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I'd just like to review with PowerPoint a few of the

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important points I've made in showing you cases of

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neoplasms in the intradural-intramedullary space.

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So as I mentioned,

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ependymomas overall are the most

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common spinal cord tumor.

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They generally are better defined than

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astrocytomas. In the filum region,

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we think of them not as intramedullary

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but as extramedullary in location.

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They have a higher rate of hemorrhage, and may show

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that hemosiderin cap sign at the superior or inferior

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border of the mass. These tumors are associated with

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Neurofibromatosis type 2.

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Here is an example of a grade two ependymoma in which

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you have a mass which has multiple characteristics

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of cystic components, as well as

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solid enhancing components,

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and it generally, has a well-defined border

1:00

at the C2 level with edema

1:03

showing above that border.

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So really the edge of the tumor is at the C2

1:10

level. This area above does not represent neoplasm

1:13

but just cord edema.

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And this lesion has both a cystic component

1:18

identified as non-enhancing, as well as the solid

1:23

enhancing component and goes

1:25

out of the field of view.

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Here is another patient who has Neurofibromatosis

1:29

type 2. So we know it's going to be occurring.

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There are bilateral vestibular schwannomas

1:36

with multiple meningiomas.

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And as we look at the spinal cord,

1:42

we see a mass that has both a cystic, as well as a

1:46

solid component, as well as multiple

1:49

nodules of contrast enhancement.

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So this is Neurofibromatosis type 2.

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Here we have meningioma

1:56

which I will be talking about

1:57

in my Intradural

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Extramedullary Tumor Talk. Here's the cystic

2:04

component with a solid component to this ependymoma.

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But there are multiple ependymomas in this case who

2:12

has NF2. Again also demonstrated on

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the T2-weighted scan, both the cyst,

2:19

the solid cystic component, and then more

2:21

diffuse portion, as well as a meningioma.

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MISME, multiple intracranial schwannomas,

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meningiomas, and ependymomas.

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Astrocytoma is the second most common tumor in adults,

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the most common tumor in children.

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It's usually less-defined.

2:43

It may also have cysts associated with it.

2:45

It favors the cervical region as opposed to the

2:48

lumbosacral region for the conus and filum

2:51

ependymoma, and it is associated

2:54

with Neurofibromatosis type 1.

2:57

Here we have a patient who has a diffuse

3:00

process which may actually be holocord.

3:03

When you see a holocord,

3:05

all of the cord involved lesion.

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We're going to suggest it's an astrocytoma.

3:11

If we identify necrotic areas within the tumor,

3:15

we may suggest it's of a higher grade and, therefore,

3:18

more likely to represent a glioblastoma.

3:21

You notice that this patient,

3:23

by virtue of the signal

3:25

intensity and picture of the vertebral bodies,

3:29

is a child. And in children,

3:31

astrocytomas predominate.

3:34

Here is another astrocytoma in a young adult,

3:37

again looks like the bone marrow signal of the

3:41

cervical spine represents a younger patient

3:46

rather than showing degenerative changes.

3:48

So, an astrocytoma again,

3:50

in a younger patient with both a solid, as well as

3:54

cystic component but extending over multiple

3:57

levels. This patient does not show

4:00

cap sign of hemosiderin

4:02

which would have suggested instead an ependymoma.

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Here is a grade three astrocytoma,

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so anaplastic astrocytoma.

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What would suggest a higher-grade tumor such as

4:15

anaplastic astrocytoma or glioblastoma? For this,

4:19

again,

4:20

we need to look at the contrast-enhanced component.

4:23

So if we look at the contrast-enhanced component,

4:26

we see areas that look like they're not just cystic,

4:29

but more angry-looking necrosis.

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So the sine qua non of the higher-grade astrocytomas

4:37

of the spinal cord will be the necrosis and the

4:41

irregular contrast enhancement that you may also

4:45

identify on the T2-weighted scan with the area of

4:50

necrosis being brighter in signal intensity

4:52

than the rest of the tumor.

4:54

Grade three astrocytoma in an adult patient.

4:58

Numerous investigators

5:00

have utilized diffusion tensor imaging and attempted

5:05

to distinguish ependymoma from astrocytomas by

5:10

virtue of their features on DTI and the

5:15

diffusion tractography. This, again,

5:18

is not quite ready for primetime.

5:22

Most people would say that if the tracts of the

5:26

white matter are displaced but not infiltrated,

5:30

it's more likely to represent an ependymoma.

5:33

But we can have higher-grade ependymomas that disrupt

5:36

the fibers. In this article by Asim Choudhri,

5:41

it suggests that the DTI,

5:43

when it's showing the fibers displaced

5:48

by the ependymoma or astrocytoma,

5:50

you have a better prognosis than if they

5:53

are infiltrated. So on the left,

5:56

we have a case where the fibers are displaced

6:00

outwardly by the tumor,

6:02

whereas on the right-hand side, you

6:05

have infiltration of the fibers.

6:08

So this is more of an infiltrative

6:10

pattern of the fibers.

6:12

Whereas here, you see that the fibers are displaced

6:16

outwardly and the tumor resides in the center of the

6:19

spinal cord. Let's move on to hemangioblastoma.

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Hemangioblastomas, as I mentioned, may be in the

6:27

spinal cord or they may be pial-based.

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When they're in the spinal cord,

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they're usually along the periphery where you

6:34

see a mural nodule associated with cysts.

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If you have flow voids associated with

6:42

a tumor in the spinal cord,

6:44

we're going to suggest that it

6:46

represents hemangioblastoma.

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The hemangioblastoma intensely enhances to a greater

6:52

extent than the ependymoma and astrocytomas, and

6:56

by and large, they may be posteriorly located.

6:59

We.

7:00

Remember as well that these may be associated with

7:02

multiplicity indicative of Von Hippel-Lindau disease.

7:07

Spinal hemangioblastomas favor the thoracic region,

7:11

astrocytomas,

7:12

the cervical region, ependymomas, the filum

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terminale, and lumbosacral region.

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I gave you the rule of one-thirds.

7:22

One-third of patients with spinal hemangioblastoma

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have Von Hippel-Lindau disease,

7:28

and about one-third of patients with Von Hippel-Lindau

7:32

disease will have a spinal hemangioblastoma.

7:35

This means that two-thirds of spinal

7:39

hemangioblastomas occur de novo without

7:44

Von Hippel-Lindau disease.

7:46

So it's more common without Von Hippel-Lindau

7:49

disease than with Von Hippel-Lindau disease.

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Here is our classic example of a hemangioblastoma, a

7:56

well-defined lesion on T2-weighted scan that shows

8:00

a mural nodule which is showing contrast enhancement.

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Let me just highlight that on the post-gad T1-

8:07

weighted scan. Here is that mural nodule

8:11

which was not evident as much on the pre-gad,

8:14

but you might have suggested it

8:16

on the T2-weighted scan.

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Another example of hemangioblastoma

8:21

with cyst and nodule.

8:23

This is the case that I showed

8:25

as part of the case review.

8:27

And this may or may not be associated

8:29

with a mural nodule

8:31

cystic lesions in the posterior fossa representing

8:35

cerebellar hemangioblastoma

8:37

in a patient with Von Hippel-Lindau disease.

8:41

I showed a separate case of a lesion in the conus

8:46

medullaris that had cyst and solid

8:50

nodular enhancement.

8:51

This one I like a little bit better because

8:54

as you can see, in this case, Dr.

8:56

Yusum does not lie. Cyst

9:00

and nodule.

9:02

So this is the cystic component, and

9:05

this is the nodule component.

9:07

And remember, I said that with Von Hippel-Lindau

9:11

disease or hemangioblastoma,

9:13

you can have both intradural intramedullary lesions,

9:16

as well as intradural extramedullary lesions.

9:19

And here is that enhancing lesion in the cauda

9:25

equina nerve root, so below the

9:26

level of the spinal cord.

9:28

This would represent intradural extramedullary pial-

9:33

based nerve root hemangioblastoma associated with

9:39

Von Hippel-Lindau disease by virtue of

9:41

the multiplicity of the nodules.

9:46

Here's some information about

9:47

Von Hippel-Lindau disease.

9:49

Remember that you can get retinal angiomas,

9:54

as well as abdominal imaging findings

9:57

which include renal cysts,

10:00

renal cell carcinoma, pancreatic cysts,

10:03

pancreatic neuroendocrine tumors,

10:05

pheochromocytomas, and endolymphatic sac tumors.

10:10

I did not show an example of metastasis

10:12

as one of the cases.

10:14

This is probably the fourth most common tumor of

10:17

the spinal cord after Von Hippel-Lindau disease.

10:20

Of the lesions that cause mets to the spinal cord,

10:24

lung cancer is most common,

10:27

breast cancer is the next most common,

10:29

and they usually occur in any part of the

10:32

spinal cord, be it cervical, thoracic, or lumbar.

10:36

This is an example of two different patients

10:40

who had metastases to the spinal cord.

10:43

In general,

10:44

they show solid enhancement and they may be

10:48

difficult to distinguish from primary cord tumors.

10:52

So this is three different patients.

10:55

One showing a solid met from lung cancer,

10:58

another showing a met from

11:00

breast cancer.

11:01

And this is the axial scan before

11:06

and after radiation therapy

11:11

showing the treatment effect on the metastasis.

11:16

This was the lipoma that was demonstrated being

11:19

a lesion that kind of spans the tumor versus

11:23

a congenital lesion within the spinal cord, and

11:27

demonstrating it with CT scan and fat-sat post-gad.

11:31

So on the fat-sat post-gad T1-weighted scan to the right,

11:35

you notice nothing enhancing

11:37

which is typical of a lipoma.

11:40

Were we to see any enhancement,

11:41

we might worry about something like a liposarcoma.