Haemorrhagic intramedullary spinal cord lesion: Answer

Abstract

1.AnswerC. Intramedullary spinal cord metastasis2.Discussion Intramedullary spinal tumours are uncommon, representing about 4% of spinal tumours [[1]Balmaceda C. Chemotherapy for intramedullary spinal cord tumors.J Neuro-Oncol. 2000; 47: 293-307Crossref PubMed Scopus (72) Google Scholar]. The most common are astrocytoma and ependymoma [[2]Samartzis D. et al.Intramedullary spinal cord tumors: part I – epidemiology, pathophysiology, and diagnosis.Global Spine J. 2015; 5: 425-435Crossref PubMed Scopus (101) Google Scholar]. Intramedullary spinal cord metastases (ISCM) are rarer, accounting for about 2% of intramedullary tumours [2Samartzis D. et al.Intramedullary spinal cord tumors: part I – epidemiology, pathophysiology, and diagnosis.Global Spine J. 2015; 5: 425-435Crossref PubMed Scopus (101) Google Scholar, 3Rykken J.B. et al.Intramedullary spinal cord metastases: MRI and relevant clinical features from a 13-year institutional case series.Am J Neuroradiol. 2013; 34: 2043-2049Crossref PubMed Scopus (45) Google Scholar]. Disease spread is thought to be commonly haematogenous, and symptoms can develop rapidly prior to diagnosis [[4]Grem J.L. et al.Clinical features and natural history of intramedullary spinal cord metastasis.Cancer. 1985; 56: 2305-2314Crossref PubMed Scopus (169) Google Scholar]. Primary tumours are commonly lung, breast, melanoma, lymphoma and renal cell carcinoma [[5]Kalayci M. et al.Intramedullary spinal cord metastasis: diagnosis and treatment – an illustrated review.Acta Neurochir. 2004; 146: 1347-1354Crossref PubMed Scopus (142) Google Scholar]. Common symptoms include weakness, pain, with sensory loss, bladder or bowel dysfunction [3Rykken J.B. et al.Intramedullary spinal cord metastases: MRI and relevant clinical features from a 13-year institutional case series.Am J Neuroradiol. 2013; 34: 2043-2049Crossref PubMed Scopus (45) Google Scholar, 5Kalayci M. et al.Intramedullary spinal cord metastasis: diagnosis and treatment – an illustrated review.Acta Neurochir. 2004; 146: 1347-1354Crossref PubMed Scopus (142) Google Scholar]. Frequently these can be the only presenting symptoms [3Rykken J.B. et al.Intramedullary spinal cord metastases: MRI and relevant clinical features from a 13-year institutional case series.Am J Neuroradiol. 2013; 34: 2043-2049Crossref PubMed Scopus (45) Google Scholar, 5Kalayci M. et al.Intramedullary spinal cord metastasis: diagnosis and treatment – an illustrated review.Acta Neurochir. 2004; 146: 1347-1354Crossref PubMed Scopus (142) Google Scholar]. MRI is the imaging modality of choice [[2]Samartzis D. et al.Intramedullary spinal cord tumors: part I – epidemiology, pathophysiology, and diagnosis.Global Spine J. 2015; 5: 425-435Crossref PubMed Scopus (101) Google Scholar], and most lesions are contrast-enhancing [3Rykken J.B. et al.Intramedullary spinal cord metastases: MRI and relevant clinical features from a 13-year institutional case series.Am J Neuroradiol. 2013; 34: 2043-2049Crossref PubMed Scopus (45) Google Scholar, 5Kalayci M. et al.Intramedullary spinal cord metastasis: diagnosis and treatment – an illustrated review.Acta Neurochir. 2004; 146: 1347-1354Crossref PubMed Scopus (142) Google Scholar]. Although not well supported by evidence, treatment often consists of resection (where appropriate), chemotherapy and stereotactic radiotherapy [[5]Kalayci M. et al.Intramedullary spinal cord metastasis: diagnosis and treatment – an illustrated review.Acta Neurochir. 2004; 146: 1347-1354Crossref PubMed Scopus (142) Google Scholar]. Treatment aims to preserve neurological function and minimise symptoms. Prognosis is poor for ISCM, with median survival less than three months [[4]Grem J.L. et al.Clinical features and natural history of intramedullary spinal cord metastasis.Cancer. 1985; 56: 2305-2314Crossref PubMed Scopus (169) Google Scholar]. In this patient, we performed formal catheter angiography, because of the prominent vasculature seen dorsal to the lesion, thus excluding arteriovenous malformation. A repeat MRI demonstrated a low-enhancing intramedullary mass at T3-4 with development of syrinx (Fig. 2B). The lesion was biopsied and histopathology demonstrated adenocarcinoma, likely of oesophageal origin. A CT abdomen revealed a concentric oesophageal mass, proven as adenocarcinoma on endoscopic biopsy. This case represents one of possibly three cases of oesophageal adenocarcinoma ISCM reported in the literature. Unfortunately, this patient’s only preceding symptom of oesophageal cancer was abdominal pain. He had no history of gastro-oesophageal reflux, nor dysphagia. Given his severe neurological injury, there was no role for palliative radiotherapy and he declined chemotherapy. Haemorrhagic intramedullary spinal cord lesionJournal of Clinical NeuroscienceVol. 48PreviewA 59 year-old man was referred with acute bilateral lower limb weakness, altered sensation and urinary retention. He also described having three months of abdominal and bilateral lower limb pain, and unsteady gait. He had a medical history of ischaemic heart disease treated by coronary artery bypass, and was on aspirin. He had no history of malignancy and was a non-smoker. Examination demonstrated bilateral profound lower limb weakness, decreased sensation up to the level of T4 with decreased anal tone. Full-Text PDF