Clinical History
The patient presented to the emergency department with a 1-month history of left hemiparesis and loss of proprioception, and loss of sensation on the right hemibody.
Imaging Findings
Intradural extramedullary lesion, of the left-anterior aspect of the spinal canal, compressing the cervical spinal cord, deviated to the right and posteriorly. On MRI the lesion was iso- to slightly hyperintense on T1WI (Figure 1) and T2WI (Figure 2), with moderate homogeneous enhancement after intravenous gadolinium administration (Figure 3).
The lesion was adjacent to the dura, with a classic "dural tail" identifiable on post-contrast images, most strikingly the saggital T1+Gad (Figure 3A).
There were no identifiable signal changes of the cord and there was no spinal cord enhancement after gadolinium administration.
Discussion
Background
Meningiomas arising from the spinal dura mater represent a minority of all meningiomas (12%).(1, 2) They are the second most common intradural extramedullary spinal tumor, with an estimated prevalence of around 25%.(1, 2, 5) The thoracic spine is the most commonly affected area, with only 15% involving the cervical spine.(1, 2, 5) Spinal meningiomas have a peak incidence in the fifth and sixth decades, with a female predominance (80%).(5) There is an increased incidence in patients with neurofibromatosis type 2, especially in the paediatric population or in the case of multiple meningiomas.
Clinical Perspective
Spinal meningiomas are usually small in size and tend to be asymptomatic until they exert mass effect on the spinal cord or spinal nerves, which due to the confines of the spinal canal can result in significant neurologic dysfunction. Neurological deficits depend on the location.
Brown-Séquard syndrome is a clinical syndrome that reflects an incomplete hemi-lesion of the spinal cord, often in the cervical segment. Patients present with ipsilateral upper motor neuron paralysis and loss of proprioception, as well as contralateral loss of pain and temperature sensation.(4) It can arise from multiple intrinsic or extrinsic cord lesions, but Brown-Séquard syndrome secondary to meningiomas is rare.
Imaging Perspective
Computed tomography can show an isodense or moderately hyperdense mass. There may be hyperostosis although it is less common than in the intracranial forms.(5) MRI is the gold standard for evaluation of these lesions and their effect on the spinal cord.(3) They are usually well-circumscribed masses, with a broad-based dural attachment and may exhibit a dural tail. Their signal characteristics are similar to those of intracranial meningiomas, with a iso- to high signal intensity relative to the spinal cord on both T1 and T2WI, with moderate homogeneous enhancement after intravenous gadolinium administration.(3,5) Occasionally, densely calcified meningiomas are hypointense on T1 and T2WI, and show only minimal contrast enhancement.
Outcome
The aim of the treatment is to protect neurological structures through surgical removal of the tumor. Spinal meningiomas are typically slow growing. Surgery is the treatment of choice and complete tumour removal is achieved in the vast majority of patients. Less than 10% experience recurrence.(2, 5)
Take Home Message, Teaching Points
The most important diagnostic clue when facing a spinal lesion is its location (extra/intradural, extra/intramedullary)
Most common intradural extramedullary lesions
Extramedullary lesions can cause medullary syndromes, secondary to compression
MRI is the imaging diagnostic tool of choice.
Differential Diagnosis List
Cervical intradural extramedullary meningioma (Grade I WHO)
Spinal schwannoma
Spinal neurofibroma
Spinal dermoid/epidermoid cysts
Intradural extramedullary metastases
Malignant peripheral nerve sheath tumor (WHO grade III/IV)
Final Diagnosis
Cervical intradural extramedullary meningioma (Grade I WHO)
