Letters to Editor
Intramedullary spinal cord metastasis detected with whole body diffusion‑weighted imaging Sir, Intramedullary spinal cord metastasis (ISCM) is an extremely rare and often difficult to diagnose. Early diagnosis and institution of therapy may improve the prognosis and quality of life for patients with ISCM. Several cases of ISCM were reported with whole body imaging techniques such as positron emission tomography/computed tomography (PET/CT).[1,2] But to the best of our knowledge, there is no report based on the whole body diffusion‑weighted imaging (DWI). We report one such case. A 58‑year‑old man diagnosed with small cell lung cancer presented to us in September, 2008, with complaints of persistent dizziness. Brain CT revealed multiple brain metastases. He underwent whole brain radiation treatment at a dose of 40 Gy combined with traditional Chinese medicine (TCM). On day‑4 of radiation treatment, he complained of numbness and weakness in the limbs. Whole body DWI was done to exclude metastasis elsewhere using b values of 0 and 600 mm²/s (Philips Healthcare, 1.5T Intera Scanner). Whole body DWI revealed a hyperintense signal in the conus medullaris [Figure 1a and b]. This was confirmed by conventional magnetic resonance
a
Conventional MRI is sufficiently sensitive for detecting intramedullary lesions, but its field of view is limited.
a
b
Figure 1: (a) Whole‑body DWI images in a 58‑year‑old man with small‑cell lung carcinoma metastasis to the conus medullaris. Coronal whole‑body DWI image shows a hyperintense signal in the conus medullaris, as well as multiple hyperintense signals in the bilateral neck, supraclavicular fossa, hilum, and mediastinum (white arrow). (b) Axial DWI image shows multiple hyperintense signals at the level of the conus medullaris (black arrow)
c
b
e
imaging (MRI) [Figure 2a and b], which revealed an increased diameter of the spinal cord conus and hyperintensity on T2‑weighted images. Radiotherapy, 40 Gy was given to the conus medullaris metastasis in February, 2009. The tumor size and intramedullary high signal area decreased on magnetic resonance images after radiotherapy [Figure 3a and b]. However, the neurologic manifestations improved and his quality of life was restored. Four months later, he noticed rapidly progressive weakness, sensory disturbances of the lower limbs, and bowel/bladder dysfunction. He died from respiratory failure nine months after the diagnosis of ISCM.
f
d
g
Figure 2: (a) Sagittal T2‑weighted MR image shows a hyperintense signal in the conus medullaris (white arrow). (b) Axial T2‑weighted MR image shows a hyperintense signal in the conus medullaris (white arrow). (c) Axial CT soft tissue window image shows a right hilar mass, a thicker bronchus wall and bronchostenosis in the right inferior lobar bronchus. (d) Axial CT soft tissue window image shows subcarinal lymph node enlargement. (e) Axial CT soft tissue window image shows mediastinal lymph node enlargement. (f) Axial CT soft tissue window image shows left hilar lymph node enlargement. (g) Axial CT soft tissue window image shows right hilar lymph node enlargement
Neurology India | Sep-Oct 2013 | Vol 61 | Issue 5
555
Letters to Editor
References
a
b Figure 3: (a) Sagittal T2‑weighted image shows tumor size and intramedullary high‑signal area were decreased after radiotherapy. (b) Axial T2‑weighted image shows tumor size and intramedullary high‑signal area were decreased after radiotherapy
As whole body imaging technologies, PET/CT could be used to detect ISCM. Nevertheless, it requires radiation use. Takahara et al., [3] reported a unique whole body DWI concept which had the advantages of a wider coverage range and without radiation exposure. In the present case, whole body DWI allowed lesions of the primary lung cancer [Figure 2c], subcarinal [Figure 2d], mediastinal, [Figure 2e] bilateral hilar lymph nodes [Figure 2f and g] and entire spinal cord, including distant metastases in the conus medullaris to be imaged simultaneously compared to MRI and CT. The mean apparent diffusion coefficient (ADC) values for the conus medullaris on whole body DWI were lower than those elsewhere in the spinal cord (0.781 × 10‑3 mm²/s vs. 0.825 × 10‑3 mm²/s), consistent with results in the literature. The diagnosis of ISCM seems reliable. The patient’s clinical history and rapidly progressing neurological symptoms allowed us to distinguish ISCM from a primary intramedullary tumor, which typically presents with slower symptom progression.[4] Optimal treatment for ISCM remains controversial. We adopted a treatment approach of chemoradiotherapy combined with TCM. The patient died in 2009 June, 9 months from the diagnosis of ISCM. In summary, this report shows that early diagnosis by whole body DWI allows detection of the suspected ISCM, enabling timely treatment prior to the development of neurological symptoms which might improve the patients’ prognoses. However, further large‑scale studies are needed to come up with general conclusions concerning the value of whole body DWI in ISCM.
Yan Zhang1,2, Yongbo Huang3, Xixing Wang4, Jun Wang1 1
Departments of Radiology and 3Orthopedics, The Second Hospital of Shanxi Medical University, Taiyuan, 2Departments of Radiology and 4Oncology, Shanxi Province Hospital of Traditional Chinese Medicine, Taiyuan, Shanxi, China. E‑mail: [email protected]
556
1. Sari O, Kaya B, Kara Gedik G, Ozcan Kara P, Varoglu E. Intramedullary metastasis detected with 18F FDG‑PET/CT. Rev Esp Med Nucl Imagen Mol 2012;31:299‑300. 2. Pellegrini D, Quezel MA, Bruetman JE. Intramedullary spinal cord metastasis. Arch Neurol 2009;66:1422. 3. Takahara T, Imai Y, Yamashita T, Yasuda S, Nasu S, Van Cauteren M. Diffusion weighted whole body imaging with background body signal suppression (DWIBS): Technical improvement using free breathing, STIR and high resolution 3D display. Radiat Med 2004;22:275‑82. 4. Madhukar M, Maller VG, Choudhary AK, Iantosca MR, Specht CS, Dias MS. Primary intramedullary spinal cord germinoma. J Neurosurg Pediatr 2013;11:605‑9. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.121954
Received: 27‑08‑2013 Review completed: 01‑09‑2013 Accepted: 13‑10‑2013
Spontaneous rupture of hydrocephalic head Sir, A 6‑month‑old female child, a product of non‑consanguineous marriage, and born at full term by normal vaginal delivery, presented to us with a large head and a swelling over the lower back region since birth. She was diagnosed to have hydrocephalous in the antenatal period at 8 months of gestation, but termination of pregnancy could not be done. She was born with a large head and the head size kept on increasing gradually. She also had weakness in both lower limbs (power 0/5). She was diagnosed to have meningomyelocele (MMC) and congenital hydrocephalous and was advised repair of MMC and ventriculoperitoneal shunt. Parents did not give consent for surgery and the child was taken back home. While at home, she developed dehiscence of the skin over the vertex with cerebrospinal fluid (CSF) leakage from it without any form of preceding trauma. [Figures 1a, b and 2]. There was big skin defect over the vertex when she was brought to emergency department. She was running fever and her total leucocyte count was raised. Non‑contrast computed tomography head revealed bilateral large subdural hematoma with pneumocephalous and pneumoventricle. The brain tissue was protruding out through the ruptured skin [Figure 3]. Neurology India | Sep-Oct 2013 | Vol 61 | Issue 5
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Intramedullary spinal cord metastasis detected with whole body diffusion‑weighted imaging Sir, Intramedullary spinal cord metastasis (ISCM) is an extremely rare and often difficult to diagnose. Early diagnosis and institution of therapy may improve the prognosis and quality of life for patients with ISCM. Several cases of ISCM were reported with whole body imaging techniques such as positron emission tomography/computed tomography (PET/CT).[1,2] But to the best of our knowledge, there is no report based on the whole body diffusion‑weighted imaging (DWI). We report one such case. A 58‑year‑old man diagnosed with small cell lung cancer presented to us in September, 2008, with complaints of persistent dizziness. Brain CT revealed multiple brain metastases. He underwent whole brain radiation treatment at a dose of 40 Gy combined with traditional Chinese medicine (TCM). On day‑4 of radiation treatment, he complained of numbness and weakness in the limbs. Whole body DWI was done to exclude metastasis elsewhere using b values of 0 and 600 mm²/s (Philips Healthcare, 1.5T Intera Scanner). Whole body DWI revealed a hyperintense signal in the conus medullaris [Figure 1a and b]. This was confirmed by conventional magnetic resonance
a
Conventional MRI is sufficiently sensitive for detecting intramedullary lesions, but its field of view is limited.
a
b
Figure 1: (a) Whole‑body DWI images in a 58‑year‑old man with small‑cell lung carcinoma metastasis to the conus medullaris. Coronal whole‑body DWI image shows a hyperintense signal in the conus medullaris, as well as multiple hyperintense signals in the bilateral neck, supraclavicular fossa, hilum, and mediastinum (white arrow). (b) Axial DWI image shows multiple hyperintense signals at the level of the conus medullaris (black arrow)
c
b
e
imaging (MRI) [Figure 2a and b], which revealed an increased diameter of the spinal cord conus and hyperintensity on T2‑weighted images. Radiotherapy, 40 Gy was given to the conus medullaris metastasis in February, 2009. The tumor size and intramedullary high signal area decreased on magnetic resonance images after radiotherapy [Figure 3a and b]. However, the neurologic manifestations improved and his quality of life was restored. Four months later, he noticed rapidly progressive weakness, sensory disturbances of the lower limbs, and bowel/bladder dysfunction. He died from respiratory failure nine months after the diagnosis of ISCM.
f
d
g
Figure 2: (a) Sagittal T2‑weighted MR image shows a hyperintense signal in the conus medullaris (white arrow). (b) Axial T2‑weighted MR image shows a hyperintense signal in the conus medullaris (white arrow). (c) Axial CT soft tissue window image shows a right hilar mass, a thicker bronchus wall and bronchostenosis in the right inferior lobar bronchus. (d) Axial CT soft tissue window image shows subcarinal lymph node enlargement. (e) Axial CT soft tissue window image shows mediastinal lymph node enlargement. (f) Axial CT soft tissue window image shows left hilar lymph node enlargement. (g) Axial CT soft tissue window image shows right hilar lymph node enlargement
Neurology India | Sep-Oct 2013 | Vol 61 | Issue 5
555
Letters to Editor
References
a
b Figure 3: (a) Sagittal T2‑weighted image shows tumor size and intramedullary high‑signal area were decreased after radiotherapy. (b) Axial T2‑weighted image shows tumor size and intramedullary high‑signal area were decreased after radiotherapy
As whole body imaging technologies, PET/CT could be used to detect ISCM. Nevertheless, it requires radiation use. Takahara et al., [3] reported a unique whole body DWI concept which had the advantages of a wider coverage range and without radiation exposure. In the present case, whole body DWI allowed lesions of the primary lung cancer [Figure 2c], subcarinal [Figure 2d], mediastinal, [Figure 2e] bilateral hilar lymph nodes [Figure 2f and g] and entire spinal cord, including distant metastases in the conus medullaris to be imaged simultaneously compared to MRI and CT. The mean apparent diffusion coefficient (ADC) values for the conus medullaris on whole body DWI were lower than those elsewhere in the spinal cord (0.781 × 10‑3 mm²/s vs. 0.825 × 10‑3 mm²/s), consistent with results in the literature. The diagnosis of ISCM seems reliable. The patient’s clinical history and rapidly progressing neurological symptoms allowed us to distinguish ISCM from a primary intramedullary tumor, which typically presents with slower symptom progression.[4] Optimal treatment for ISCM remains controversial. We adopted a treatment approach of chemoradiotherapy combined with TCM. The patient died in 2009 June, 9 months from the diagnosis of ISCM. In summary, this report shows that early diagnosis by whole body DWI allows detection of the suspected ISCM, enabling timely treatment prior to the development of neurological symptoms which might improve the patients’ prognoses. However, further large‑scale studies are needed to come up with general conclusions concerning the value of whole body DWI in ISCM.
Yan Zhang1,2, Yongbo Huang3, Xixing Wang4, Jun Wang1 1
Departments of Radiology and 3Orthopedics, The Second Hospital of Shanxi Medical University, Taiyuan, 2Departments of Radiology and 4Oncology, Shanxi Province Hospital of Traditional Chinese Medicine, Taiyuan, Shanxi, China. E‑mail: [email protected]
556
1. Sari O, Kaya B, Kara Gedik G, Ozcan Kara P, Varoglu E. Intramedullary metastasis detected with 18F FDG‑PET/CT. Rev Esp Med Nucl Imagen Mol 2012;31:299‑300. 2. Pellegrini D, Quezel MA, Bruetman JE. Intramedullary spinal cord metastasis. Arch Neurol 2009;66:1422. 3. Takahara T, Imai Y, Yamashita T, Yasuda S, Nasu S, Van Cauteren M. Diffusion weighted whole body imaging with background body signal suppression (DWIBS): Technical improvement using free breathing, STIR and high resolution 3D display. Radiat Med 2004;22:275‑82. 4. Madhukar M, Maller VG, Choudhary AK, Iantosca MR, Specht CS, Dias MS. Primary intramedullary spinal cord germinoma. J Neurosurg Pediatr 2013;11:605‑9. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.121954
Received: 27‑08‑2013 Review completed: 01‑09‑2013 Accepted: 13‑10‑2013
Spontaneous rupture of hydrocephalic head Sir, A 6‑month‑old female child, a product of non‑consanguineous marriage, and born at full term by normal vaginal delivery, presented to us with a large head and a swelling over the lower back region since birth. She was diagnosed to have hydrocephalous in the antenatal period at 8 months of gestation, but termination of pregnancy could not be done. She was born with a large head and the head size kept on increasing gradually. She also had weakness in both lower limbs (power 0/5). She was diagnosed to have meningomyelocele (MMC) and congenital hydrocephalous and was advised repair of MMC and ventriculoperitoneal shunt. Parents did not give consent for surgery and the child was taken back home. While at home, she developed dehiscence of the skin over the vertex with cerebrospinal fluid (CSF) leakage from it without any form of preceding trauma. [Figures 1a, b and 2]. There was big skin defect over the vertex when she was brought to emergency department. She was running fever and her total leucocyte count was raised. Non‑contrast computed tomography head revealed bilateral large subdural hematoma with pneumocephalous and pneumoventricle. The brain tissue was protruding out through the ruptured skin [Figure 3]. Neurology India | Sep-Oct 2013 | Vol 61 | Issue 5
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
