Tumor or hematoma? : An unusual case of an extradural lesion of the lumbar spine.

PURPOSE: Spinal epidural hematoma is a rare clinical entity. We present a case of atypical contrast enhancement pattern in a chronic epidural hematoma of the lumbar spine mimicking an extradural tumor. CASE REPORT: A 76-year-old man on treatment with oral anticoagulants presented with a 1-month history of lower back pain radiating into his right upper thigh accompanied by spinal claudication. Preoperative MRI showed a posterior epidural lesion compressing the cauda equina with almost homogeneous contrast enhancement. Surgery was performed under the presumptive diagnosis of spinal extradural neoplasm. Intraoperative and histological findings were consistent with a chronic spinal epidural hematoma. Postoperatively, the patient had instant relief of his symptoms. CONCLUSION: Chronic spinal epidural hematoma may resemble an extradural tumor, requiring surgery for histological confirmation and decompression.

Neoplastic meningitis: How MRI and CSF cytology are influenced by CSF cell count and tumor type.

BACKGROUND: Although CSF cytology and MRI are standard methods to diagnose neoplastic meningitis (NM), this complication of neoplastic disease remains difficult to detect. We therefore reevaluated the sensitivity of gadolinium (GD)-enhanced MRI and cerebrospinal-fluid (CSF)-cytology and the relevance of tumor type and CSF cell count. METHODS: We retrospectively identified 111 cases of NM diagnosed in our CSF laboratory since 1990 with complete documentation of both MRI and CSF cytology. 37 had haematological and 74 solid neoplasms. CSF cell counts were increased in 74 and normal in 37 patients. RESULTS: In hematological neoplasms, MRI was positive in 49% and CSF cytology in 97%. In solid tumors, the sensitivity of MRI was 80% and of cytology 78%. With normal CSF cell counts, MRI was positive in 59% (50% hematological, 72% solid malignancies) and CSF cytology in 76% (92% in hematological, 68% in solid neoplasms). In cases of elevated cell counts, the sensitivity of MRI was 72% (50% for hematological, 83% for solid malignancies) and of CSF cytology 91% (100% for haematological and 85% for solid neoplasms). 91% of cytologically positive cases were diagnosed at first and another 7% at second lumbar puncture. Routine protein analyses had a low sensitivity in detecting NM. CONCLUSIONS: The high overall sensitivity of MRI was only confirmed for NM from solid tumors and for elevated CSF cell counts. With normal cell counts and haematological neoplasms, CSF-cytology was superior to MRI. None of the analysed routine CSF proteins had an acceptable sensitivity and specificity in detecting leptomeningeal disease.

[Neoplastic meningitis. Diagnosis and individualised therapy]. / Meningeosis neoplastica. Diagnostik und individualisierte Therapie.

Neoplastic meningitis is a diffuse dissemination of tumour cells in the cerebrospinal fluid (CSF), leptomeninges, or both. It occurs in approximately 5-10% of malignant diseases, most often in breast cancer, lung cancer, melanoma, and B-cell lymphoma. Symptoms of neoplastic meningitis include head or back pain, cranial nerve palsies, diffuse radicular symptoms, and psychiatric disturbances. Magnetic resonance imaging shows nodular contrast enhancement lining the CSF spaces. Positive CSF cytology requires optimal sampling and processing, and the treatment of neoplastic meningitis must be individualized. The CSF dissemination can be treated with intrathecal chemotherapy with methotrexate or Ara-C. Radiotherapy should be applied only to symptomatic solid spinal manifestations or fast progressing cranial nerve palsies. Systemic chemotherapy is needed to control solid manifestations or, in the case of substances entering the CSF, to support intrathecal chemotherapy.