Spine tumors 2 – Intramedullary lesions

In this lecture in the spine tumor series, we take a look at intramedullary lesions within the spinal cord. These are lesions that are within the dura and the substance of the spinal cord.

The most common intramedullary tumors are primary tumors of the cord itself, most commonly ependymomas and astrocytomas. Other things such as hemangioblastoma and cavernous malformations can also happen in the spinal cord. For the rest of this lecture, we take a look at a few case based examples of intramedullary tumors.

Case 1 – Astrocytoma. Astrocytomas are the second most common cord tumors and the most common tumors in young adults. They frequently have enhancement. Low grade tumors (grade 2) are the most common although glioblastomas/high grade tumors can also occur.

Case 2 – Ependymoma. Ependymomas are the most common cord tumors and the most common tumors in adults. They often have a cystic appearance with a well marginated nodular lesion. Hemorrhage and a “cystic cap” are common. Ependymomas are associated with neurofibromatosis type 2.

How to differentiate astrocytomas from ependymoma. Ependymomas are usually older patients with shorter segment lesions and well-defined margins, while astrocytomas are younger patients with more ill-defined margins.

Cord glioblastoma. Intramedullary glioblastoma has the same appearance as glioblastoma and appears like a high-grade lesion with mass effect, ill-defined margins, and necrosis.

Case 3 – Hemangioblastoma. Hemangioblastomas are common cord tumors and are associated with Von Hippel Lindau (VHL) syndrome. 1/3 are associated with the syndrome while 2/3 are spontaneous. Tumors often appear as a cyst with an enhancing nodule. You may see flow voids similar to those you see in the brain, although they are often harder to see. Patients with VHL may also have brain hemangioblastomas, endolymphatic sac tumors, and other systemic tumors (such as renal tumors).

Case 4 – Cavernous malformation. Cavernous malformations, sometimes referred to as cavernomas, can occur in the spinal cord. They have a similar appearance to cavernous malformations in the brain, often with a rim of siderosis and central T1 and T2 hyperintensity. Little to no enhancement is common.

Causes of hematomyelia (blood in the spinal cord). The differential for hematomyelia includes coagulation disorder, vascular malformations, anticoagulation medications, trauma, or cord tumor with repeated hemorrhage.

Take-home points.

  • The spinal cord is an extension of the brain and affected by similar pathologies
  • Tumors are the most common pathology. Astrocytomas (< 20 years old) and ependymomas (> 20 years old)
  • Other tumors can also affect the spinal cord

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.