Spinal astrocytoma

Case contributed by A/Professor Pramit Phal

Presentation

Pain, proprioception loss. T10 level

Patient Data

Age: 27
Gender: Male
Modality: MRI

Spine:

Partially cystic/solid lesion is identified at the T3 level. This lesion appears intradural extramedullary on the sagittal sequence (image seven series 13) but appears more intra-medullary on axials appearing to be centered posteriorly within the cord and eccentrically expands the cord at this level.

The lesion extends a vertical length 1 vertebral body height.

Central cystic component measures 1 cm.

The solid component more inferiorly demonstrates diffuse mild homogeneous enhancement. No blood product seen on T2. No flow voids.

Multifocal slightly T1 hyperintense to cord, mildly enhancing soft tissue nodules also extend along the entire length of cord in the subarachnoid space.

There is also diffuse mild leptomeningeal enhancement along the spinal cord. Vertebral bodies demonstrate normal signal and morphology. Visualized paravertebral soft tissue structures within normal limits.

Brain (not shown): 

No focal parenchymal lesion is identified.Ventricular size is age-appropriate. There is a FLAIR hyperintense subtly enhancing soft tissue nodule abutting right superior colliculus and posterior thalamus at the right quadrigeminal plate cistern adjacent to the right side of the pineal gland which has a lobular contour measuring up to 8mm. Adjacent pineal gland is separate from this lesion and has a normal appearance. No mass lesion seen in the region of the suprasellar cistern and posterior cranial fossa abnormality. No abnormal meningeal enhancement. Vascular flow voids are preserved.

Impression:

Appearance is that of "carcinomatous meningitis". If the T3 lesion is intramedullary, then an astrocytoma with a cystic component or syrinx with subarachnoid seeding is favoured over that of an ependymoma or haemangioblastoma. If the T3 lesion is intradural extramedullary, then metastasis from a non-intracerebral source (melanoma?) or lymphoma needs to be considered, although both usually demonstrate more vivid enhancement and a cystic component would be unusual unless it is loculated CSF. A non neoplastic cause such as spinal sarcoidosis is also a possibility.

Modality: MRI

MRI whole spine

Treatment with surgery, chemotherapy, radiotherapy. Deterioration.

Findings:

There has been marked progression of leptomeningeal metastatic disease.

At the cervical cord there is extensive enhancing extramedullary tumour encasing and compressing the spinal cord between C2 and T1 vertebral levels over distance of 11.5 cm. This distorts and compresses the cord at multiple levels, most marked at the level of C1/2 where a component of the tumour measuring 0.9 x 1.1 x 1.2 cm bulges significantly into the cord from the right posterolateral cord surface and causes marked compression of the cord parenchyma (to under 3 mm in thickness). No preexisting intramedullary enhancing lesion is identified at this location.

There is patchy abnormal increased T2 signal throughout the cervical cord.

There has been increase in the size of the lobulated extramedullary disease at the conus and cauda equina.

A lobulated enhancing mass measuring 9.7 cm in craniocaudal length encases the distal cord, conus and upper aspect of the cauda equine between levels of T11/12 and L2/3. This has progressed from the previous identified 2 x 1.2 x 2.3 cm ovoid extramedullary lesion previously present.

Small nodules throughout the cauda equina spinal nerve roots are again demonstrated.

Decompressive laminectomy from T1-T3 is again demonstrated. Myelomalacia and dorsal cord tethering again noted.

Extensive marrow signal changes in keeping with previous radiotherapy again demonstrated.

Impression:

Marked progression of leptomeningeal metastatic disease with encasement of almost the entire cervical cord, resulting in marked cord compression and oedema.

Further marked disease progression with compression at the conus and cauda equina.

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Case Information

rID: 34468
Case created: 22nd Feb 2015
Last edited: 27th Sep 2015
Inclusion in quiz mode: Included

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