Spinal meningioma imaging Poster No.: C-0448 Congress: ECR 2018 Type: Educational Exhibit Authors: M. Smoljan, D. Zadravec ; Zagreb/HR, Zageb/HR Keywords: Neoplasia, Imaging sequences, Education, MR, CT, Neuroradiology spine, CNS DOI: 10.1594/ecr2018/C-0448 1 2 1 2 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 26
Learning objectives To present the radiomorphological appearance of spinal meningiomas on different imaging modalities and to show their differential diagnosis. Page 2 of 26
Background Spinal meningiomas are rare, much less common than intracranial meningiomas (spinal meningiomas represent 12% of all meningiomas). They are slow-growing, predominantly benign, mostly solitary tumors, occuring at any age (peak incidence is at 50-60 years), more common in females. More than 95% are WHO grade I tumors. They are the second most common intradural extramedullary tumor, just after schwanommas. A very small percentage of spinal meningiomas is extradural or mixed extra/intradural with the dumbbell appearance. Multiple meningiomas are associated with neurofibromatosis type II and are usually found in younger patients. Although they usually are relatively small when discovered, they can cause severe neurological symptoms due to the lack of space in the spinal canal. Page 3 of 26
Findings and procedure details Meningiomas are dural-based, well-circumscribed tumors which sometimes displace and compress the spinal cord. Spinal meningiomas are mostly found in the thoracic spine (80%), followed by cervical spine. Location in the lumbar spine is the rarest. They are most commonly located posterolaterally, except in cervical spine where they are usually anterolaterally/anteriorly placed. They are best depicted on magnetic resonance imaging (MRI) with the intravenous injection of gadolinium-based contrast agent. The main protocol at our department is T1-weighted images (T1-WI), T2-weighted images (T2-WI) and post-contrast T1-weighted images in axial and sagittal planes. Meningiomas appear isointense/slightly hypointese to grey matter on T1-WI, isointense/ slightly hyperdense to grey matter on T2-WI, with homogenous post-contrast enhancement. 'Dural tail' sign is often seen. When calcified, they show low signal on all sequences and low contrast-enhancement. Rare malignant variants have variable appearance. Other imaging modalities are less sensitive for meningioma imaging. If MRI cannot be performed, contrast-enhanced computed tomography (CT) is the modality of choice as it shows meningiomas as vividly homogenously enhancing lesions. Non-contrastenhanced CT is less sensitive for depicting spinal meningeomas as they appear isodense or slightly hyperdense to grey matter. Sensitivity increases if they contain calcifications or if there is hyperostosis of underlying bone. Meningiomas are rarely seen on plain films unless they have calcifications, an indirect sign can also be bone erosions or localized widening of the spinal canal. Spinal meningioma primary differential diagnosis are spinal schwannomas and neurofibromas. Those tumors do not show signs of calcification, they are more commonly placed anteriorly and they tend to be multiple. Schwannomas and neurofibromas may have lowenhancing central areas on contrast-enhanced images, they do not have the 'dural tail' sign or the broad dural base and are more commonly forming the dumbbell apperance with the widening of neural foramina. Nerve sheath tumors are usually hyperintense Page 4 of 26
to the spinal cord on T2-WI, whereas meningiomas usually are isointense or slightly hyperintense to the spinal cord on T2-WI. Page 5 of 26
Images for this section: Fig. 1: Sagittal T1-WI shows a meningioma of the cervicocranial junction compressing and dislocating the medulla spinalis. Page 6 of 26
Fig. 2: Sagittal T2-WI shows a meningioma of the cervicocranial junction compressing and anteriorly dislocating the medulla spinalis. Page 7 of 26
Fig. 3: Contrast-enhanced sagittal T1-WI shows a homogenous enhancement of cervicocranial junction meningioma. Page 8 of 26
Fig. 4: Contrast-enhanced coronal T1-WI shows a homogenously enhancing meningioma of the cervicocranial junction with the dislocation of the medulla spinalis. Page 9 of 26
Fig. 5: Sagittal T1-WI shows a meningioma of the cervicocranial junction with dorsal dislocation of the medulla spinalis. Page 10 of 26
Fig. 6: Sagittal T2-WI shows a meningioma of the cervicocranial junction with dorsal dislocation and compression of the medulla spinalis. Page 11 of 26
Fig. 7: Contrast-enhanced sagittal T1-WI shows a homogenous enhancement of the cervicocranial junction meningioma. Page 12 of 26
Fig. 8: Contrast enhanced axial T1-WI shows a homogenous enhancement of the cervicocranial junction meningioma with dorsolateral dislocation of the medulla spinalis. Page 13 of 26
Fig. 9: Sagittal contrast-enhanced T1-WI shows a small anterolaterally placed meningioma of the cervicocranial junction. Page 14 of 26
Fig. 10: Axial contrast-enhanced T1-WI shows a small anterolaterally placed meningioma of the cervicocranial junction. Page 15 of 26
Fig. 11: Coronal contrast-enhanced T1-WI shows a small meningioma of the cervicocranial junction. Page 16 of 26
Fig. 12: Sagittal T1-WI shows a thoracic spine meningioma compressing and dislocating the medulla spinalis. Page 17 of 26
Fig. 13: Sagittal T2-WI shows a thoracic spine meningioma compressing and dislocating the medulla spinalis. Page 18 of 26
Fig. 14: Coronal contrast-enhanced T1-WI shows a thoracic spine meningioma compressing and dislocating the medulla spinalis. Page 19 of 26
Fig. 15: Sagittal contrast-enhanced T1-WI shows a thoracic spine meningioma compressing and dislocating the medulla spinalis. Page 20 of 26
Fig. 16: Sagittal T2-WI shows anterolaterally placed small lumbar spine meningioma. Page 21 of 26
Fig. 17: Axial T2-WI shows a small anterolaterally placed lumbar spine meningioma. Page 22 of 26
Fig. 18: Sagittal contrast-enhanced T1-WI shows a homogenous enhancement of a small anterolaterally placed lumbar spine meningioma. Page 23 of 26
Fig. 19: Axial contrast-enhanced T1-WI shows a homogenous enhancement of a small anterolaterally placed lumbar spine meningioma. Page 24 of 26
Conclusion Spinal meningiomas are an important differential diagnosis in patients with motor and sensory deficits, weakness and/or radicular pain. Page 25 of 26
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