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Differential Diagnosis of Spinal Epidural Meningioma and Hemangioma at MR Imaging

Department of Radiology, Trakya University School of Medicine, Edirne, Turkey 11 kisim, Yasemin Apt, D blok, Daire 35, Ataköy, Istanbul, Turkey 34158 e-mail: demirkemal{at}superonline.com

Editor:

Diagnosis Please cases have become a teaching exercise for every radiologist to review and improve his or her knowledge and differential diagnostic skills. Thus, we carefully read "Case 100: Spinal Epidural Meningioma" (1) by Drs Sahar M. El Khamary and Ibrahim A. Alorainy in the November 2006 issue of Radiology with great interest, as we have the others. We would like to use this opportunity to discuss the differential diagnosis of spinal epidural meningioma mainly with spinal epidural cavernous or capillary hemangioma.

Hemangiomas with pure spinal epidural location are uncommon vascular tumors in comparison with those in the other sites of spinal column. Most of the reported cases are cavernous type (2,3). These tumors are usually located in the posterior part of the epidural space at the thoracic spine. Spinal epidural hemangiomas have characteristic magnetic resonance (MR) imaging findings. The signal intensity of these tumors is generally homogeneous and is similar to that of spinal cord because of the slow blood flow on T1-weighted images, and the signal intensity is high on T2-weighted images because of the high content of stagnant blood. Spinal epidural hemangiomas, similar to meningiomas, show almost homogeneous and intense contrast enhancement on MR images after administration of gadolinium-enhanced contrast material, owing to high vascularization. The presented patient's age, clinical symptoms, thoracic intraspinal epidural location, and MR imaging findings are all consistent with epidural cavernous or capillary hemangioma (2–4).

In the presented case, the T2-weighted image of the meningioma shows heterogeneously high signal intensity in comparison with that of uncompressed parts of the cord but isointensity to the compressed edematous cord, which is very unusual for spinal meningiomas. Meningiomas are typically isointense to the normal brain cortex or spinal cord on T1- and T2-weighted images. However, the signal intensity of a meningioma is not always constant on MR images and may be variable on both T1- and T2-weighted images. Especially on T2-weighted images, about half of cranial meningiomas may show high signal intensity in comparison with the brain cortex, which has not previously been reported for spinal meningiomas (5).

In this respect, the presented patient's most likely diagnosis can be epidural cavernous hemangioma rather than meningioma. At least, these two benign entities can not be differentiated when the epidural mass shows hyperintensity to the spinal cord on T2-weighted images, as in Diagnosis Please Case 100.

	References

TOP References References

 

1. El Khamary SM, Alorainy IA. Case 100: spinal epidural meningioma. Radiology 2006;241:614–617.[Free Full Text]
2. Nagi S, Megdiche H, Bouzaidi K, et al. Imaging features of spinal epidural cavernous malformations. J Neuroradiol 2004;31:208–213.[Medline]
3. Aoyagi N, Kojima K, Kasai H. Review of spinal epidural cavernous hemangioma. Neurol Med Chir (Tokyo) 2003;43:471–475.[CrossRef][Medline]
4. Badinand B, Morel C, Kopp N, Tran Min VA, Cotton F. Dumbbell-shaped epidural capillary hemangioma. AJNR Am J Neuroradiol 2003;24:190–192.[Abstract/Free Full Text]
5. Nakano T, Asano K, Miura H, Itoh S, Suzuki S. Meningiomas with brain edema: radiological characteristics on MRI and review of the literature. Clin Imaging 2002;26:243–249.[CrossRef][Medline]

Response

Department of Radiology and Medical Imaging, Mansoura University Hospital, PO Box 341957, Riyadh 11333, Saudi Arabia e-mail: saharelkhamary2000{at}yahoo.com

We thank Dr Demir and colleagues for their interest in our case of epidural meningioma (1), and we absolutely agree with them that hemangioma (cavernous or capillary) should be included in the differential diagnosis of an epidural lesion. As we have indicated in our discussion of the case of this 13-year-old girl, epidural spinal meningiomas occur more commonly in children than in adults. On the other hand, epidural hemangioma is seen predominantly in adults older than 40 years (2). In addition, spinal meningiomas are more common in female patients, while epidural hemangiomas are seen in male patients twice as often as in female patients (3). As Dr Demir and colleagues indicated, cranial meningioma may have high signal intensity in comparison with that of the brain cortex on T2-weighted MR images. This has also been reported in spinal meningiomas (4). In view of this, the most likely diagnosis in our case should be meningioma, although hemangioma is a very reasonable differential diagnosis.

The main aim of presenting this case in "Diagnosis Please" was to bring the readers' attention to the importance of correlating the imaging findings with the clinical data in patients with an epidural mass, as many epidural lesions (particularly meningioma, neurogenic tumor, and hemangioma) are similar and indistinguishable on imaging grounds alone (3). Moreover, the "dural tail sign" has been reported in intradural extramedullary capillary hemangioma (5) and is also seen in spinal meningiomas (6).

	References

TOP References References

 

1. El Khamary SM, Alorainy IA. Case 100: spinal epidural meningioma. Radiology 2006;241(2):614–617.[Free Full Text]
2. Hatiboglu MA, Iplikcioglu AC, Ozcan D. Epidural spinal cavernous hemangioma. Neurol Med Chir (Tokyo) 2006;46(9):455–458.[CrossRef][Medline]
3. Aoyagi N, Kojima K, Kasai H. Review of spinal epidural cavernous hemangioma. Neurol Med Chir (Tokyo) 2003;43(10):471–475.[CrossRef][Medline]
4. De Verdelhan O, Haegelen C, Carsin-Nicol B, et al. MR imaging features of spinal schwannomas and meningiomas. J Neuroradiol 2005;32(1):42–49.[Medline]
5. Choi BY, Chang KH, Choe G, et al. Spinal intradural extramedullary capillary hemangioma: MR imaging findings. AJNR Am J Neuroradiol 2001;22(4):799–802.[Abstract/Free Full Text]
6. Alorainy IA. Dural tail sign in spinal meningiomas. Eur J Radiol 2006;60(3):387–391.[CrossRef][Medline]

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