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Case 351

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A 51-year-old female patient initiated paresthesia of the inferior members one year ago. The patient developed worsening of symptoms, presenting with paresis of the inferior members, gait difficulties, progressive dysphagia for solids and liquids, dysarthria and dysphonia. CT scan of the brain was performed (image 1). Based on its findings, magnetic resonance imaging (MRI) of the cervical spine was requested (images 2 and 3).

Considering the clinical history and radiological findings, what is the most likely diagnosis?

a) Multiple sclerosis

25%

b) Meningioma

25%

c) Arnold-Chiari malformation

25%

d) Intramedullary tumor

25%
   

Image analysis

Image 1: Analysis: Contrast-enhanced brain CT, axial section at the medulla oblongata level. It demonstrates hypodense expansile lesion in the medulla oblongata, without contrast uptake, measuring 21 x 21 millimeters and slightly compressing the lower portion of the fourth ventricle.

 

Image 2: Analysis: MRI of the cervical spine, sagittal section, weighed in T2, after injection of intravenous contrast agent. It demonstrates intramedullary expansile lesion, with regular borders and partially defined limits, measuring approximately 25 x 10 millimeters, localized between C6 and T1 (red circle). It is characterized by subtle contrast enhancement. It associates with upper syringomyelia and syringobulbia (red arrow). Below the lesion, there is dilation of the central canal of the spinal cord until the level of T4-T5.

 

Image 3: Analysis: MRI of the spine, weighed in T2, axial section at the level of C6, after intravenous contrast agent injection. It demonstrates expansile lesion with regular borders, partially defined limits and intermediate signal intensity exhibiting subtle contrast uptake.

 

Highlights

- The radiological finding of syringomyelic cavity is usually secondary to an underlying disease.

- The main cause of syringomyelia is Arnold-Chiari type I malformation; rachidian tumors and spinal cord trauma are less frequent causes.

- Rachidian tumors may be extramedullary or intramedullary.

- Extramedullary tumors are more frequent (e.g. meningioma, schwannoma).

- Among the most common intramedullary tumors are the ependymomas and astrocytomas. The ependymomas are more prevalent and have better prognosis.

- MRI is the imaging method of choice for evaluation of syringomyelia.

References

1)       Mancall EL. Siringomielia. In: Rowland LP, Pedley TA. Merritt tratado de neurologia. 12 ed. Rio de Janeiro: Guanabara Koogan, 2011.

2)       McCormick PC, Rowland LP. Tumores raquianos. In: Rowland LP, Pedley TA. Merritt tratado de neurologia. 12 ed. Rio de Janeiro: Guanabara Koogan, 2011.

3)       Welch WC, Schiff DS, Gerszten PC. Spinal cord tumors. Available in: uptodate.com/contents/spinal-cord-tumors?search=syrinx&topicRef=5093&source=see_link#H9.

4)       Abul-kasim K, Thurnher MM, McKeever P, Sundgren PC. Intradural spinal tumors: current classification and MRI features. Neuroradiology. 2008;50:301-14.

5)       Haouimi A, Wein S et al. Intramedullary spinal tumors. Available in: radiopaedia.org/articles/intramedullary-spinal-tumours?lang=us

Authors

Mateus Jorge Nardelli, 4th year medical student at Universidade Federal de Minas Gerais.

E-mail: mateus.nardelli[at]gmail.com

Supervisor

Professor Aluízio Augusto Arantes Júnior, Neurosurgeon and Adjunt Professor of the Department of Surgery at Medical School of Universidade Federal de Minas Gerais.

E-mail: aluizio_arantes[at]uol.com.br

 

Carlos Magno da Silva, MD, Ph.D., Voluntary Professor and Doctor of the Radiology Service at Medical School of Universidade Federal de Minas Gerais.

Email: carlosbresil[at]hotmail.com

Reviewers

Felipe Lopes, Letícia de Melo Elias, Violeta Braga, Gabriel de Figueiredo, Bruno Chaves, Viviane Parisotto Marinho

Translated by

Ana Luísa Melgaço Almeida, 5th year medical student at Universidade Federal de Minas Gerais.

E-mail: analuisamelgaco[at]outook.com

Test question

a)

25%

b)

25%

c)

25%

d)

25%

e)

25%
   

Commentics

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