0:00

This is a 25-year-old man,

0:02

neck pain and stiffness,

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numbness in both hands,

0:05

and a motor vehicle accident in December of 2014.

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This exam was done about five and a half months later.

0:14

Just to get you oriented,

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we're going to scroll through some sagittal images using a

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sagittal series of water-weighted images.

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We've got a PD spur on the left,

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a T2 spin echo in the middle, and a T1 spin echo,

0:29

non-contrast on the right.

0:32

And I'm sure you all have locked

0:36

into this area of puffiness,

0:39

gentle mass effect that has occurred in which space?

0:44

The intramedullary space.

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That should be one of the first things you do.

0:48

You should decide whether you are dealing with

0:50

something that is extradural narrowing

0:52

the subarachnoid space.

0:54

Something that would be intradural right here.

0:58

That would expand the subarachnoid space above

1:01

and below, or something in the cord itself.

1:05

And if the cord is expanded,

1:07

that would encroach on the thecal space.

1:10

So this red area would get smaller on both sides.

1:14

That's just basic blocking and

1:16

tackling from myelography.

1:17

And everybody needs to know that if they are going

1:20

to be professional imagers at the expert level.

1:24

So now we have to decide what to do with this thing.

1:27

It's got a little bit of mass effect.

1:29

It's in the upper cervical spine at about C2.

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What's the differential diagnosis?

1:36

So in a case like this,

1:38

any intramedullary lesion,

1:40

first thing is going to be tumor.

1:41

Is this a tumor? You need to rule out a tumor.

1:44

Then you can think of all the other rarer types of

1:47

things such as whether it's a vascular malformation

1:52

or a demyelinating lesion. Okay,

1:54

let's start with that.

1:55

Let's start with those two

1:57

demyelinating lesions.

2:01

They typically don't have much mass effect.

2:04

No. And the classic one is MS.

2:05

And where do you see that?

2:06

Usually in the cord,

2:07

typically peripheral wedge-shaped type appearance.

2:12

Front or back? Usually back.

2:13

Usually back. Back or side.

2:16

I think we both agree this thing's

2:17

a little bit in the front.

2:18

Now,

2:18

one caveat is that MS is a sort of a progressive

2:24

but yet stuttering, waxing and waning.

2:27

There's remissions associated with MS.

2:31

And unfortunately this entity which we're going to

2:34

describe has that same type of clinical course.

2:37

So that can be a little bit confusing.

2:39

So at least clinically it's in the differential

2:41

diagnosis. But radiographically? No, it's not.

2:45

In fact,

2:46

I think our thing looks a little

2:48

nodular, almost like popcorny.

2:51

Let me blow up the middle one.

2:53

Just to sort of emphasize that.

2:54

Just to go back to your point about MS,

2:56

typically you would expect to see other lesions.

2:58

So here we can see the pons.

2:59

The majority of the pons, the medulla,

3:01

and the rest of the cervical spinal cord,

3:03

which there are no other signal abnormalities.

3:05

Great point. Yeah. No skip lesions.

3:08

So now I turn my next question to you.

3:10

You're a young, hard charging,

3:12

brilliant radiologist tumor is what everybody wants to

3:17

know. The clinician wants to know, is this a tumor?

3:19

Is my patient going to die?

3:20

I think the patient wants to know that, too.

3:23

So is it a tumor?

3:25

And if it's not a tumor, why not?

3:27

So how do you figure that out?

3:28

So, one that Dr.

3:29

Palmer has just alluded to is that

3:30

popcorn-type appearance.

3:31

So you have different heterogeneous T1 and

3:33

T2 weighted signals in this lesion.

3:36

The other things to think about would be in this case,

3:41

there's not much mass effect.

3:43

A, there's no cord edema at this point.

3:45

B,

3:46

the other things to look at would be,

3:49

does it have a hemosiderin ring,

3:51

or does it have hemosiderin staining?

3:53

Let's check that out while you're talking about it.

3:55

I've got a gradient echo here.

3:57

It's not the prettiest, but there is some sclerosis.

4:00

I'll blow it up right here.

4:01

I think I may have a better one right there.

4:03

And then on this

4:06

gradient echo sequence, no worries,

4:09

you get this Blooming artifact.

4:10

Sure.

4:11

So these are all signs that would point toward

4:14

something that is not as aggressive as an intramedullary

4:18

neoplasm. Yeah. And just for our audience,

4:20

blooming refers to exaggeration of signal

4:24

hypointensity when you go from a spin echo to

4:27

a gradient echo, so the signal goes down.

4:30

Another characteristic of Blooming is you get

4:33

geometric distortion if you have iron deposition,

4:38

paramagnetic phenomena when you go from

4:42

a spin echo to a gradient echo.

4:44

So the tissue positions will also start to shift,

4:47

and you might even see something like a dark hole with

4:52

kind of a lighter rim around the outside as part

4:55

of a Blooming phenomenon. Here, though,

4:58

there's no question we've got a dark siderotic area.

5:02

It's dark, but it's not lossless.

5:04

Lossless means there's absolutely flat out no signal.

5:07

That's lossless, that's air. So low signal,

5:11

but not lossless.

5:12

So let's go back now to a summary of your thoughts,

5:16

which are excellent.

5:18

The degree of mass effect for the lesion size not

5:21

great. Not a lot. There's really no edema.

5:25

The lesion has this sort of popcorny look to it.

5:28

The zone of transition is pretty tight.

5:32

The signal intensity,

5:33

when you look at the T2 is a little bit

5:35

heterogeneous. It's got hemosiderin staining,

5:39

and it doesn't have a lot of length.

5:42

When you think about something like ependymoma,

5:45

which would come to mind anytime something

5:47

has siderotic staining, it's got length.

5:50

When you think about an astrocytoma,

5:53

it looks like a cigar, you know,

5:55

in the spinal cord,

5:57

it also has length. So.

5:59

The shape isn't good for that.

6:01

And an intramedullary metastasis,

6:04

which is most common from lung and breast,

6:06

tremendous amounts of edema and swelling.

6:08

I've seen many of them.

6:10

They usually occur in the thoracic and lumbar area.

6:13

So we're into something different and in this case,

6:16

we're into a low flow state, vascular abnormality,

6:21

namely a cavernoma.

6:23

So let's talk a little bit about cavernomas.

6:27

They're three to 5% of all cavernomas are in

6:31

the spine. Most of them are in the brain.

6:34

But the brain ones have a very different natural

6:36

history. They usually don't bleed.

6:39

And it is said that they can be acquired.

6:42

You can get them from trauma,

6:43

you can get them from radiation.

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So they can develop throughout life.

6:48

The ones in the cord, there's more controversy about.

6:52

Some people think they can be acquired,

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but there's a whole nother subset of scientists that

6:58

believe that these are familial or genetically

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mediated. And in fact, when they are multiple,

7:06

20% will be familial.

7:09

And this has a much higher incidence in

7:11

people of Hispanic extraction. Now,

7:14

another difference between the brain ones,

7:16

the brain ones don't bleed.

7:18

These bleed we already alluded to the fact

7:21

you get this sort of stuttering,

7:22

waxing and waning phenomenon clinically, like MS.

7:26

And then another very different characteristic

7:29

is these don't calcify.

7:30

The ones in the brain almost always calcify.

7:34

So that's kind of strange.

7:35

And then cavernomas tend to occur more in women.

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And this happens to be a man.

7:42

And bizarrely enough,

7:44

we showed some dural AVFs and those were women.

7:47

So we showed you the opposite in terms of sex,

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of what you would expect.

7:52

There's normal dural AVFs, men and cavernomas women.

7:56

Just so happens that strange things happen.

7:59

This is a cavernoma and it's occurred in a man.

8:05

So in terms of bleeding, we said these things bleed.

8:09

It's kind of a waxing and waning stuttering bleed.

8:12

They bleed about one to 5% per year and they like the

8:19

thoracic spine best, about 50% in the thoracic spine,

8:22

40% cervical, and very uncommon in the CONUS,

8:25

about 10%. So a cone lesion whole differential, right?

8:30

Yes. When you think CONUS,

8:31

what do you think about myxopapillary ependymoma

8:33

would be the first thing that pops the most common

8:35

tumor that could happen in the spinal cord?

8:37

Sure.

8:38

Or you could even relate it back to previous

8:40

discussions of a vascular malformation,

8:43

depending on the characteristics. Agreed.

8:44

And myxopapillary ependymomas,

8:47

they have myxoid tissue inside, but they also bleed.

8:50

So that's a little bit confusing because the

8:52

myxoid tissue is sort of high on T1 weighted images.

8:55

The bleed is high on T1.

8:57

So that can get a bit confusing but a lot more.

9:00

Mass effect. Unfortunately,

9:01

this lesion is pretty uncommon in the CONUS.

9:04

I don't have any other comments about this.

9:07

These do get resected sometimes when they bleed.

9:11

In fact, they have to be resected.

9:13

I will say there are a couple of other

9:15

lesions that I didn't mention.

9:18

One specifically that I think is important,

9:20

and that is the hemangioblastoma.

9:23

These are usually well and they're like little tiny

9:27

nodules. I made a gray little spot there.

9:30

I don't think that's good enough.

9:31

I need something a little brighter

9:33

to please the audience here.

9:34

So you see these little nodules kind of studding

9:37

the back. And when a surgeon looks in there,

9:39

that's exactly what they see.

9:41

They see a cherry red nodule right along the dorsal

9:45

peel surface. And there's usually more than one.

9:48

So even though these are both vascular lesions,

9:51

they look very different from one another.

9:54

Hemangioblastomas are multiple.

9:57

They're associated with Von Hippel-Lindau syndrome.

10:00

Cavernomas are not.

10:02

I don't have any other comments in this case, do you?

10:04

So the only thing I would comment on is going back

10:07

to the history of a motor vehicle accident.

10:09

The one thing I would probably not do is to

10:11

confuse this with spinal cord trauma.

10:13

What would spinal cord trauma look like?

10:15

It would essentially you would have

10:17

especially remote six months,

10:18

five and a half months ago you would see a focal

10:21

myelomalacia type signal within the spinal cord

10:23

which is contracted or atrophied spinal cord.

10:26

In this case,

10:26

the lesion is actually it's puffed

10:29

out the spinal cord.

10:30

So to attribute this to a traumatic event

10:34

would be misleading or wrong diagnosis.

10:37

I think that's a great point.

10:38

And I think a general radiologist reading this in a

10:40

stack of films with that history

10:42

would go down that pathway.

10:44

So the fact that there is mass effect is really

10:47

important. I think you've articulated it very well.

10:49

Let's move on to another case, shall we?