Spine tumors 1 – Introduction to a location-based approach
Spine tumors can be a challenging topic for a neuroradiologist because we deal less with tumors in the spinal cord and spinal canal. However, there is a relatively simple approach that can hep you hone your differential diagnosis. This involves taking a location-based approach which divides the spinal canal into 3 main regions.
Intramedullary – in the spinal cord
Extramedullary intradural – in the thecal sac (within the dura) but outside the spinal cord
Extradural – outside the dura
Then, you can formulate your differential based on the normal structures in those regions. You can’t always tell the exactly location of a lesion, but you can use the displacement of normal structures to help you try to decide. Then you know how to guide your differential.
By the end of this video you will be able to name the three main compartments of the spine for classification of tumors. The subsequent videos will help walk you through the more specific locations using case examples and potential mimics.
Special thanks to Dr. Michael Hoch for helping with this lecture and Dr. John Loh for handing down the drawing over the generations!
The level of this lecture is appropriate for radiology residents, radiology fellows, and trainees in other specialties who have an interest in neuroradiology or may see patients with spine tumors.
Other videos on the spine tumor playlist are found here.
Spine tumors can be a challenging topic for a neuroradiologist because we deal less with tumors in the spinal cord and spinal canal. However, there is a relatively simple approach that can hep you hone your differential diagnosis. This involves taking a location-based approach which divides the spinal canal into 3 main regions. This series of videos shows the general approach as well as specifics about making a differential diagnosis in each of these locations.
Be sure to check back often as more videos are added that cover your favorite neuroradiology exams, or check out our full channel on Youtube.
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Spine tumors 1 – Introduction to a location-based approach
his case is the fourth and final case that goes with the vascular capstone course. On that page, there is a scrollable case that you can go through to teach you how to approach a CTA of the head in a real patient.
This case is a 41 year-old man after a trauma in a motor vehicle collision (MVC). Take a look and see what you think before continuing on (https://bit.ly/CTAcaseD).
Starting with the CTA of the neck, this is not a normal case. If you follow your normal search pattern, you will see that there are a number of abnormalities, starting from the right internal carotid artery (ICA), which is lumpy and irregular looking. The left ICA is worse, with areas of narrowing, outpouchings, and linear filling defects that represent little areas of the intima that are lifted up by trauma. The little outpouchings along the margins of the vessel are little pseudoaneurysms, or areas where the vessel is injured and contrast is able to leak out into the surrounding area of damaged vessel. Both vertebral arteries are also abnormal with multifocal irregularity and a small pseudoaneurysm on the right.
This is a dramatic example of traumatic vascular injury in the neck. After high energy or penetrating (think gunshot or stab wound), the great vessels can be injured and jeopardize the blood supply to the brain. These injuries are graded on the Denver, or Biffl, scale which ranges from 1-5. You can read more about it on Radiopaedia. Injuries to the vessels in the neck are most commonly pseudoaneurysms, meaning that one layer or more of the vessel is injured and the wall of the aneurysm does not contain all the layers (intima-media-adventitia). Contrast this to intracranial aneurysms, which are true aneurysms and the wall contains all the layers.
This is the last of the case examples for the vascular capstone course. If you haven’t already, I recommend going back to the vascular capstone course, where you can review the other browseable cases with explanations.
This case is the third of four cases that go with the vascular capstone course. On that page, there is a scrollable case that you can go through to teach you how to approach a CTA of the head in a real patient.
This case is a 43 year-old woman with seizure. Take a look and see what you think before continuing on ( https://bit.ly/CTAcaseC).
On the noncontrast CT, you see some high density material in the right frontal lobe. It is more dense than contrast, which is consistent with calcium. If you look more closely at the morphology, it is almost curvilinear or tubular, giving the impression that it might be calcification along vascular structures. The sulci of the frontal lobe are effaced with masslike effect on the brain.
While the diagnosis is uncertain, there are enough features to make us think that there is an underlying vascular malformation. To check, we need to do some sort of vascular imaging. The most readily available and fastest is to do a CT angiogram.
On the CT angiogram, the proximal vessels are normal, but the abnormalities start at the proximal middle cerebral artery (MCA) and anterior cerebral artery (ACA) on the right. There are too many vessels in this region and they are too tortuous. If you follow them up, they go to a large and tortuous vascular abnormality in the right frontal lobe.There are enlarged draining veins that empty into the superior sagittal sinus.
This is the classic imaging appearance of arteriovenous malformation (AVM) within the brain. AVMs are congenital vascular abnormalities that consist of an abnormal connection of arteries and veins with a tangle of abnormal vessels, the nidus. Go on and look at the volume rendered (VR) reconstruction and the coronal maximum intensity projection (MIP) images to better understand what this abnormality looks like.
Once you’ve finished this video, I recommend going back to the vascular capstone course, where you can review the other browseable cases with explanations. The capstone overview is here , if you’d like to see all the cases and videos.
This case is the second of four cases that go with the vascular capstone course. On that page, there is a scrollable case that you can go through to teach you how to approach a CTA of the head in a real patient.
This case is a 47 year-old woman with new neurologic symptoms. Take a look and see what you think before continuing on (https://bit.ly/CTAcaseB).
The patient in this case has scattered small infarcts in the left MCA distribution on diffusion weighted imaging from an MRI (top left window). This raises suspicion for an underlying vascular abnormality. Remember, for stroke and vascular supply issues, you want to include CTA of the neck because these vessels supply the vessels of the circle of Willis.
On the CTA, you see multiple abnormalities. The right internal carotid artery (ICA) is tortuous and irregular in the superior neck, which is highly atypical for a patient of this age. The left internal carotid artery (ICA) is even more abnormal, with smooth tapering of the vessel to severe narrowing just above the bifurcation. The low density filling defect is thrombus, some of which is probably under a dissection flap and some of which is free-floating in the vessel. The more distal ICA also has tortuosity and narrowing similar to the right, confirming the abnormality is bilateral.
Don’t forget to complete your search pattern, but the vertebral arteries and intracranial vessels are pretty normal.
Given the multiple areas of vascular narrowing of the cervical carotid in a middle age woman with an ICA dissection on the left, this patient most likely has fibromuscular dysplasia (FMD). Fibromuscular dysplasia is the most common vasculopathy in middle-aged women and frequently affects the renal arteries, ICAs, and vertebral arteries. Characteristic findings are the beads on a string appearance of the vessel with multifocal areas of narrowing interspersed with dilation.
Once you’ve finished this video, I recommend going back to the vascular capstone course, where you can review the other browseable cases with explanations. The capstone overview is here, if you’d like to see all the cases and videos.
This case is the first of four cases that go with the vascular capstone course. On that page, there is a scrollable case that you can go through to teach you how to approach a CTA of the head in a real patient.
This case is an 80 year-old woman who presented with altered mental status. Take a look and see what you think before continuing on.
The patient in this case has subarachnoid and parenchymal hemorrhage on a noncontrast CT. Because aneurysms and vascular malformations are possible causes of subarachnoid hemorrhage, we proceeded with vascular imaging, or a CT angiogram of the head, to look for aneurysms or other possible vascular causes. Remember, for an intracranial hemorrhage you don’t need the CTA of the neck because these don’t commonly have any pathology that can explain intracranial hemorrhage.
On the CTA, you see multiple abnormal outpouchings of the intracranial vessels, otherwise known as an aneurysm. Intracranial aneurysms are abnormal outpouchings of the vessels thatt contain all the layers of the vessel wall (true aneurysms). They have a risk of rupture of several percent per year, and can be treated with surgical clipping or endovascular methods such as coils. Remember, it is common for patients to have more than one aneurysm, as is seen in this case.
Once you’ve finished this video, I recommend going back to the vascular capstone course, where you can review the other browseable cases with explanations. The capstone overview is here, if you’d like to see all the cases and videos.
This lecture is the third part of a capstone course we have for our 4th year medical students. In the first lecture, we discussed general concepts about how to approach vascular imaging of the head and neck, including angiography, CT angiography, MR angiography, and ultrasound. The second part of the lecture covers a general search pattern for vascular imaging of the head and neck on a CT angiogram. To see more about this course, check out the full vascular capstone page. It contains interactive cases that you can scroll on your own as well as some additional videos explaining them.
In this lecture, we welcome back our special guest, Dr. Cynthia Wu, who is going to go over some of the common pathologies you might encounter on vascular imaging of the head and neck.
Common pathologies
There are a few common pathologies you might be looking for on vascular imaging of the head and neck, including aneurysm, thrombosis, dissection, and vascular malformations. Read on to learn more about each one.
Aneurysms
Aneurysms are abnormal outpouchings of the vessels. Sometimes they contain all the layers of the vessel wall (true aneurysms) or may be contained ruptures of one or more of the walls (false aneurysms, or pseudoaneurysms). Most intracranial aneurysms are true aneurysms while aneurysms in the neck are pseudoaneurysms.
Thrombosis
Thrombosis is occlusion of a vessel secondary to a blood clot. This is most commonly seen or suspected in the setting of a stroke, and can arise from rupture of an atherosclerotic plaque or from transmission of a thrombus more proximal in the circulation, such as from a cardiac valve or in the internal carotid artery. Most of the time, a thrombus will appear as abrupt severe narrowing or truncation of a vessel.
Thrombosis can also occur in veins, such as the dural venous sinuses. Venous thrombus will more commonly appear as a central filling defect.
Dissection
Dissection is a tear or injury to the lining of the artery, or intima. In this case, then blood goes into the space between the layers of the vessel wall, an area known as the false lumen. When the vessel is large enough, this vessel may fill with contrast on the injection, but in smaller vessels this may thrombose and be seen as a smooth tapering or narrowing of the vessel that can even result in occlusion. You can also sometimes get irregular enlargement of the vessel past it, or pseudoaneurysm.
Vascular malformations
Arteriovenous malformations, or AVMs, are abnormal clusters of vessels which have abnormal connections between the terminal arteries and veins. This results in a shunt, or passage of blood from an artery to a vein without a terminal capillary bed. Arteries and veins then are enlarged and at higher risk of rupture. The Spetzler Martin grading system is a grading system used to rate the risk of surgical mortality on resection which can help guide management.
What’s next?
Once you’ve finished this video, I recommend moving on to the next section of the vascular capstone, where you can review individual browseable cases with explanations. The capstone overview is here, if you’d like to see all the cases and videos.
This is a short course in learning about vascular imaging of the head and neck. The first videos have an overview of how to approach these studies, while the additional videos show you specific cases.
Introduction to Vascular Imaging of the Head and Neck
This lecture is the first part of a capstone course we have for our 4th year medical students about how to approach vascular imaging of the head and neck, including angiography, CT angiography, MR angiography, and ultrasound. To see more about this course, check out the full vascular capstone page. It contains interactive cases that you can scroll on your own as well as some additional videos explaining them.
In this lecture, we have a special guest, Dr. Cynthia Wu, who is going to explain to us some of the general concepts behind vascular imaging of the head and neck, different techniques you can do to perform vascular imaging, and when you might order each type of study.
Basic concepts
In general, to see vessels better on imaging, we need to use some sort of contrast to differentiate the vessels from the surrounding tissues. For techniques like CT, we can use an injected contrast agent to see the vessels. For other techniques such as MR angiography and ultrasound, we can use intrinsic properties of flowing blood to emphasize the vessels.
This section covers the key concepts behind how we see the vessels for these major techniques.
When do I order these tests?
Once you know about the different possible techniques, then you have to figure out when you would possibly order them. Each technique (CTA, MRA, and US) have different advantages and disadvantages that make them more or less suited to different scenarios.
How to read a CT angiogram (CTA) of the Head and Neck
With increasing ability to image vascular phenomena, such as stroke and vascular malformations, through the use of very efficient and high speed computed tomography scanner (CT), we now have the ability to perform angiographic imaging of large segments of the body at one time. This has led to an explosion of vascular imaging of the head and neck to look for a variety of pathologies, including stroke, vascular malformations, and other vascular abnormalities. Every starting radiology resident needs a firm foundation in how to interpret these images.
Overview
Because there are a ton of images and a ton of structures that you need to look at, you really need a regimented approach, or search pattern, to use as you look through the images. In this video, I teach you how to look at a CT angiogram of the head and neck from start to finish so you can learn how to do it yourself. There are interactive examples that you can follow along on the vascular capstone page.
I divide the study into the CTA of the neck, which I review first, and the CTA of the head, which I review second. My pattern goes as follows:
Nonvascular structures
I first like to look at all the nonvascular structures to make sure I’m not missing anything. I look at the lungs, the thyroid, the soft tissues of the neck (particularly to look for lymph nodes or mucosal masses), and the brain. I use a soft tissue window to look at these. Then I go back through with a bone window to look at the bones.
Neck Vessels
For the vessels of the neck, I use an approach that first does anterior vessels and then posterior vessels, moving from right to left. I follow the right common carotid artery through the bifurcation, and then follow the internal carotid to the skull base. I then repeat this pattern for the left carotid system. Then, I start from the right vertebral origin and follow it up to the skull base. Then the left vertebral artery. Once I’m finished, I restart at the skull base.
Head Vessels
For the vessels of the head, I follow a similar approach. I first follow the right ICA through the carotid terminus and then follow the right middle cerebral artery (MCA) and anterior cerebral artery(ACA). Once finished, I return to the skull base and repeat this pattern on the left. I then move to the posterior circulation, where I first follow the right vertebral artery, the basilar artery, and the right posterior cerebral artery (PCA). Then I repeat it on the left. My final search is to quickly look at the deep venous sinuses.
Summary
While others may have a different strategy, the most important part is to have a strategy and stick to it. This pattern of dividing the study into discrete sections will help you see all the findings and describe them accurately when reading cases on your own.
