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Spinal Cord Metastases


KEY FACTS

Terminology

  • Metastatic lesion from primary carcinoma in another organ (including brain)

Imaging

  • Focal, enhancing cord lesion(s) with extensive edema

  • Typically small (< 1.5 cm)

  • T1WI: Enlarged cord

  • T2WI/PD/STIR: Focal high signal represents diffuse edema

    • Rarely syrinx

  • T1WI C+: Focal enhancement

  • T2* GRE: Hypointensity due to hemorrhagic components

Top Differential Diagnoses

  • Demyelinating disease

    • Multiple sclerosis

    • Acute disseminated encephalomyelitis

  • Primary cord tumor

  • Inflammatory granuloma

    • Tuberculosis

    • Sarcoidosis

  • Inflammatory myelitis

  • Radiation myelopathy

Clinical Issues

  • Brown-Séquard syndrome

  • Rapidly progressive flaccid paraparesis

  • Sphincter disturbance

    • Urinary and bowel dysfunction with conus involvement predominate

  • Intramedullary spinal cord metastatic heralds poor prognosis

Diagnostic Checklist

  • Full craniospinal imaging when focal cord lesion found

  • Edema out of proportion to focal small cord lesion suggests metastasis, even if solitary

Graphic depicts metastases to the skeleton
, epidural space
, and cord
. The hemorrhagic intramedullary metastasis expands the cord. Rapid onset of symptoms is characteristic for intramedullary spinal cord metastatic (ISCM). Asymmetric dysfunction of the spinal cord mimicking Brown-Séquard has been reported in 30-40% in ISCM but is exceptional in patients with epidural spinal cord compression.

Sagittal T1WI C+ MR shows an avidly enhancing nonsmall cell metastasis to the conus
.

Sagittal T2WI MR demonstrates a well-defined intramedullary lesion in the thoracic spinal cord
due to angiosarcoma metastases. The lesion has a hyperintense center and hypointense rim. Also note spinal cord edema extending above and below the lesion
.

Sagittal T1WI C+ MR reveals subtle enhancement of the angiosarcoma metastasis
. Nonneoplastic lesions, such as radiation myelopathy, demyelinating plaques, and paraneoplastic necrotizing myelopathy, can be difficult to differentiate from ISCM.

TERMINOLOGY

Synonyms

  • Intramedullary spinal cord metastatic (ISCM) disease

Definitions

  • Metastatic lesion from primary carcinoma in another organ (including brain)

IMAGING

General Features

  • Best diagnostic clue

    • Focal, enhancing cord lesion(s) with extensive edema

  • Location

    • Cervical > thoracic > lumbar, conus

  • Size

    • Typically small (< 1.5 cm)

  • Morphology

    • Well circumscribed

    • Spherical or oval

CT Findings

  • CECT

    • May rarely depict hypervascular mets as enhancing intraspinal foci (e.g., hypernephroma)

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