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Astrocytoma, case 5

 

Clinical history
60-year-old man with an 11 year history of neurogenic claudication and radicular syndrome on the right side, which subsequently spread to the left side.

On neurological examination there was a Lasègue sign on the right, dysesthesia in the right leg, accompanied by altered pain and temperature sensation. Degree of disability: McCormick grade I.
A lumbar CT performed two years before showed congenital lumbar spinal stenosis, most severe at L4-L5, without evidence of disk herniation.
As the patient's condition worsened, lumbar myelography was performed in order to evaluate the dynamic aspect of the lumbar spinal stenosis. Lumbar spinal stenosis was confirmed, but an almost complete myelographic block was discovered at the level of T9. CSF examination showed an elevated albumin content (0.5 g/l).
An MRI was immediately performed to better evaluate the cephalad extent of this intramedullary process.

Pre-operative MRI
Image 1: Sagittal T1WI. There is spinal cord enlargement from T2 to T9 due to an ill-defined low signal intensity lesion. After contrast injection no enhancement was seen within the lesion. Note the presence of a well-delineated high signal intensity area within the antero-superior aspect of the T11 vertebral body (vertebral hemangioma).
Images 2 - 3: Sagittal T2WI. The lesion is hyperintense on these T2 weighted images, with well-defined margins. Caudal to the mass, a small intramedullary hyperintense area is seen, corresponding to mild edema.

Surgery (April 1990)
Total removal of the tumor was accomplished, as a clear cleavage plane could be found. No cystic cavity or hemorrhage was seen.

Histology
Grade II astrocytoma.

Post-operative clinical course
Immediately after surgery the patient's condition worsened substantially: McCormick grade III. However, three months later the patient could again walk (McCormick grade II). There was persistent hypoesthesia, starting at the T4 level, with moderate spasticity. Clinical improvement continued and after one year, the degree of disability was reduced to McCormick grade I.

First follow-up MRI (March 1991)
Images 4 - 5: Sagittal T1WI. The resection area is clearly visible due to the spinal cord atrophy. Note the small syrinx at the top of the resection area.
Image 6: Sagittal PD and image 7: Sagittal T2WI. Spinal cord atrophy is again shown, however, signal abnormalities are no longer seen.
Image 8: Axial T1WI. Syringomyelia is clearly demonstrated.

Clinical course
Although the patient remained clinically stable, regular follow-up MRIs suggested recurrence.

Follow-up MRI (January 1994)
Image 9: Sagittal T1WI. The spinal cord at the upper margin of the resection area shows slight enlargement (see image 10). The syrinx is no longer clearly visible.
Image 11: Sagittal T2WI. Within the enlarged spinal cord ill-defined hyperintense areas are again visible.
Image 12: Sagittal Gd T1WI. The enlarged spinal cord does not enhance after contrast injection.
Images 13 - 14: Axial Gd T1WI. Tumor recurrence is confirmed.

Follow-up MRI (June 1994)
Image 15: Sagittal Gd T1WI.
Images 16 - 17: Axial Gd T1WI.
The recurrence is now obvious and peripheral contrast enhancement is now present.

As the patient's clinical condition remained remarkably stable, surgery was postponed but further follow-up MRIs are planned at more frequent intervals.

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Fig. 1

Astrocytoma, case 5, Fig. 1
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Astrocytoma, case 5, Fig. 17