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17b - Answer: Cauda Equina Syndrome in a 22-year-old. Prior intracranial tumor resection

David Yousem MBA, MD
David M Yousem, MBA, MD
Professor of Radiology, Vice Chairman and Associate Dean
Includes DICOM files

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Case Report

HISTORY: Cauda Equina Syndrome in a 22-year-old. Prior intracranial tumor resection.

TECHNIQUE: The following imaging sequences of the head were obtained: sagittal T1, axial T2, axial FLAIR, and post-contrast axial and coronal T1. Intravenous gadolinium contrast was injected without acute complication identified. Axial diffusion weighted scans and post-processed ADC maps were also performed.

Sagittal T1 weighted, sagittal T2 weighted, axial T1 weighted, and axial T2 weighted scans were performed through the cervical, thoracic, and lumbar spine. Post contrast scans after administration of intravenous gadolinium contrast agent were also performed.

Brain MRI with and without contrast:

FINDINGS:

There are postoperative changes of previously resected midline cerebellar mass, evidenced by ex-vacuo dilatation of the 4th ventricle, areas of encephalomalacia involving medial aspects of both cerebellar hemispheres, and posterior skull base tissue defect. Mild diffuse cerebellar atrophy is also noted.

After injection of contrast, several areas of enhancement representing subarachnoid tumor seedings are noted in pial surface of the interpeduncular cistern, ependymal surface of the 4th ventricle at level of the left superior/middle cerebellar peduncle, and perineural regions of right sided VII-VIII and  IX-XI nerve root complex (cisternal part).

Diffusion restriction and low ADC map values are noted in mentioned areas of tumoral seedings indicating high cellularity of the primary neoplasm (medulloblastoma).

MRI spine:

FINDINGS:

Postoperative changes of a C1 laminectomy are seen with prominent CSF space at this site. 

Fatty marrow replacement is noted in C1-C2 level due to previous regional radiation therapy.

Multiple pial surface enhancing nodules in favor of drop metastases are noted dominantly in posterior surface of the cervical (C4-C5 and C7 level) and Thoracic (T2-T6 and T10 levels) spinal cord, also involving the cauda equina nerve roots and filling the sacral thecal sac at L5-S3 levels with opacification of the nerve root sleeves of the right S1 nerve root.

There is degenerative change within the cervical discs, with mild disc bulges at C4-5, C5-6 and a left central disc protrusion at C6-C7 levels indenting the ventral aspect of the cervical subarachnoid space with no evidence of significant spinal canal stenosis or foraminal compromise.

There is a minimal disc bulge at T8-9, and a small central disc protrusion at T9-10 indenting the ventral aspect of the thoracic subarachnoid space.

There is facet degeneration at L4-L5. No evidence of significant central spinal canal stenosis is seen.

IMPRESSIONS:

Evidence of recurrent disease is present with metastatic CSF seeding from medulloblastoma.

  1. Enhancing subarachnoid tumor seedings in pial surface of the interpeduncular cistern, ependymal surface of the 4th ventricle at level of the left superior/middle cerebellar peduncle, and perineural regions of right sided IAC and jugular foramen nerve root complex (cisternal part).
  2. Multiple pial surface enhancing nodular drop metastases dominantly in posterior surface of the cervical (C4-C5 and C7 level) and Thoracic (T2-T6 and T10 levels) spinal cord and surrounding the cauda equina nerve roots filling the sacral thecal sac at L5-S3 levels with extension into right sided S1 neural foramina.
LESSON 5, TOPIC 6

Case Challenge: Spine MRI Cases - I-MED Study

Content reviewed: May 12, 2022