Wk 9, Case 2 - Review

Patient History
30 year old female no significant PMH who presents with the first symptom of constipation. She then developed intermittent whole leg numbness, first the left leg, then the right leg. Her sensation would return after shaking her legs multiple times. She then developed back pain and leg pain that is described as pressure, as if someone is grabbing her legs and holding them in a vice. At present, she has severe crushing pain in her hips. She was started on gabapentin that has not helped. Nothing makes the pain better. Sitting and moving makes the pain worse. She has decreased sensation in her legs, and her legs feeling heavy to the point where she has had multiple falls a day. About 1 month ago, she began having to use a walker to assist her. She also endorses difficulty with initiation of urination and she does not feel that she is emptying fully. For the last 2 weeks, she has noticed intermittent decreased sexual feeling.

Findings
MRI brain with and without contrast:

The ventricles and sulci are unremarkable. There is a small cavum septum pellucidum and cavum vergae. The white and gray matter differentiation is preserved. There is no restricted diffusion to suggest acute ischemic infarcts. No evidence of acute hematomas, focal mass effect or midline shift is seen. There is no pathologic contrast enhancement. Basal cisterns are patent. The major intracranial flow voids are maintained. Prominent perivascular space is noted in the inferior aspect of the basal ganglia bilaterally. The sella and suprasellar cistern are unremarkable. The cerebellar tonsils are normal in position.There is trace mucosal thickening in the ethmoid sinuses. The mastoid air cells are clear. Unremarkable orbital contents bilaterally.MRI cervical spine with and without contrast:Vertebral bodies demonstrate unremarkable signal intensity, height and alignment. There is no acute compression fractures or subluxations of vertebral bodies. Mild bulging disc is noted at C5-C6. The craniocervical junction is unremarkable.The spinal canal and neural foramina are patent without significant stenosis.The spinal cord demonstrates unremarkable signal intensity, caliber and contour. There is no pathologic contrast enhancement within the spinal cord or in the spinal canal. No focal paraspinal soft tissue swelling or fluid collections.

MRI thoracic and lumbar spine with and without contrast:There is a well-defined ovoid expansile cystic lesion with hyperintense T2 and hypointense T1 signal measuring approximately 1.1 x 1.1 x 4.1 cm (AP by transverse by craniocaudal) within the spinal cord at the T12-L1 level involving distal thoracic spinal cord and conus medullaris. There is focal nodular enhancement measuring approximately 0.7 x 0.5 x 0.9 cm (AP by transverse by craniocaudal) in the left lateral aspect of the cystic lesion. There is mild hyperintense T2 signal in the thoracic spinal cord superior to the cystic lesion, compatible with vasogenic edema. The conus medullaris terminates at the L1 level. There is prominent vascular structures along the posterior aspect of the thoracic spinal cord at the T9, T10 and T11 level.Irregular endplates with marrow signal change, hyperintense STIR signal of T9 vertebral body likely secondary to degenerative changes. There is no evidence of acute compression fractures or subluxations of vertebral bodies. Bulging disc with mild indentation of the ventral thecal sac noted at the multiple levels, T6-T7, T7-T8 and T8-T9. Mild facet arthropathy at L5-S1. The visualized sacrum demonstrates unremarkable signal intensity and alignment.There is effaced CSF space at the level of the spinal cord lesion. The spinal canal superior and inferior to the lesion is patent without significant stenosis. Neural foramina are patent bilaterally.There is no focal paraspinal soft tissue swelling or fluid collections.

Impressions
A well-defined cystic expansile intramedullary lesion measuring approximately 1.1 x 1.1 x 4.1 cm at the T12-L1 level involving distal thoracic spinal cord and conus medullaris with a focal enhancing nodule measuring up to 0.9 cm. Mild vasogenic edema of the spinal cord superior to the cystic lesion. Prominent vascular structures along the posterior aspect of the spinal cord superior to the lesion are indeterminate but would therefore favor a spinal hemangioblastoma. A pilocytic astrocytoma and ependymoma are included in the differential diagnosis.