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Neuroradiology Case of the Week
Case 427
July 2009
Balasubramanya Kolar, MD, Henry Wang, MD, PhD,
and P-L Westesson, MD, PhD, DDS
Clinical
Presentation: A 70-year-old male presented with progressive right hemiparesis and left sided weakness. MRI was requested to evaluate cord compression.
Imaging Findings: MR imaging showed a focal T2 hyperintense lesion in the lower part of medulla extending through the cervicomedullary region to the upper cervical level. There was peripheral enhancement on contrast images. There was no cord expansion.
PET images showed minimal uptake within the lesion which was similar to gray matter of brain.
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Figures 1A&B: Axial T2-weighted and post-contrast T1-weighted images show T2 hyperintense lesion with peripheral enhancement in the medullary region.
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| Figures 2A&B: Sagittal T2 and post-contrast T1-weighted images show hyperintense lesion with peripheral enhancement in the cervical cord without any expansion of cord. |
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| Figure 3: PET image shows uptake within the lesion equal to the uptake of rest of the gray matter of brain (SUV-2.6). |
Diagnosis: Glioblastoma of medulla and upper cervical spinal cord
Discussion: Intramedullary gliomas are rare tumors and account for 8% of primary spinal cord tumors [1]. Patients are generally young with an age range from 5 to 48 years and duration of illness of less than a year.
Gliomas and in general neoplastic lesions within the spinal cord usually are associated with cord expansion. There is also evidence of perilesional edema in most cases. A very interesting feature of our case was the lack of any cord expansion.
The differential diagnosis for intramedullary lesions with similar appearances and absence of cord expansion include demyelinating lesions (tumefactive lesions), sarcoidosis, inflammatory pseudotumor, and infectious lesions [2]. The lack of cord expansion in fact has caused many authors to consider nonneoplastic etiologies.
The prognosis for these lesions is also poor. Also, the lesions tend to metastasize to the intracranial compartment [3]. The chances of an intramedullary glioma spreading to the brain are much higher than an intracerebral lesion to the spinal cord.
References:
- Slooff JL, Kernohan JW, MacCarty CS. Primary Intramedullary Tumours of the Spinal Cord and Filum Terminale. London: Saunders, 1964.
- Lee M, Epstein FJ, Rezai AR, Zagzag D. Nonneoplastic intramedullary spinal cord lesions mimicking tumors. Neurosurgery. 1998 Oct;43(4):788-94; discussion 794-5. PMID: 9766305 [PubMed]
- Hely M, Fryer J, Selby G. Intramedullary spinal cord glioma with intracranial seeding. J Neurol Neurosurg Psychiatry. 1985 Apr;48(4):302-9. PMID: 3998737 [PubMed]
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