PMC7294160_01
Cervical CT with contrast (a: sagittal and b: axial) and MRI (c: sagittal and d: axial) shows a longitudinally oriented epidural enhancing soft-tissue mass lesion occupying the left side of the spinal canal opposite C2 down to the C7 vertebra. MRI (c: sagittal and d: axial) shows intraspinal epidural and paraspinal avidly enhancing cervical lesions with multiple neural foraminal extensions and cord compression, which was most severe at C5.
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F1
Contrasted cervical CT (a: sagittal and b: axial) during the CT-guided biopsy, preprocedure scan demonstrated improvement of the prevertebral tissue, likely related to steroids treatment. Due to the lack of enough safety margin to perform biopsy, the procedure was cancelled. Repeated cervical MRI (c: sagittal and d: axial), showed the lesion response to the steroids more profoundly.
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F2
However, due to the initiation of steroids (dexamethasone 4 mg every 6 h), the tumor had significantly decreased in size (e.g., repeat MRI showed that the lesion had profoundly regressed), and a biopsy was no longer feasible/ reliable [Figure 2a-d].
The cervical spine MRI (a: sagittal and b: axial) was repeated after 2 weeks from the previous MRI [Figure 2] while stopping the steroids and showed a significant recurrence.
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F3
The next MR performed 2 weeks after cessation of steroids revealed significant tumor recurrence [Figure 3a and b].
(1) Low magnification - H&E stain (a) shows a well- demarcated granuloma. (2) High magnification - H&E stain (b) the granuloma consists of epithelioid histiocytes and mature lymphocytes.
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F4
This was followed by an open anterior C5-C6 biopsy of the large recurrent extradural lesion; the latter confirmed the diagnosis of neurosarcoidosis (i.e., nonnecrotizing granulomatous lymphadenitis) neurosarcoidosis [Figure 4a and b].