0:01

This was a gentleman who was complaining

0:02

about neck pain.

0:04

And we did this study initially without

0:07

contrast. On the scans that you see,

0:10

we noticed that there's relatively little in

0:13

the way of degenerative changes in the

0:15

cervical spine. On the axial scans, again,

0:19

not much was identified. However,

0:23

the patient had evidence of prior surgery.

0:27

And so for that reason, we gave gadolinium.

0:30

On the post-gadolinium-enhanced scan,

0:33

we saw areas of contrast enhancement on the

0:37

posterior surface of the spinal cord in

0:40

the intradural extramedullary space.

0:43

So here we see one of the lesions at

0:46

the cervicomedullary junction.

0:48

Here we see another lesion on the

0:49

surface of the spinal cord.

0:51

And if I move the image up a little bit more,

0:55

down here, we also were worried

0:57

about some of the areas

1:00

of enhancement at the cervicothoracic

1:02

junction, as far as these enhancing nodules.

1:05

I'm just going to try to magnify that as well

1:08

and move this around so you could see

1:10

this a little bit better down here.

1:13

And this was our area of concern.

1:15

When we performed the axial scans,

1:17

we again saw areas of concern that were within

1:22

the thecal sac but outside the spinal cord.

1:25

So, intradural extramedullary.

1:27

And we had one large nodule here,

1:30

which was at that cervicomedullary junction.

1:33

And then here,

1:34

as we approached the thoracic region,

1:37

we had small areas of enhancement, as well.

1:39

So we started to go through a differential diagnosis.

1:42

And when you see multiple nodules of

1:44

enhancement on the surface of the spinal cord,

1:46

we were most worried about things like

1:48

subarachnoid seeding as the most common thing

1:51

that would occur here. And in addition,

1:54

we were concerned about something that might

1:56

be infectious on the surface of the spinal cord.

1:59

However, fortunately, we did include portion of the

2:04

cerebellum in the scan.

2:05

And as we go to the top of the scan,

2:08

you'll notice that there is another lesion in the

2:11

cerebellum that's faintly seen on

2:13

the topmost scan. Of course,

2:15

the clinicians hadn't given us any history

2:17

about the previous surgery for this patient.

2:20

And the only history we had was neck pain.

2:24

This patient had had a previous

2:26

hemangioblastoma resected from the cerebellum,

2:29

had an additional hemangioblastoma.

2:32

And this was a patient with Von Hippel Lindau

2:34

disease with multiple intradural extramedullary

2:37

hemangioblastomas throughout the cervical

2:40

and cervicothoracic junction.

2:43

When we proceeded to scan a little bit

2:45

more superiorly into the brain,

2:48

we identified more clearly that

2:50

enhancing mass. And of course,

2:52

there were additional ones.

2:54

When you have a patient who has hemangioblastomas,

2:57

I just want to remind you to look at two other areas

3:00

of the anatomy that are important in patients

3:02

with hemangioblastomas and Von Hippel Lindau

3:05

disease. That is the temporal bone,

3:08

because you can get endolymphatic sac tumors

3:12

of the temporal bone in patients with

3:15

Von Hippel Lindau disease. And additionally,

3:17

you want to look at the retina,

3:19

because retinal hemangioblastomas or retinal

3:22

angiomas can occur in association with

3:25

Von Hippel Lindau disease, as well.

3:27

So any little focal area of enhancement,

3:29

as you see here along the posterior

3:31

margin of the globe,

3:33

you want to consider the possibility of

3:36

a retinal angioma associated with Von Hippel Lindau.

3:40

Of course, in the abdomen,

3:42

you would be worried about the renal cell

3:45

carcinomas and pancreatic lesions.

3:47

So an example of multiple intradural

3:50

extramedullary hemangioblastomas in a patient

3:53

with Von Hippel Lindau disease and

3:56

cerebellar hemangioblastomas.