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This is a young gentleman who presented with

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bowel and bladder incontinence.

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In this case, we have the T1-weighted,

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the T2-weighted scans,

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and I'm going to show the sagittal STIR image as well.

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What one sees is that this looks like a

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predominantly cystic lesion at the conus medullaris,

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which is the termination of the spinal cord.

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So, a cystic lesion in this location could be

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secondary to a distal terminal syrinx,

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or it could be from a cystic neoplasm.

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For this reason,

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the post-gadolinium-enhanced scan is most helpful.

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As we scroll side to side,

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we note that the patient does indeed show a

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contrast enhancing nodule along the posterior

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lateral wall of the cystic mass.

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This cystic mass has all the characteristics

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of an intradural intramedullary lesion,

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in that the CSF space is narrowed at the site of the lesion.

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So how do we know where this cystic

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mass, that has a mural nodule,

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is an ependymoma, an astrocytoma

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or a hemangioblastoma?

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Classically, a lesion that is cystic with a mural nodule of

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enhancement is going to be a hemangioblastoma.

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However, in this case, we have one added feature

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which is important to note.

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If I magnify this sagittal T2-weighted scan

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and drop it down lower,

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we are seeing prominence to the blood vessels

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on the surface of the spinal cord.

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And this is duplicated

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on the post-gadolinium-enhanced scan.

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So as I scroll,

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we see multiple blood vessels on the surface of

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the spinal cord, which are larger

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in size than one would expect.

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And they seem to go down towards that mural nodule.

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That identifies that this is likely a hypervascular mass,

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which is typical of hemangioblastoma.

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Just for completion sake,

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let's look at the axial post-gadolinium

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enhanced sequences.

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And again, we see that the patient has the mural

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nodule on the left side posteriorly,

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the cystic component associated with it,

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and the prominent blood vessels

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superficially along the

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conus medullaris, as well as in the cauda equina

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nerve roots, coursing down the large blood vessels

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posteriorly located.

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So, a classic hemangioblastoma of the spinal cord,

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differential diagnosis with ependymoma and

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astrocytoma being mural nodule associated with a cyst,

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with hypervascularity identified by

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demonstrating large blood vessels leading to the mass.