Neuroradiology 14, 147-149 (1977)
Neuroradiolngv
© by Springer-Ver]ag1977
Angiographic Demonstration of Cervical Extradural Meningioma K. Sartor, E. Fliedner and E. Pfingst Departments of Diagnostic Radiology and Neurosurgery, Allgemeines Krankenhaus Altona, Hamburg, FRG
Summary. The diagnosis of a cervical extradural meningioma was made preoperatively on the basis of angiographic criteria. The entire extent of the tumor that partially encircled the dural sac could be demonstrated with regional spinal angiography. Key words: Spinal extradural meningioma - Spinal angiography.
Spinal extradural meningiomas are rare lesions. As calculated from several reports on spinal tumors [1, 2, 3, 4, 7] they represent less than 7% of all spinal meningiomas. Their diagnosis is almost never made preoperatively, plain radiographs and myelographic films usually showing only the unspecific signs of an extradural space occupying lesion. A specific diagnosis, however, can be made, or at least strongly suspected, on the basis of angiographic criteria. The following report is, to our knowledge, the first one on angiographic demonstration of a spinal extradural meningioma.
Case Report A man, aged 29 years, was admitted with the tentative diagnosis of cervical myelopathy. He had a history of two automobile accidents 4 and 2 years ago, each time with compression trauma to the cervical spine. Ever since the first accident he had had pain in the neck. Following chiropractic manipulation about one year prior to admission there had been a quadriparesis of short duration. His present complaints, aside from almost constant pain in the neck, included numbness, stiffness, and loss of postural sensibility in both upper and lower extremities.
These symptoms had been slowly progressive during the last 6 months. There were no sphincter disturbances. On neurological examination spastic quadriparesis was found, the involvement of the arms being comparatively mild. There was bilateral ankle clonus and the plantar response was extensor bilaterally. Plain radiographs of the cervical spine revealed an abnormally wide distance between the arches of the first and second cervical vertebrae. Duroliopaque myelography revealed a marked impedance to the flow of the contrast medium at the level of the uppermost four cervical vertebrae where the dural sac appeared to be displaced anteriorly, most marked at C2_3 (Fig. 1). An extradural space occupying lesion was therefore suspected. In order to evaluate its etiology selective cervical spinal angiography was performed with injections of both vertebral arteries and thyrocervical trunks and of the costocervical trunk on the left. Contrast injection of the left vertebral artery filled multiple muscular and probably also hypertrophied (external) meningeal branches of the vertebral artery. This was followed by early opacification of pathological vessels which, on the lateral view, projected mainly between the arches of C1-C2 and on the anterior half of the spinal canal at the level of C2-C 3. The tumor stain subsequently became better circumscribed and slightly more homogeneous, persisting well into the venous phase, when prominent draining veins of the external vertebral plexus were visualized (Fig. 2 a-c). On injection of the right vertebral artery there was also contrast filling of a number of hypertrophied arterial branches, particularly at the C1-C2 level, leading to a small tumor blush that also projected between the arches of the two uppermost cervical vertebrae. In addition there was a promi-
148
K. Sartor et al.: Cervical Extradural Meningioma
Fig. 1. Spinal extradural meningioma. Myelogram showing anterior displacement of dura by posterior mass at C1--C2 Fig. 2. a and h Following injection of left vertebral artery early opacification of pathological vessels and tumor blush at CI-C3. e Persistence of tumor stain into venous phase. Stain most prominent between C1--C2 arches and at C2-Ca anteriorly, d On injection of right vertebral artery additional small tumor blush between C1-Cz arches and at C4 anteriorly and posteriorly Fig. 3. Spinal extradural meningioma. Microscopic study shows fibromatous and endotbeliomatous components; regressive changes are prominent (van Gieson × 160)
nent, almost h o m o g e n e o u s blush at the level of C4, located partially anterior, partially posterior to the dural sac (Fig. 2 d). O n injection of b o t h thyrocervical and left costocervical trunks no abnormalities were noted. T h e diagnosis of an extradural spinal m e n i n g i o m a with cord c o m p r e s s i o n was m a d e on
the basis of the m y e l o g r a p h i c findings and the angiographic a p p e a r a n c e of the lesion. A t o p e r a t i o n a m o d e r a t e l y vascular t u m o r was f o u n d which grew b u l k y b e t w e e n the C1-C2 arches and e x t e n d e d tongue-like d o w n to the C4 level, p a r tially encircling the dural sac. It was a d h e r e n t to the
149
K. Sartor et al.: Cervical Extradural Meningioma
dura and continued into the musculature of the neck, but there was no intradural extension as could be ascertained on opening the dura. The C2 nerve root was surrounded by neoplastic tissue. The tumor could not be totally resected. Histologically it proved to be a typical benign meningioma that was predominantly fibromatous but had endotheliomatous components (Fig. 3).
Discussion
Spinal meningiomas typically are intradural tumors, mostly located in the thoracic region. They usually occur in women over 35 years of age. Myelography almost always leads to the diagnosis. Angiography has been needed only in exceptional cases [6]. In the differential diagnosis mainly neurinomas have to be considered. These tumors have a very similar myelographic appearance but their clinical symptomatology frequently differs from that of meningiomas. Spinal meningiomas can be extradural in rare cases, possibly arising from the arachnoid at the nerve root exits, where this membrane is in contact with the dura [2, 3, 5, 9]. As with intradural meningiomas the thoracic segment of the spine is most frequently the site of the lesion, relatively closely followed by the cervical segment. ~he average age of the mostly female patients is less than with intradural meningiomas, a considerable proportion being younger than 30 years [4]. Spinal extradural meningiomas are supposed to become malignant more often than their intradural counterparts [2]. Plain radiographs, including tomography, rarely contribute to the radiological diagnosis although they may show signs of a slowly growing intraspinal space occupying lesion, occasionally mimicking a neurinoma (neurofibroma) of the dumbbell type [4]. Radiographically visible calcification has not yet been found. Myelography is a valuable method as it confirms the presence of an intraspinal extradural mass, but it does not provide any information as to the etiology of the lesion. Regional selective spinal angiography, however, can provide this very important information. As our case suggests the anglographic characteristics of extradural spinal meningiomas are similar to the ones of intracranial meningiomas, an important feature being the long duration of the tumor stain. Differentiation from neurinomas should be possible in most cases as
the latter are usually less vascular. However, neurinomas, indistinguishable angiographically from intra- and extradural meningiomas, may occur [8]. Angiography can also be helpful to determine if the lesion had already undergone malignant transformation. In our case the tumor vessels were quite regular, and there was no premature venous filling. In conclusion we feel that regional selective spinal angiography is the radiological method of choice where the nature of an extradural spinal mass lesion, accompanied by symptoms and signs of relatively long standing, has to be determined. In such cases the possibility of an ectopic (extradural) meningioma always should be considered, particularly in the younger age group. The exact role of computed spinal tomography with extradural tumors still remains to be determined but might prove to be of great value in the diagnostic study of lesions of this kind in the future.
References 1. Arseni, M.C., Ionesco, S.: Les compressions m6dullaires due des tumeurs intrarachidiennes. Etude clinicostatistique de 362 cas. Chir. 75, 582-594 (1958) 2. Bull, J.W.D.: Spinal meningiomas and neurofibromas. Acta radiol. 40, 283-300 (1953) 3. Elsberg, C.A.: Surgical diseases of the spinal cord, membranes and nerve roots. Symptoms, diagnosis and treatment. New York: Hoeber 1941 4. Fortuna, A., Gambacorta, D., Occhipinti, E.M.: Spinal extradural meningiomas. Neurochirurgia 12, 166-180 (1969) 5. Haft, H., Shenkin, H.A.: Spinal epidural meningioma. J. Neurosurg. 20, 801-804 (1963) 6. Klausberger, E.M., Zeiler, K.: Zervikales Meningeom im Vertebralisangiogramm. Wien. Med. Wochenschr. 47; 694-697
(1974) 7. Lombardi, G., Passerini, A.: Spinal cord tumors. Radiology 76, 381-392 (1961) 8. Moscow, N.P., Newton, T.H.: Angiographic features of hypervascular neurinomas of the head and neck. Radiology 114, 635-640 (1975) 9. Pecker, J., Jevalet, A., Simon, J., Loussouarn, Y.: Les tumeurs 6pidurales b6nignes de la moelle. Neurochirurgie 13, 647~560 (1967)
Received: August 15, 1977 Dr. Klaus Sartor Department of Diagnostic Radiology Allgemeines Krankenhaus Altona Paul-Ehrlich-Str. 1 D-2000 Hamburg 50 Federal Republic of Germany
Neuroradiolngv
© by Springer-Ver]ag1977
Angiographic Demonstration of Cervical Extradural Meningioma K. Sartor, E. Fliedner and E. Pfingst Departments of Diagnostic Radiology and Neurosurgery, Allgemeines Krankenhaus Altona, Hamburg, FRG
Summary. The diagnosis of a cervical extradural meningioma was made preoperatively on the basis of angiographic criteria. The entire extent of the tumor that partially encircled the dural sac could be demonstrated with regional spinal angiography. Key words: Spinal extradural meningioma - Spinal angiography.
Spinal extradural meningiomas are rare lesions. As calculated from several reports on spinal tumors [1, 2, 3, 4, 7] they represent less than 7% of all spinal meningiomas. Their diagnosis is almost never made preoperatively, plain radiographs and myelographic films usually showing only the unspecific signs of an extradural space occupying lesion. A specific diagnosis, however, can be made, or at least strongly suspected, on the basis of angiographic criteria. The following report is, to our knowledge, the first one on angiographic demonstration of a spinal extradural meningioma.
Case Report A man, aged 29 years, was admitted with the tentative diagnosis of cervical myelopathy. He had a history of two automobile accidents 4 and 2 years ago, each time with compression trauma to the cervical spine. Ever since the first accident he had had pain in the neck. Following chiropractic manipulation about one year prior to admission there had been a quadriparesis of short duration. His present complaints, aside from almost constant pain in the neck, included numbness, stiffness, and loss of postural sensibility in both upper and lower extremities.
These symptoms had been slowly progressive during the last 6 months. There were no sphincter disturbances. On neurological examination spastic quadriparesis was found, the involvement of the arms being comparatively mild. There was bilateral ankle clonus and the plantar response was extensor bilaterally. Plain radiographs of the cervical spine revealed an abnormally wide distance between the arches of the first and second cervical vertebrae. Duroliopaque myelography revealed a marked impedance to the flow of the contrast medium at the level of the uppermost four cervical vertebrae where the dural sac appeared to be displaced anteriorly, most marked at C2_3 (Fig. 1). An extradural space occupying lesion was therefore suspected. In order to evaluate its etiology selective cervical spinal angiography was performed with injections of both vertebral arteries and thyrocervical trunks and of the costocervical trunk on the left. Contrast injection of the left vertebral artery filled multiple muscular and probably also hypertrophied (external) meningeal branches of the vertebral artery. This was followed by early opacification of pathological vessels which, on the lateral view, projected mainly between the arches of C1-C2 and on the anterior half of the spinal canal at the level of C2-C 3. The tumor stain subsequently became better circumscribed and slightly more homogeneous, persisting well into the venous phase, when prominent draining veins of the external vertebral plexus were visualized (Fig. 2 a-c). On injection of the right vertebral artery there was also contrast filling of a number of hypertrophied arterial branches, particularly at the C1-C2 level, leading to a small tumor blush that also projected between the arches of the two uppermost cervical vertebrae. In addition there was a promi-
148
K. Sartor et al.: Cervical Extradural Meningioma
Fig. 1. Spinal extradural meningioma. Myelogram showing anterior displacement of dura by posterior mass at C1--C2 Fig. 2. a and h Following injection of left vertebral artery early opacification of pathological vessels and tumor blush at CI-C3. e Persistence of tumor stain into venous phase. Stain most prominent between C1--C2 arches and at C2-Ca anteriorly, d On injection of right vertebral artery additional small tumor blush between C1-Cz arches and at C4 anteriorly and posteriorly Fig. 3. Spinal extradural meningioma. Microscopic study shows fibromatous and endotbeliomatous components; regressive changes are prominent (van Gieson × 160)
nent, almost h o m o g e n e o u s blush at the level of C4, located partially anterior, partially posterior to the dural sac (Fig. 2 d). O n injection of b o t h thyrocervical and left costocervical trunks no abnormalities were noted. T h e diagnosis of an extradural spinal m e n i n g i o m a with cord c o m p r e s s i o n was m a d e on
the basis of the m y e l o g r a p h i c findings and the angiographic a p p e a r a n c e of the lesion. A t o p e r a t i o n a m o d e r a t e l y vascular t u m o r was f o u n d which grew b u l k y b e t w e e n the C1-C2 arches and e x t e n d e d tongue-like d o w n to the C4 level, p a r tially encircling the dural sac. It was a d h e r e n t to the
149
K. Sartor et al.: Cervical Extradural Meningioma
dura and continued into the musculature of the neck, but there was no intradural extension as could be ascertained on opening the dura. The C2 nerve root was surrounded by neoplastic tissue. The tumor could not be totally resected. Histologically it proved to be a typical benign meningioma that was predominantly fibromatous but had endotheliomatous components (Fig. 3).
Discussion
Spinal meningiomas typically are intradural tumors, mostly located in the thoracic region. They usually occur in women over 35 years of age. Myelography almost always leads to the diagnosis. Angiography has been needed only in exceptional cases [6]. In the differential diagnosis mainly neurinomas have to be considered. These tumors have a very similar myelographic appearance but their clinical symptomatology frequently differs from that of meningiomas. Spinal meningiomas can be extradural in rare cases, possibly arising from the arachnoid at the nerve root exits, where this membrane is in contact with the dura [2, 3, 5, 9]. As with intradural meningiomas the thoracic segment of the spine is most frequently the site of the lesion, relatively closely followed by the cervical segment. ~he average age of the mostly female patients is less than with intradural meningiomas, a considerable proportion being younger than 30 years [4]. Spinal extradural meningiomas are supposed to become malignant more often than their intradural counterparts [2]. Plain radiographs, including tomography, rarely contribute to the radiological diagnosis although they may show signs of a slowly growing intraspinal space occupying lesion, occasionally mimicking a neurinoma (neurofibroma) of the dumbbell type [4]. Radiographically visible calcification has not yet been found. Myelography is a valuable method as it confirms the presence of an intraspinal extradural mass, but it does not provide any information as to the etiology of the lesion. Regional selective spinal angiography, however, can provide this very important information. As our case suggests the anglographic characteristics of extradural spinal meningiomas are similar to the ones of intracranial meningiomas, an important feature being the long duration of the tumor stain. Differentiation from neurinomas should be possible in most cases as
the latter are usually less vascular. However, neurinomas, indistinguishable angiographically from intra- and extradural meningiomas, may occur [8]. Angiography can also be helpful to determine if the lesion had already undergone malignant transformation. In our case the tumor vessels were quite regular, and there was no premature venous filling. In conclusion we feel that regional selective spinal angiography is the radiological method of choice where the nature of an extradural spinal mass lesion, accompanied by symptoms and signs of relatively long standing, has to be determined. In such cases the possibility of an ectopic (extradural) meningioma always should be considered, particularly in the younger age group. The exact role of computed spinal tomography with extradural tumors still remains to be determined but might prove to be of great value in the diagnostic study of lesions of this kind in the future.
References 1. Arseni, M.C., Ionesco, S.: Les compressions m6dullaires due des tumeurs intrarachidiennes. Etude clinicostatistique de 362 cas. Chir. 75, 582-594 (1958) 2. Bull, J.W.D.: Spinal meningiomas and neurofibromas. Acta radiol. 40, 283-300 (1953) 3. Elsberg, C.A.: Surgical diseases of the spinal cord, membranes and nerve roots. Symptoms, diagnosis and treatment. New York: Hoeber 1941 4. Fortuna, A., Gambacorta, D., Occhipinti, E.M.: Spinal extradural meningiomas. Neurochirurgia 12, 166-180 (1969) 5. Haft, H., Shenkin, H.A.: Spinal epidural meningioma. J. Neurosurg. 20, 801-804 (1963) 6. Klausberger, E.M., Zeiler, K.: Zervikales Meningeom im Vertebralisangiogramm. Wien. Med. Wochenschr. 47; 694-697
(1974) 7. Lombardi, G., Passerini, A.: Spinal cord tumors. Radiology 76, 381-392 (1961) 8. Moscow, N.P., Newton, T.H.: Angiographic features of hypervascular neurinomas of the head and neck. Radiology 114, 635-640 (1975) 9. Pecker, J., Jevalet, A., Simon, J., Loussouarn, Y.: Les tumeurs 6pidurales b6nignes de la moelle. Neurochirurgie 13, 647~560 (1967)
Received: August 15, 1977 Dr. Klaus Sartor Department of Diagnostic Radiology Allgemeines Krankenhaus Altona Paul-Ehrlich-Str. 1 D-2000 Hamburg 50 Federal Republic of Germany
