If any imaging modality is recommended before paravertebral mass biops

 

Images

Doctor's Information

Name : Morteza, Hamidreza
Family : Sanei Taheri, Haghighatkhah
Affiliation :Radiology Department,Shohada Tajrish Hospital,SBMU
Academic Degree : Associate Professor of Radiology
Email : This email address is being protected from spambots. You need JavaScript enabled to view it.
Resident : Parham Pashangpour, Mohsen Zakavati

 

Case Section

Cardiovascular

 

Patient's Information

Gender : Male
Age : 89

 

Clinical Summary

A 89 years old man with three weeks history of paraparalysis (2/5 Force), this patient was admitted in neurosurgery ward and was reffered to radiology department for CT guided biopsy of paravertebral mass.

 

Imaging Findings

On MR imaging there is a high signal mass lesion in T1 and T2 sequences with a signal compatible with blood, is seen that measured 68x56mm anterior to T9-T11 vertebral body with myelopathy and destruction of these vertebral bodies. Contrast-enhanced CT reveals an incidentally found aortic aneurysm. Intraluminal thrombosis makes irregular border with the patent lumen. CT without intravenous administration of contrast agent shows impending rupture in aortic aneurysm associated with hyper-attenuating crescent sign, in which the attenuation of intraluminal thrombosis of the aneurysm is more than that of the patent lumen. Also attenuation of intraluminal thrombosis of aneurysm more than psoas muscle in enhanced computed tomography (CT), shows impending rupture in aortic aneurysm.

 

Differential Diagnosis

neurogenic tumours:
schwannoma
neurofibroma
malignant peripheral nerve sheath tumour
neuroblastic tumours:
neuroblastoma
ganglioneuroma
non-neurogenic tumours:
chordoma 2
phaeochromocytoma 3
paraspinal abscess
descending aortic aneurysm
oesophageal neoplasm
hernias :
hiatus hernia
Bochdalek hernia
lymphadenopathy or lymphoma
extramedullary haematopoiesis
foregut duplication cysts:
neurenteric cyst
oesophageal duplication cyst
thoracic meningocoele

 

Final Diagnosis

Severe erosion of vertebral body because of an aortic aneurysm.

 

Discussion (Related Text)

Erosion of a vertebral body because of an thoracic aortic aneurysm is a rare condition. Vertebral erosion may be observed secondary to aortic aneurysm that develops because of inflammation, infection [1,2], and pathologies such as Behcet’s disease and syphilitic aortitis. Collapse and lytic lesions of the vertebrae are generally associated with fracture, tumor, osteoporosis, spondylodiscitis, or spondylitis. In our case, chronic thoracic aortic aneurysm caused vertebral erosion and may mimic tumor or infection. This is a very rare condition that is detected in patients admitted to the hospital with a complaint of paraparalysis and generally diagnosed coincidentally during radiological examination. There are only a few case reports published on chronic aortic rupture causing vertebral erosion [3,4]. Almost all previous reports are about vertebral destruction caused by a pseudoaneurysm that develops after graft operations. The patient reported in this study manifested vertebral erosions secondary to a primary aortic aneurysm.[5] These erosions developed as a result of a passive process. Aortic aneurysm may cause pain according to the degree of the destruction or neurological deficit caused by the pressure on neural elements [3]. In our case, neurological evaluation revealed a three weeks history of paraparalysis.
Imaging findings:
-Intraluminal thrombosis: Intraluminal thrombosis frequently occurs in aortic aneurysm and may be definitely diagnosed based on its presence along the inner aspect of intimal calcification as well as its irregular border with the patent lumen. In contrast to conventional angiography, CTA is able to detect the presence and also the extent of intraluminal thrombus.
-Impending rupture: Interestingly, the growth rate of even small aortic aneurysm in sequential studies is correlated with increased likelihood of aneurismal rupture. Therefore, periodic radiologic surveillance is advised for all aortic aneurysms. When the diameter of Aortic aneurysm increases, the thrombus-to-patent lumen ratio of aneurysm will decrease. Thus, decreased thrombus-to-patent lumen ratio is another sign of impending rupture. Another helpful radiological finding, in favor of impending rupture is hyperattenuating crescent sign which reflects hemorrhage in the mural thrombosis or in the aneurysm wall. This sign, if present, appears as an intramural area with attenuation of more than patent luminal region in unenhanced computed tomography (CT) or more than that of psoas muscle in contrast-enhanced CT. Extravasation of contrast media into mural thrombosis of aortic aneurysm, in the absence of frank hemorrhage, is also considered another sign of impending rupture and represents dissection of blood from patent lumen into luminal thrombosis which has not disrupted the aneurysm wall yet.
-Contained rupture: Previous rupture into a confined anatomic compartment should be suspected in patients with known history of aortic aneurysm, previous episodes of pa

 

References

[1] El Maghraoui A, Tabache F, El Khattabi A, et al. Abdominal aortic aneurysm with lumbar vertebral erosion in Behcet’s disease revealed by low back pain: a case report and review of the literature. Rheumatology (Oxford) 2001;40:472–3.
[2] Leung JS, Mok CK, Leong JC, Chan WC. Syphilitic aortic aneurysm with spinal erosion. Treatment by aneurysm replacement and anterior spinal fusion. J Bone Joint Surg Br 1977;59:89–92.
[3] Grevitt MP, Fagg PS, Mulholland RC. Chronic contained rupture of an aortic aneurysm mimicking infective spondylitis. Eur Spine J 1996;5:128–30.
[4] Mii S, Mori A, Yamaoka T, Sakata H. Penetration by a huge abdominal aortic aneurysm into the lumbar vertebrae: report of a case. Surg Today 1999;29:1299–300.
[5] Mehmet Aydogan, Omer Karatoprak, Cuneyd Mirzanli, et al. Severe erosion of lumbar vertebral body because of a chronic ruptured abdominal aortic aneurysm. The Spine Journal 8 (2008) 394–396
[6]R. Pourghorban, M. Sanei Taheri, H. Haghighatkhah et al. MDCT findings of abdominal aortic aneurysm and its complications. 10.1594/ecr2013/C-0055

 

end faqaq

 

Go to top