0:00

This was a woman who was complaining about

0:03

paresthesias in both the upper extremities,

0:05

as well as the lower extremity.

0:08

And the patient was requested for complete

0:11

spine evaluation, as well as the brain.

0:14

The brain was unremarkable. On the spinal

0:17

images, we have the T1-weighted scan,

0:20

the STIR image in the center,

0:22

and the T2-weighted scan.

0:24

On the initial evaluation,

0:25

it was a little bit peculiar in that the

0:28

spinal cord seemed to have an unusual contour

0:31

and was tented posteriorly in one location in

0:34

the mid thoracic region. But in general,

0:37

not much was suspected.

0:40

And when we did the axial T2-weighted

0:43

scans through the spinal cord, again,

0:45

there were some unusual contour features of

0:49

the spinal cord, in that it was a little bit

0:51

flattened in some areas and had a funny shape to it,

0:56

but we really weren't suspecting all that much.

0:59

We thought maybe this was arachnoidal

1:00

adhesions, possibly from lumbar puncture.

1:04

And we went through this scan and said, you know, well,

1:07

not looking too much, you know,

1:09

maybe from, you know, previous instrumentation

1:12

and arachnoid adhesions.

1:15

And then we came to the post-gadolinium

1:17

enhanced images. Wow.

1:19

So here you see, on the surface of the

1:22

spinal cord contrast enhancement,

1:25

both anteriorly as well as posteriorly in the

1:28

cervical region. In the thoracic region,

1:31

that tenting that we described previously,

1:33

you can see, again posteriorly,

1:36

but there are little nodules of enhancement in

1:39

addition to sort of sugar coating of the

1:42

spinal cord with contrast enhancement.

1:45

And then in the lumbar region,

1:47

we see very thick enhancement of the cauda equina

1:51

nerve roots throughout the lumbar

1:53

region. So going back through the history,

1:56

this patient turned out had breast cancer.

1:58

So this is an example of subarachnoid seeding

2:02

in a woman who has had breast cancer, in which

2:05

there is both sugar coating or candle

2:08

guttering of the spinal cord,

2:10

as well as more focal nodularity leading to

2:13

the scarring and tenting of the

2:16

spinal cord posteriorly,

2:18

as well as cauda equina nerve root seeding.

2:22

And this was the abnormality that was

2:24

accounting for the patient's upper and lower

2:26

extremity paresthesias. Once again,

2:29

in this situation,

2:29

I would recommend scanning the brain and

2:32

making sure that there is not a parenchymal

2:35

enhancement in the brain that could be the

2:37

source for the subarachnoid seeding.

2:39

Because parenchymal lesions that shed in the CSF are a

2:46

more common source of subarachnoid seeding

2:49

in breast cancer than de novo

2:54

seeding of the subarachnoid space

2:56

without a parenchymal lesion.