Weekly Case

Title : Case 672

Age / Sex : 45 / M


Chief complaint :


left thigh paresthesia


What is your diagnosis?

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



Courtesy : 정희석, Hee Seok Jeong/양산부산대학교병원, Pusan National University Yangsan Hospital


Diagnosis:

Cystic spinal schwannoma



Discussion


Findings:


about 2.1 x 1.8cm sized, well-defined high SI lesion on T2WI and iso SI lesion on T1WI with rim enhancement at left intradural extramedullary area of T12 level


 


Differential Diagnosis:


dermoid cyst, epidermoid cyst, arachnoid cyst, enterogenous cyst and cystic meningioma


 


 


Discussion:


Intradural extramedullary cystic schwannomas are rare.


Cystic schwannomas are most common in the lumbar region and occur rarely in the thoracic region.


MRI is the choice of modality for the evaluation of intradural spinal tumours. Schwannomas tend to have signal intensity equal to or less than that of the spinal cord on T1WI and mild to marked hyperintensity on T2WI. Schwannomas usually show fluid signal intensity on T2WI, which could be a useful predictor in its diagnosis.


Intradural extramedullary cysts, such as dermoid cysts, epidermoid cysts, arachnoid cysts, and enterogenous cysts, should also be differentiated from the severe cystic changes of spinal intradural extramedullary schwannomas. Dermoid cysts are diagnosed easily because of their fat content. Epidermoid cysts show various characteristics on MRI but they usually show signal intensity similar to that of CSF on T1- and T2-weighted sequences. They can have a thin or slightly thick peripheral capsule with or without enhancement. On diffusion weighted MRI, the epidermoid cyst shows restricted diffusion due to its keratin content in contrast to the severe cystic changes of spinal intradural extramedullary schwannomas . Presence of dermal sinus tract or other spinal dysraphism can be helpful in the diagnosis of both dermoid and epidermoid cysts. Intradural arachnoid cysts unusually arise from the region of the septum posticum at the thoracic level and have an extremely thin wall without enhancement. Enterogenous cysts are likely to develop anteriorly and be confined to the cervical region. Usually, their walls are very thin and not enhanced


 


References:


Surg Neurol Int. 2014 Aug 28;5(Suppl 7):S349-53.


J Coll Physicians Surg Pak. 2014 Feb;24(2):145-7


J Korean Soc Radiol 2015;72(6):393-400



Correct Answer
Total applicants 39 Correct answers 14
Name Institution
장민영 국민건강보험공단 일산병원, 전문의
이동규 경인지방병무청, 전문의
변성환 전공의
이수민 전문의
김동언 국군양주병원, 전문의
김지환 전공의
이승보 서울아산병원, 전문의
권기언 서울아산병원, 전문의
노지훈 중앙보훈병원, 전공의
현혜란 인천사랑병원, 전문의
김성진 365병원, 전문의
정치형 단국대학교병원, 전공의
안태란 길병원, 전문의
김유진 전문의
Semi-Correct Answer
Total applicants 39 Semi-Correct answers 9
강지희 전문의
이현규 전문의
여현정 전문의
이규정 고대안암병원, 전문의
전인환 전문의
최희석 다니엘병원, 전문의
박준동 마이크로병원, 전문의
김정환 국군대전병원, 전문의
최형인 군의관, 전문의


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