Astrocytoma, case 1
Clinical history
This 4-year-old girl complained of neck pain and torticollis.
Neurological examination was normal. The sole clinical finding was stiffness of the neck. Radiography of the cervical spine demonstrated enlargement of the cervical canal, and MRI was recommended.
Pre-operative MRI (November 1993)
Images 1 - 2: Sagittal T1WI. Extensive spinal cord enlargement is seen from C1 to T5, with an iso- to slightly hypointense solid nodule at C5-T1, capped at both ends by two cystic components.
Images 3 - 4: Sagittal T2WI. The solid nodule is hyperintense, compared to normal cord. Note the hyperintense appearance of the medulla oblongata and upper cervical cord, due to associated edema.
Image 5: Sagittal Gd T1WI. Shows intense contrast uptake in the solid nodule. Note that there is no contrast enhancement in the cyst wall.
Images 6 - 7: Axial PD image and axial T2WI at the upper cervical level show the cystic component with smooth margins.
Surgery
Video 1: partial resection of a cervical astrocytoma
Only partial resection of the tumor could be accomplished and radiotherapy was not delivered.
Stage 1: View of the enlarged cord.
Stage 2: Opening of the arachnoid and the pia mater.
Stage 3: Separation of the posterior columns.
Stage 4: Opening of the spinal cord and of the inferior cyst: the inferior pole of the tumor bulging within cyst.
Stage 5: Attachment of the pia mater to the dura mater.
Stage 6: Biopsy.
Stage 7: Debulking with CUSA (Cavitron Ultrasonic Surgical Aspirator).
Stage 8: Dissection of the tumor and further debulking with CUSA.
Stage 9: Low magnification view after tumor resection.
Stage 10: Closure of the spinal cord and pia mater.
Histology
Astrocytoma Grade II.
Post-operative clinical course
Post-operative clinical course was uneventful, and the patient remained symptom-free. Regular follow-up MRIs are performed to monitor the known residual tumor.
Follow-up MRI (June 1994)
Image 8: Sagittal T1WI. The spinal cord is less expanded. The cystic components have substantially collapsed. The remaining tumor is mainly iso-intense to the normal cord.
Image 9: Sagittal T2WI. The remaining tumor infiltration is heterogeneously iso- to hyperintense.
Image 10: Sagittal Gd T1WI. The tumor component shows patchy contrast enhancement, seen more clearly on axial and coronal images.
Images 11 - 12: Axial T1WI.
Images 13 - 14: Axial Gd T1WI.
Image 15: Coronal Gd T1WI.
Clinical follow-up (1998)
This patient is clinically stable and she is presently symptom-free at the age of 9. Annual follow-up MRI was performed.
Late follow-up MRI (October 98)
Image 16: Sagittal T1WI. This sagittal image shows that the patient is growing normally. The cervical spinal cord is mildly enlarged and discrete signal abnormalities are seen within the spinal cord at the level of C2-C4.
Image 17: Sagittal T2WI.
Also on the T2 weighted images, some small patchy high signal intensity areas are found: post-operative changes?
Image 18: Sagittal Gd T1WI. After contrast injection, surprisingly, no area of enhancement is seen especially when you compare those images to the post-operative control MRI shown before.
Image 19: Axial Gd T1WI.
Axial images are useful to confirm the absence of any intramedullary enhancing areas.
Comment
This case is very important as it demonstrates why we recommend not to irradiate patients after surgery when the surgeon reports partial removal. We recommend performing follow-up MR examination and eventually to re-operate only in cases of definite re-growth or progression of the residual tumor.
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