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Ependymal cyst, case 1

CLINICAL HISTORY:
This 59-year old woman has a long history of disturbances of ocular motility, right cerebellar signs and paresis of the right leg. On a CT a "schizis" of the mesencephalon was described. Now she complains of increasing headache, vomiting and disequilibrium.

NEUROLOGICAL EXAMINATION reveals gait instability and impaired coordination of the right side. There is right hemiparesis.

MRI:
a) TRANSAXIAL T2-WEIGHTED (2500/90/1) SPIN-ECHO SEQUENCE (IMAGES 1 - 2 - 3 - 4): The fourth ventricle is considerably dilated. In the midline a cystic lesion (arrow) is found, dividing the mesencephalon into two separate parts. The signal void of the substantia nigra and red nucleus (arrowheads) are clearly recognized on both sides of the cyst. Ventrally the mammilary bodies (small arrows) can be seen.

b) TRANSAXIAL T1-WEIGHTED (680/20/1) SPIN-ECHO SEQUENCE (IMAGES 5 - 6 - 7 - 8): Again the cystic nature of the lesion is recognized. Notice that within the upper part of the cyst some flow artifact (arrowheads) can be seen.

c) SAGITTAL T1-WEIGHTED SPIN-ECHO SEQUENCE (IMAGES 9 - 10 - 11): On this sequence there seems to be continuity of the dilated fourth ventricle with the intermesencephalic cyst. The aqueduct cannot be recognized. There is clear elevation of the floor of the third ventricle (arrowheads). The cerebellum is considerably displaced posteriorly.

RADIOLOGICAL DIFFERENTIAL DIAGNOSIS includes a congenital lesion, for instance a schizis of the mesencephalon, or a cyst within the fourth ventricle.

SURGICAL FINDINGS: At surgery, performed via suboccipital craniotomy, the fourth ventricle seemed to be filled with a thin-walled cyst. The cyst apparently continued to the level of the aqueduct. The content of the cyst was clear fluid. Surgical therapy consisted of resection of the wall of the cyst and cystoventricular drainage. Repeat CT shows collaps of the cyst (IMAGE 12).

ANATOMOPATHOLOGY (IMAGE 13) was consistent with ependymal cyst.

Search also:
Neuroglial (neuro-epithelial) cysts

 

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Fig. 1

Ependymal cyst, case 1, Fig. 1
Ependymal cyst, case 1, Fig. 2
Ependymal cyst, case 1, Fig. 3
Ependymal cyst, case 1, Fig. 4
Ependymal cyst, case 1, Fig. 5