansion,
MORPHOLOGY
occasional exophytic component
Radiological features
MR Findings
T1-w:
a) Iso- or slightly
hypointense to spinal
cord
b) Hemorrhage
ISOHYPOINTENSE
LESION
Radiological features
MR Findings
T2-w:
a)Hyperintense
b) Polar (rostral
or caudal) or
intratumoral
cysts
(50-90%)
HEMOSIDERIN
“CAP SIGN”
Hemosiderin
“Cap sign”
c) Syrinx
d) Focal hypointensity
e) Surrounding cord oedema
Radiological features
HEMOSIDERIN
“CAP SIGN”
MR Findings
STIR:
a) Hyperintense
T1-w post-contrast:
a) Intense,welldelineated
homogeneous c.e.
(50%)
b) Nodular,
peripheral,
heterogeneous c.e.
c) Minimal or no
c.e. rare
C.E.
ASTROCYTOMA
EPENDYMOMA
Astrocytoma
Ependymoma
cervical
Eccentric posterior
-
conus
central
hemorragic
hyercellularity
Pseudocapsule
(plane)
Infiltrative (poor
borders)
MYXOPAPILLARY EPENDYMOMA
from ependymal cells of filum terminale
27-30% of all ependymomas
90% of all filum terminale
tumors
Radiological features
MR Findings
T1-w: a) Usually Isointense
with cord
b) Hyperintensity
(accumulation of
mucin!)
T2-w: a) Hyperintense
b) Hypointensity at tumor
margins (hemosiderin)
STIR: a) Hyperintense
T1-w post-contrast: a) Intense c.e.
From Rossi et al 2007
INTENSE
C.E.
From Rossi et al 2007
DIFFERENTIAL DIAGNOSIS
ARTERO-VENOUS FISTOLA
SPINAL MENINGIOMA
From Rossi et al 2007
•Isointense with cord on T1-w and T2-w
•More common in thoracic and cervical spine
(conus and filum location unusual)
•Hemorrhage uncommon
•Bony changes rare
1.c. SPINAL CORD HEMANGIOBLASTOMA
Capillary rich
neoplasms
WHO I
1-5% of all spinal cord neoplasms:
•75% sporadic
•25% associated with von Hippel-Lindau
(VHL)
•Autosomal dominant (chromosome 3p)
•Cerebellar hemangioblastomas, retinal angiomas, pheochromocytoma,
renal cell carcinoma, angiomatous or cystic lesions of kidneys, pancreas
and epididymis
General features
Demographic features:
BEST
DIAGNOSTIC
CLUE
LOCATION
SIZE
A) Age: mean age at presentation 30 ys
B) Gender: M = F
Intramedullary mass with serpentine “flow
voids”
Thoracic > Cervical
Subpial
(posterior, rarely anterior)
often associated with intraspinal cysts
Few mm to several cm
MORPHOLOGY Round, well-defined margins
Radiological features
MR Findings
T1-w:
Small:
a) Isointense
b) Cyst!!
(> 50%)
Large:
a) hypoisointense
b) “flow voids”
(lesion >
2,5 cm)
ISOHYPOINTENSE
LESION
+
SYRINX
Radiological features
MR Findings
T2-w:
a) Uniformly hyperintense
(small lesions)
mixed hyperintense
(hemorrhage common)
a) +/- peritumoral oedema
b) Syrinx fluid
HYPERINTENSE
LESION
+
CYST
Radiological features
MR Findings
T1-w post contrast:
Cyst/
Syrinx:
Well-demarcated, no c.e.
a) Subpial nodule
intense,
homogeneous C.E.
(often on surface
of dorsal cord)
SUBPIAL
NODULE ON
THE DORSAL
SURFACE
ARTERIOVENOUS
MALFORMATION (AVM)
CAVERNOUS MALFORMATION
•Pattern of prior hemorrhage, hemosiderin rim
•Minimal c.e.
•Cord often normal/small, gliotic
• focal nodule absent, dorsal veins prominent
•M 50-60 y insidious onset of lower
extremities weakness
From Chabert E et al. J
Neuroradiol 1999; 26:262-268
Ependymoma
metastasis
mass centrally located
Astrocytoma
Crowley, Neurosurgery 2008
not hypervascular;
peritumoral oedema common
Renal cell carcinoma
1)they tend to enlarge the cord either focally or diffusely
2) on T2-w they produce high signal intensity
3) They enhance
Symptoms include pain, weakness and muscle atrophy
Demylinating diseases
Infections
Inflammation
Multiple Sclerosis
ADEM
Cord swelling from
extramedullary infectious
process (as meningitis
producing vascular
compromise)
AIDS
Sarcoid
LES
Syringohydromyelia
Vascular lesions
Causes of subacute
necrotizing myelopahty
Hemorrage
Acute infarction
Venous hypertension
Cavernous angioma
Arterovenous
malformation
ADEM
Devic, MS
HZV,Rubeola,
Mononucleosis, mumps
Toxo, TBC
Lupus
Spinal dural AVM
Venous hypertension
2. INTRADURAL EXTRAMEDULLARY TUMORS
DURA MATER
ARACHNOID
DURAL NERVE
ROOT SLEEVE
DENTICULATE
LIGAMENT
SPINAL CORD
AND PIA
EPIDURAL FAT
SUBDURAL SPACE
JUNCTION OF DURAL
SLEEVE AND SPINAL
NERVE PERINEURIUM
EPIDURAL FAT
SEPTUM POSTICUM
Schwannoma, Neurinoma
Arise from single nerve,
from one side
 Typically dorsal root
 Schwann cells
Do NOT envelope the
adiacent nerve root
Lobulated
Single
Neurofibroma
Schwann cells and
fibroblasts between dispersed
nerve fibers, mps matrix
Spreads apart axons
DO envelope the adiacent
nerve root
Fusiform
Multiple
2.a. SCHWANNOMA
Neoplasm of nerve
sheath in PNS
Most common WHO grade I
intradural
extramedullary
mass
30% primary
spinal tumors
•Mostly sporadic
(inactivation of NF2 gene)
• Association with NF2,
bilateral multiple
General features
A) Age: 40 ys
Demographic features: B) Gender: M = F
C) Ethnicity: no racial predilection
BEST
DIAGNOSTIC
CLUE
Well-circumscribed, “dumbbell” shaped, enhancing
spinal mass
Thoracic > Cervical = Lumbar
LOCATION
70-75% intradural extramedullary
15% completely extradural
15% “dumbbell” (both intra- and extradural)
SIZE
Few mm
Giant schwannoma: > 2 vertebral segments
MORPHOLOGY Round, lobulated
Radiological features
T1-w:
Isointense
ISOINTENSE
LESION
T2-w:
a) hyperintense
b) 45%cyst 10% hemorrage
c) “Target sign”
HYPERINTENSE
LESION WITH
TARGET SIGN
Radiological features
T1-w post-contrast:
a) Intense c.e.
(uniform or peripheral)
C.E.
2.b. NEUROFIBROMA
Localized, diffuse or
plexiform neoplasm of
nerve sheath
WHO grade I
WHO grade III/IV
•5% of all benign soft tissue tumors •Association with
neurofibromatosis 1 (NF1)
13-65% have spinal
neurofibromas
ISOINTENSE
LESION
HYPERINTENSE
LESION
+
HYPOINTENSE
SEPTATIONS
C.E.
DIFFERENTIAL DIAGNOSIS
CHRONIC INFLAMMATORY DEMYELINATING
POLYNEUROPATHY (CIDP)
2.c. MENINGIOMA
Origin from arachnoid
Attached to the dura mater for infiltration
SECOND MOST
COMMON
INTRADURAL
EXTRAMEDULLARY
TUMOR
> 25% WHO I
Meningothelial
Fibroblastic
Psammomatous
angiomatous
 Genetic predisposition in
women!
•Almost all have chromosome
22 abnormalities
•Association with
neurofibromatosis 2 (NF2)
Solitary
General features
Demographic features:
A) Age: 50-60 yrs
B) Gender: F:M=4:1 (>70-80% female!)
BEST
DIAGNOSTIC
CLUE
LOCATION
SIZE
Enhancing intradural extramedullary mass with “dural
tail”
Thoracic (80%)>> Cervical (16%) > Lumbar (4%)
Typical intradural extramedullary
Posterolateral (anterior cervical)
Variable
MORPHOLOGY Typically round with dural attachment, Ca ++ < 5%
Radiological features
ISOINTENSE LESION
WITH CALCIFICATION
MR Findings
T1-w: a) Isointense
T2-w: b) Iso- hyperintense
c) Hypointense
(calcification)
Radiological features
C.E.
T1-w post-contrast:
a) Prominent c.e.
b) May see enhancing
“dural tail”
Differential diagnosis
NEURINOMA
More anterior
Very hyperintense on T2-w
with Target sign
Cystic change, hemorrhage
more common
No dural attachment
 more frequent enlargment
of neural foramen
DROP METASTASIS
3. EXTRADURAL TUMORS
DURA MATER
ARACHNOID
DURAL NERVE
ROOT SLEEVE
DENTICULATE
LIGAMENT
SPINAL CORD
AND PIA
EPIDURAL FAT
SUBDURAL SPACE
JUNCTION OF DURAL
SLEEVE AND SPINAL
NERVE PERINEURIUM
EPIDURAL FAT
SEPTUM POSTICUM
METASTASIS
LYMPHOMA
Female (breast and lung)
Male (prostate and lung)
Thoracic (70%)> lumbar (20%) > cervical (10%)
From Thurner et al.
DROP METASTASIS
DIFFERENTIAL DIAGNOSIS
ANGIOMIOLIPOMA
DIFFERENTIAL DIAGNOSIS
GRANULOMATOSIS
INTRADURAL ARACHNOID CYST
EPIDURAL EMATOMA
Grazie per l’attenzione