PMC7332509_01
Sagittal (a) and axial (b) T1-weighted gadolinium- enhanced, sagittal (c), and axial (d) T2-weighted magnetic resonance imaging sequences showing a C1-C2 intramedullary expansive lesion (10 mmx15 mm), T2-hypointense and T1-hyperintense after gadolinium administration.
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F1
The cervical spinal MRI revealed an intramedullary expansive lesion (10 mmx15 mm) at C1-C2 that markedly enhanced with gadolinium [Figure 1].
Axial abdominal contrast-enhanced computed tomography scan image showing a voluminous mass (about 85 mm) (black asterisk) involving the upper polar region and the middle third of the right kidney, the ipsilateral adrenal gland, and extends posteriorly to infiltrate the ipsilateral psoas muscle. This lesion, which presents an inhomogeneous hypodense aspect with hypervascular foci in this context, is associated with collateral circles in the peri- and pararenal space, with the infiltration of the upper right calyxes. A neoplastic thrombosis of the renal vein and inferior vena cava in the subhepatic tract is also present and may explain hematogenous spread through Batson's venous plexus.
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F2
As the differential diagnosis included potential metastatic disease, a total body computed tomography (CT) scan was performed that revealed a large mass (about 85 mm in size) involving the upper polar region and the middle third of the right kidney, extending to the adrenal gland, and ipsilateral psoas muscle [Figure 2].
Intraoperative findings during microsurgical removal of the lesion: a good exposure of the posterior surface of the spinal cord at level C1-C2 after opening the dura mater is performed (a). After arachnoid dissection and preservation of the posterior spinal arteries, the posterior median sulcus is identified and the posterior myelotomy is performed, with access to the intramedullary lesion which shows a reddish-gray and highly vascularized appearance (b).
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F3
Through a posterior C2, myelotomy, and the lesion were macroscopically fully resected [Figure 3].
Sagittal (a) and axial (b) T2-weighted magnetic resonance imaging sequences showing a macroscopic total removal of the lesion and a physiological evolution of the operative field with the left median-paramedian malacic area.
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F4
The 1-week postoperative cervical spine MRI showed postoperative changes, but full lesion excision [Figure 4].