British Journal of Radiology (2004) 77, 691-693
© 2004 British Institute of Radiology
doi: 10.1259/bjr/26882389
Haemorrhage within an intramedullary astrocytoma presenting with a mild clinical course and a fluid–fluid level on MRI
S Abdi, MB ChB, MRCS, FRCR and
R K Lenthall, MB BS, MRCP, FRCR
Department of Radiology, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH, UK
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Introduction
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Detection of a fluid–fluid level on MRI has been described in intracerebral haematoma, haemorrhagic cerebral tumours and cystic lesions [1–4]. In the absence of trauma, haemorrhage within the spinal cord may be due to an underlying ependymoma, astrocytoma, haemangioblastoma, metastases, or vascular malformation [5–13]. Spontaneous haemorrhage has also been reported in pregnancy, syringomyelia, haemophilia and as a complication of anticoagulation with warfarin [14, 15]. Haemorrhagic cord lesions are rare and to our knowledge there is only one previous report demonstrating intramedullary fluid levels occurring in a patient with a cervical ependymoma [5]. This sign has not been reported in association with cord haemorrhage from other causes and when found it may indicate haemorrhage into a pre-existing cystic lesion. In this case MR demonstrated extensive intramedullary haemorrhage in a patient with mild clinical features.
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Case report
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A 13-year-old female was referred to the neurology department with a 2 week history of backache and sudden onset of coldness in her right hand. There was no relevant family or past medical history. On examination, she had a cold right hand with wasting of the hypothenar muscles. The power was reduced to 4/5 in her right forearm and wrist, and to 3/5 in the small muscles of the hand. She was also noted to have thoracic scoliosis with concavity to the right. There was point tenderness in the region of T4 and T5 thoracic vertebrae.
The biochemical and blood profiles were normal. The chest X-ray confirmed the scoliosis but was otherwise unremarkable. The cervical spine X-rays demonstrated widening of the spinal canal. The brain MRI was normal. MRI of her spine showed a fusiform expansion of the cord from C2 to T7 levels with an intramedullary lesion between the C5 and C7 levels. There were signal changes in keeping with blood products, extending above and below the lesion within an extensive syrinx. The solid component of the lesion had high signal intensity on T2 weighted images and low signal on T1 weighted images, with enhancement on post-gadolinium T1 weighted sequences (Figures 1–3
). There was a large cyst within the tumour, which contained fluid–fluid level on all sequences. The supernatant was of intermediate/high signal on T1 weighted images and high signal intensity on T2 weighted scans. The subnatant was of lower signal on both T1 and T2 weighted images (Figures 1 and 2). In view of the benign clinical presentation despite the extensive cord haemorrhage, the reporting radiologist gave the diagnosis of haemorrhage within a largely cystic tumour and syrinx.
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Figure 1. T1 weighted image of the cervical spine demonstrates an intramedullary cystic lesion with fluid–fluid level (arrowheads). The supernatant has intermediate/high signal intensity with the subnatant being of lower signal. The solid component of the tumour (arrows) has lower signal intensity than the normal cord.
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Figure 2. T2 weighted image showing high signal supernatant and intermediate signal subnatant. The solid component of the lesion has areas of high signal intensity within it (arrow). Note the low signal area within the syrinx, which represents haemosiderin deposition (hollow arrow).
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Figure 3. T1 weighted image following administration of contrast medium (gadopentate dimeglumine) shows avid enhancement of the solid component of the lesion (arrow).
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Surgical excision of the lesion was performed. Histopathological examination of the specimen revealed haemorrhagic intramedullary astrocytoma (grade 1 or 2) with a low proliferation index, which was more in keeping with pilocytic rather than fibrillary pattern. The superior margin of the resection was not clear.
In the early post-operative period, the patient developed hyper-reflexia, weakness and altered sensation in her right leg. These symptoms improved on clinical follow-up. Follow-up MRI scans show a small focus of enhancing residual tumour superiorly.
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Discussion
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Non-traumatic spinal cord haemorrhage has a wide differential diagnosis. It is often secondary to an underlying abnormality such as intramedullary ependymoma, astrocytoma, haemangioblastoma, or vascular malformation. Warfarin therapy may also lead to intramedullary haematoma [5–14]. Risk factors for haemorrhage within pre-existing tumours include excessive exercise, pregnancy, anticoagulation or recent epidural anaesthesia [6, 15].
Ependymoma is the most common cord tumour in adults and typically presents with a slowly progressive deficit. The presentation with a 2 week history in this case is unusual and is likely to be related to episodes of intratumoral haemorrhage within an asymptomatic tumour.
Subarachnoid haemorrhage may be more common than intramedullary haemorrhage in ependymoma and haemangioblastoma [6, 9]. Although there may be histological evidence of recent or old haemorrhage within ependymomas, this is typically asymptomatic. A mixed pattern of subacute and chronic haemorrhage is rarely demonstrated on MRI in cord tumours [7]. Spinal cavernomas however typically have mixed signal intensity on both T1 and T2 weighted images due to a combination of acute, subacute and chronic haemorrhage [6–8].
Intracranial fluid–fluid levels occurring in haemorrhagic tumours and cystic lesions are well recognized [1–4]. The high signal of the superior layer of fluid (supernatant) is most likely due to the presence of methaemoglobin or high protein concentration [4, 5]. The appearance of the dependent layer of fluid (subnatant) which has slightly higher signal than cerebrospinal fluid (CSF) on T1 weighted images and is hypointense relative to CSF on T2 weighted images can be accounted for by the presence of intracellular deoxyhaemoglobin [5, 16].
The presence of fluid–fluid level within the spinal cord on MRI, is likewise related to blood products layering within a cystic space. Haemorrhage within a tumour cyst is one explanation for these appearances, particularly if the clinical presentation is mild. While asymptomatic haemorrhage is frequently found in cord tumours at surgery, cord haematomas from tumours and vascular malformations tend to have a more devastating effect. In our case, the sudden emergence of sensory symptoms after 2 weeks of back pain in the patient suggests that there was a recent acute haemorrhage causing the sudden worsening of the symptoms. The fluid–fluid level within the expanded cervical spine on MRI is further suggestive of an early indolent haemorrhage within the tumour which may have occurred prior to the development of the sudden sensory symptoms.
The unusual presence of fluid–fluid level in conjunction with an intramedullary tumour has only been described once before in a cystic cervical intramedullary ependymoma [5]. The tumour proved to contain altered blood at the time of the surgery. In that case report, the patient presented with 2 episodes of sudden onset of unilateral sensory symptoms which were 2 years apart, with spontaneous resolution of the symptoms after the first presentation. The second episode also had a mild clinical course as in our patient.
We conclude that the occurrence of a fluid–fluid interface within a spinal cord lesion on MRI favours haemorrhage within a cystic intramedullary neoplasm over haemorrhage from other cord lesions, particularly when associated with a mild clinical course.
Received for publication August 15, 2003.
Accepted for publication November 27, 2003.
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Introduction
Case report
