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Case Report
Diffusion-Weighted MR Imaging in a Patient with
Spinal Meningioma
James D. Eastwood 1,2, Dennis A. Turner 3, Roger E. McLendon 4, James M. Provenzale 1,2
iffusion-weighted MR imaging provides unique tissue contrast that reflects the microscopic motions of
tissue water. Diffusion-weighted imaging is well
established as a useful clinical tool for the evaluation of brain abnormalities, most notably stroke
[1]. However, until recently diffusion-weighted
imaging of the spine has been technically limited. We report the findings in a case of intraspinal meningioma studied with diffusion-weighted
imaging. Knowledge of the diffusion-weighted
imaging appearance of intraspinal abnormalities
should be helpful to physicians who interpret
MR studies of the spine. To our knowledge, the
diffusion-weighted imaging findings of an intraspinal tumor have not previously been reported in the literature.

Case Report

A 48-year-old man presented with 8 months

of progressive bilateral hand tingling, numbness, and weakness. Physical examination
showed mild bilateral hand weakness and decreased sensation to a pinprick. MR images of
the cervical spine, including diffusion-weighted
images, showed a contrast-enhancing mass with
both intradural extramedullary and extradural
components that extended into the C4 and C5
neural foramen (Figs. 1A1E).

All scanning was performed on a 1.5-T clinical MR scanner (Intera Master; Philips, Best,
The Netherlands). Multishot spin-echo echoplanar diffusion-weighted scanning was performed
in the sagittal plane. Each diffusion-weighted
scan used peripheral pulse gating (from a pulse
oximeter placed on the patients finger) and
navigator echo motion correction. The TR was
one pulse-to-pulse interval, and the TE was 70
msec. A rectangular field of view measured 250
188 mm and was displayed by a matrix of 256
192. The number of signal averages was 2.
Total scanning time was 2 min 53 sec. One scan
without diffusion-sensitizing gradients (i.e., a b =
0 image) and three scans with diffusion-sensitizing gradients were obtained. The three scans
using diffusion-sensitizing gradients were identical except for the orientation of the gradients.
Diffusion-weighted scans were obtained with
diffusion-sensitizing gradients oriented in each
of three directions: anteroposterior, leftright,
and superoinferior. For each of the three diffusion-weighted scans, the degree of diffusion
sensitization (b value) was 554 sec/mm2. The
three diffusion-weighted scans acquired in this
way were then averaged to create an isotropic
diffusion-weighted image. Using the first scan
(b = 0) and the isotropic diffusion-weighted image (b = 554), a map of isotropic apparent diffusion coefficient (ADC) was created using

software available on the scanner. The isotropic

ADC map was then transferred to an imaging
workstation (Easy Vision; Philips) for regionof-interest analysis. A hand-drawn region of
interest (433 mm2) that included the central portion of the tumor on the ADC map showed a
mean ADC value of 1.42 0.44 105 cm2/sec.
The mean ADC value measured in the spinal
cord was 0.65 105 cm2/sec.
The patient subsequently underwent surgery
that included resection of the mass, which had
both extradural and intradural components.
Pathologic examination revealed the mass to be
consistent with a benign (World Health Organization grade I) [2], well-differentiated meningothelial meningioma (Fig. 1F). Histologic
examination showed the tumor had abundant intercellular collagen and overall low cellularity.

Discussion

Diffusion-weighted imaging is an established

MR imaging method with a number of clinical
and research applications for brain imaging [1,
3, 4]. Until recently, however, reports describing
in vivo diffusion-weighted imaging of the spine
have been rare. Diffusion-weighted imaging of
the spine presents a technical challenge, mainly
because of the relatively small size of the spinal
canal (requiring high spatial resolution) and the

Received March 12, 2001; accepted after revision May 10, 2001.
1

Department of Radiology, Box 3808, Duke University Medical Center, Durham, NC 27710-3808. Address correspondence to J. D. Eastwood.

Department of Radiology, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC 27705.

Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710.

Department of Anatomic Pathology, Duke University Medical Center, Durham, NC 27710.

AJR 2001;177:14791481 0361803X/01/17761479 American Roentgen Ray Society

AJR:177, December 2001

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Eastwood et al.

Fig. 1.48-year-old man with numbness, tingling, and weakness in both hands.
A, T2-weighted turbo spin-echo sagittal MR image (TR/effective TE, 2665/120) shows ovoid hypointense mass in spinal canal.
B, T1-weighted sagittal MR image (TR/TE, 615/15) after infusion of gadolinium contrast material shows diffuse signal enhancement of mass.
C, T1-weighted transverse MR image after infusion of contrast material shows extent of tumor in spinal canal and C4C5 neural foramen (arrow ).
D, Diffusion-weighted sagittal MR image using peripheral pulse gating and navigator correction (TR/effective TE, 1 pulse-to-pulse interval/70; b value, 554 sec/mm2) shows
signal intensity of mass (open arrows ) to be intermediate, less than that of brainstem (large solid arrow ) and greater than that of vertebral bodies (small solid arrows ).
E, Apparent diffusion coefficient map (two-point technique; b values, 0, 554) shows mass (arrows ) as structure of intermediate intensity.
F, Photomicrograph of sectioned spinal tumor shows tumor with spindle cells (arrowhead ) arranged in loose whorls of cells associated with psammoma body centrally
(arrow ). Nuclei were bland in appearance, with rare intranuclear cytoplasmic invaginations evident (not shown). Note lack of mitotic figures and no evidence of necrosis.

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Diffusion-Weighted MR Imaging of Spinal Meningioma

pulsatile motions of the cerebrospinal fluid and
the spinal cord. Diffusion-weighted imaging is a
technique that is highly sensitive to artifacts related to motion. Before development of successful techniques to correct the negative effects of
pulsatile motion, diffusion-weighted imaging in
the spine was limited mainly to evaluation of
the osseous vertebral column, an anatomic location largely unaffected by pulsatile motions
such as those occurring in the spinal canal. Recent improvements in diffusion-weighted imaging pulse sequence design have addressed
previous limitations and now permit diffusionweighted imaging of intraspinal structures such
as the spinal cord [5, 6].
Two techniques (both used in this study) appear to be of particular value for limiting the negative effects of motion on diffusion-weighted
imaging of intraspinal structures. First, peripheral
pulse gating using a pulse oximeter signal diminishes artifacts caused by pulsatile motions in the
spinal canal that are synchronous with cardiac
pulsation [5]. By using the signal from the pulse
oximeter to trigger the initiation of the scanner
pulse sequence, gross motion between excitations can be limited. Second, the use of a navigator echo (i.e., an additional, refocused echo
obtained to determine the presence of phase errors caused by motion) further helps to limit the
adverse effects of motion on image quality [57].
Navigator echo technology for diffusionweighted imaging is not presently widely available for routine use, but it is offered as an optional
feature by some MR scanner manufacturers.
Our study used a multishot echoplanar imaging technique for the acquisition of data for the
diffusion-weighted scans. This technique was
used instead of a single-shot echoplanar imaging
technique for two main reasons: improved image signal-to-noise ratio and decreased susceptibility artifacts. An echoplanar imaging technique
was chosen over a fast spin-echo techniquea
technique that might be expected to produce
fewer artifacts caused by magnetic susceptibilitybecause diffusion-weighted imaging using
an echoplanar technique is expected to provide
images with a greater signal-to-noise ratio.
Published reports of diffusion-weighted imaging in the spine have shown its value for

AJR:177, December 2001

evaluating osseous spinal abnormalities. Specifically, diffusion-weighted images have been

used to help differentiate osteoporotic compression fractures from compression fractures
due to metastatic tumor deposits [79]. As experience with diffusion-weighted imaging in
the spine increases, evaluation of intraspinal
masses could be similarly improved by the use
of diffusion-weighted imaging.
Meningiomas are among the most common primary tumors arising in the spine. By
reporting the diffusion-weighted imaging appearance and mean ADC value associated
with a common intraspinal tumor, this article
seeks to provide information that could be
helpful to physicians who use diffusionweighted imaging of the spine.
We are unaware of any prior descriptions of
the diffusion-weighted imaging findings of intraspinal tumors. Nonetheless, previously published studies of intracranial tumors suggest
that diffusion-weighted imaging may provide
useful information about central nervous system tumor histology. One study showed ADC
values measured in intracranial meningiomas
ranging from 0.4 to 1.8 105 cm2/sec [3]. Notably, the mean ADC values measured in
meningiomas with malignant histologic findings or cellular atypia were significantly lower
than the mean ADC values measured in meningiomas with benign histologic findings. Also, a
study of cerebral gliomas by Sugahara et al. [4]
documented that tumor cellularity correlates
negatively with mean tumor ADC values. In
that study, tumors with high cellularity had low
mean ADC values, and tumors with low cellularity had high mean ADC values.
The relationship of the ADC values to histologic findings in the tumor in our patient corresponds well to the findings of the previously
mentioned studies. The ADC value of 1.42
105 cm2/sec in our case is within the range of
values for benign meningiomas previously published (0.621.8 105 cm2/sec) and well
above values found in malignant and atypical
meningiomas [3]. In addition, the relatively
high ADC value seen in our patient corresponded to a low degree of cellularity, such as
has been reported in cerebral gliomas [4]. The

mean isotropic ADC value measured in the spinal cord in our patient (0.65 105 cm2/sec)
was similar to previously published ADC values
measured in the anteroposterior direction in
normal spinal cords [6].
In conclusion, we have reported the diffusion-weighted imaging findings of a benign intraspinal meningioma. Recent improvements in
scanning technique (such as the use of navigator
echo correction of motion) have made diffusion-weighted imaging a promising modality
for the study of intraspinal abnormalities.
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