SHORT COMMUNICATION

Spinal Cystic Schwannoma: An MRI Evaluation

Rana Netra, Ma Shao Hui, Min Zhi Gang and Zhang Ming

ABSTRACT
Spinal cystic schwannomas are a very rare entity and have been reported in only a few case reports in literature; its
diagnosis and management has remained a challenge. This study reviewed the results of magnetic resonance imaging
(MRI) of 12 patients (7 men and 5 women; aged 37 - 67 years; mean age: 52.75 years) with pathologically proven cystic
schwannoma of the spine and discussed their differential diagnosis. All patients underwent surgery at our institutions
between June 2000 and April 2012. MRI showed well-delineated intradural and extramedullary lesion of iso- to low signal
intensity on T1 weighted images, high signal intensity on T2 weighted images, and rim enhancement on contrast-
enhanced images. A precise understanding of the MRI features of spinal schwannomas, especially the typical
characteristic of enhancement, may help clinicians in their pre-operative diagnoses and surgical planning.

Key Words: Spine. Cystic. Schwannoma. MRI. Contrast enhancement.

Spinal schwannomas are frequently observed in neuro- images (T2WI), and contrast-enhanced images. MRI of
surgical practice. However, cystic spinal schwannomas all patients showed well-delineated intradural and
are very rare.1 Because of their indolent behaviour and extramedullary (IDEM) lesions of iso- to low signal
benign course, the diagnosis of schwannomas may be intensity on T1WI, high signal intensity on T2WI, and
challenging, and the imaging findings can often be strong ring-like enhancement of the cyst wall on
misleading.2 Malignant cases have been reported in contrast-enhanced images (Figures 1 and 2). Three
association with Von Recklinghausen's disease. Schwan- patients showed a lesion in the cervical region (25%)
nomas can show a variety of degenerative changes with no sign of any bony erosion and scalloping; one
such as cyst formation, calcification, haemorrhage and patient showed a lesion in the thoracolumbar region,
hyalinization.2 Cyst formation usually results from the extending from 6th thoracic (T6) to 1st lumbar vertebra
degeneration of the Antoni B portion of the schwannoma (L1) (8.33%), with bony scalloping on T10 to T12
and central ischaemic necrosis by tumour growth.3,4 In vertebrae, yet no sign of bony erosion. Spinal cord was
this report, the aim was to describe the clinical compressed posteriorly with a marked foraminal
presentation and magnetic resonance imaging (MRI) widening.
characteristics of spinal schwannomas and elucidate Eight patients had lesions in the lumbar region (66.66%),
the importance of contrast-enhanced MRI in their five showed bony scalloping but no sign of bony erosion,
differential diagnosis. and two had slight bone erosion in the lumbar L4 and L5
The magnetic resonance (MR) images of 12 patients vertebrae. Bony erosion was less frequent in our cases,
(7 men and 5 women; age range: 37-67 years; mean which may be attributable to the cystic nature of the
age: 52.75 years) with pathologically proven cystic lesions. All lesions were cystic because of their mass
schwannoma of the spine were reviewed. All patients effect, causing symptoms and intraoperative identifi-
were treated surgically at our institution between June cation of the cystic element, as well as positive MRI
2000 and April 2012 and followed-up for 6 months to 2 findings. No remarkable septation within the cyst was
years. Patient information regarding clinical presen- observed. The lesions involved 1-8 vertebral segments,
tation, tumour location, and operative findings was with an average of 2.5 vertebral segments. The average
collected retrospectively from medical records. All MR duration of the symptoms ranged from 2-60 months
images were obtained using a Philips Gyroscan Intera (mean duration: 17.66 months).
1.5T scanner with a spine surface coil. The signal The most common initial symptom was radicular pain
intensity of the lesions was compared to adjacent normal followed by motor weakness. Myelopathy, non-specific
tissue in T1 weighted images (T1WI), T2 weighted back pain, long-term history of vague flank pain,
bladder/bowel incontinence, sciatica, and radiating pain
Department of Radiology, First Affliliated Hospital of Xi'an
in the bilateral lower limbs were also reported. All these
Jiaotong University, Shaaxi-China.
symptoms were frequently found in patients with lesions
Correspondence: Prof. Zhang Ming, Department of Radiology, in the lumbar spine. Patients with lesions in the cervical
First Affliliated Hospital of Xi'an Jiaotong University, spine reported progressive neck pain in the upper
(School of Medicine) Xi'an-710061, China. cervical region, paraparesis over a period, radiating
E-mail: [email protected] pain, feeling of discomfort, and myelopathy. The patient
Received: July 07, 2012; Accepted: September 16, 2013. with the largest lesion in the thoracolumbar spine,

Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (2): 145-147 145
Rana Netra, Ma Shao Hui, Min Zhi Gang and Zhang Ming

lesions with microcystic spaces (Antoni type B).

Immunohistochemically, these tumours show diffuse
positivity for the S100 protein in the cytoplasm of the
tumour cells.
MRI is the choice of modality for the evaluation of
intradural spinal tumours. Schwannomas tend to have
signal intensity equal to or less than that of the spinal
cord on T1WI and mild to marked hyperintensity on
T2WI. Schwannomas usually show fluid signal intensity
on T2WI, which could be a useful predictor in its
diagnosis. Bony scalloping and bony erosion usually
Figure 1: Median sagittal T1WI (1A) and T2WI (1B) of cervical spine (C5 to occur in schwannomas. Enhancement is variable and
C7) shows a well defined IDEM lesion, isointense to CSF on T1WI and T2WI
(1A, thick arrow and 1B, thin arrow). A thick ring-like enhancement of the
can be intense and homogeneous in some lesions, while
lesion with irregular appearance is observed during contrast T1WI (1C, it may only show peripheral enhancement in other
dotted arrow). cases. A contrast study is necessary to differentiate
these from other cystic neoplasms. Schwannomas
enhance very strongly, most of the time with an irregular
appearance. A cystic schwannoma has a thick well-
enhancing rim enhancement of the cyst wall compared
to other cystic lesions. Strong rim enhancement of an
IDEM tumour during MRI should be considered in the
diagnosis of schwannomas,1,2,6 which was evident in all
these cases. Nevertheless, the accurate diagnosis
should be proven by pathological studies.
The differential diagnosis of schwannomas is primarily
based on location, clinical presentation, age, and gender
of the patient. The differential diagnoses of intradural
Figure 2: Median sagittal T1WI (2A) and T2WI (2B) of the lumbosacral spine
showing an intrathecal lesion at the L1 level (2A, thick arrow and 2B, thin extramedullary cystic schwannoma include cystic
arrow). A ring-like enhancement of the lesion is observed during contrast meningioma, arachnoid cyst or perineural cyst, epider-
moid cyst, dermoid cyst or cystic teratoma, neuroenteric
T1WI (2C, dotted arrow). A sacral meningeal cyst was incidentally
discovered at S2 and shows no enhancement (2C, arrow head).
cyst, hydatid cyst, and cystic ependymoma. Cystic
extending from T6 to L1 vertebral segments, had meningiomas are found more typically adjacent to the
paraparesis, back pain, numbness in both legs, and right tumour and less commonly within the tumour. Women
radiculopathy. Postoperatively, all patients achieved are frequently affected, with a high incidence in middle-
complete relief and did not experience any of the aged patients, and majority of cases are found in the
previous reported symptoms. No recurrent tumour was thoracic region. The incidence of osseous erosion and
found during the follow-up period of 6 months to 2 years. soft-tissue calcification is frequently observed. After
Schwannomas are slow-growing, mostly encapsulated, contrast administration, a thin region of enhancement
and solid benign tumours. The most common location of contiguous with the dura (dural tail sign) is often
schwannomas is on the peripheral nerves or spinal observed. In addition, cysts within the tumour are usually
nerve roots in the extradural space. The tumour eccentric, and ring-like enhancement is rarely reported.
commonly arises from the dorsal sensory roots of the Arachnoid cysts are isointense to cerebrospinal fluid
cervical and lumbar spine with less frequent involvement (CSF) on all pulse sequences and do not show
of the thoracic region.2,5,6 This study showed that a enhancement. They are usually located posterior to the
higher frequency of schwannomas in the lumbar spine thecal sac and primarily occur in adolescents and young
(66.66%). Men and women are equally affected and may adults. Epidermoid cysts are slightly hyperintense to
become symptomatic in patients at any age, but its peak surrounding tissue on T1WI and show similar intensity to
incidence is around the fourth to sixth decades of life.3,5 CSF on T2W images. They have lobulated margins with
In this study, the mean age was 52.75 years and peak peripheral enhancement or no enhancement during
incidence was also between the 4th and 6th decades. contrast-enhanced MRI. The cystic lesion of epider-
Cystic tumours have a high risk of causing progressive moids generally shows low signal intensity on the TlWI
symptomatic worsening as a result of cyst expansion. relative to the nerve tissue. Dermoid cysts are generally
Because of its slow-growing nature, few symptoms can seen with a dermal sinus tract and show high signal
be observed until the tumour has reached a large mass. intensity that is suggestive of fat tissue. Neuroenteric
Histologically, schwannomas consist of compact cellular cysts are multi-lobulated, extended, and are usually
lesions (Antoni type A) and loose, hypocellular myxoid located in the anterior intradural extramedullary

146 Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (2): 145-147
Spinal cystic schwannoma: an MRI evaluation

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