Age / Sex : 35 / M

Chief complaint :

Right sided hypesthesia for several months

What is your impression?
Two weeks later, you can see the final diagonosis with a brief discussion of this case (Please submit only one answer).

Courtesy of Joon-Yong Jung, Seoul St. Mary’s hospital

Discussion

Answer:  Cavernous malformation

Findings:

There is a small, poorly marginated intramedullary mass in the left hemicord of T1-2 level. The mass demonstrates bright signal intensity on T1-weighted image, and heterogeneous signal intensity with surrounding dark signal-intensity rim. No contrast enhancement is subtle or absent on post-contrast T1-weighted image.

Differential Diagnosis:

Spinal AVM

Spinal cord hemorrhage

Hemorrhagic intramedullary tumors

Discussion:

Cavernous malformations (CMs), once referred to as cavernous angiomas, are angiographically occult vascular lesions, which account up to 15% of all the vascular malformations. The lesions are frequently found in the brain, but can occur throughout the central nervous system (CNS). Pathologically, these lesions are composed of dilated, thin-walled capillaries that have a simple endothelial lining with variably thin fibrous adventitia. Typically, there is no brain parenchyma in between the centrally placed vascular channels.

Spinal CMs are increasingly being diagnosed by MRI in patients with varying spinal cord related symptoms or pain syndromes. Due to space occupying growth and recurrent micro-bleeding in the relatively thin spinal cord, spinal CMs can lead to severe neurological deteriorations unlike their intracranial counterparts. The risk of significant haemorrhage like other vascular malformations is considered to be low due to the low venous pressure.

The imaging findings are identical to the intracranial CMs. The lesion has a popcorn ball–like appearance with multiple high signal intensity foci on T1-weighted images, and a low-signal-intensity rim due to hemosiderin deposition.

References:

1. S Fontaine, D Melanson, R Cosgrove, G Bertrand. Cavernous hemangiomas of the spinal cord: MR imaging. Radiology 1988:839-841


2. T Krings, M Mull, JM Gilsbach, A Thron. Spinal vascular malformation. Eur Radiol. 2005;15:267-278


3. Zevgaridis, R.J. Medele, C. Hamburger, H.J. Steiger, H.J. Reulen. Cavernous haemangiomas of the spinal cord. A review of 117 cases. Acta neurochirurgica (Wien), 1999;141:237-245.


4. Maslehaty, H. Barth, A.K. Petridis, A. Doukas, H.M. Mehdorn Symptomatic spinal cavernous malformations: indication for microsurgical treatment and outcome Eur Spine J, 2011;20:1765-1770