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Astrocytoma grade II

 

Clinical history
During pregnancy, this 31-year-old woman noticed progressive numbness in the right hand, which subsequently spread to the left hand. Three months after the onset of the symptoms, she was no longer able to hold objects in her hands. At the same time she began to complain of severe neck pain.

Neurological examination
On neurological examination there was diminished pain and temperature sensation and reduced proprioception of both hands. There was a right Babinski sign, without other motor impairement. Degree of disability: McCormick II.

Pre-operative MRI (December 1990)
Image 1: Sagittal T2WI. Can you differentiate tumor infiltration from associated edema?
Image 2: Additional sagittal T2WI (left)/PD image.
Images 3 - 4: Sagittal Gd T1WI and images 5 - 6: Axial Gd T1WI. Is the lesion centrally or eccentrically located within the cord? Can you provide an opinion regarding tumor resectability?
Images 7 - 8: Coronal Gd T1WI.

First post-operative MRI (February 1991)
Images 9 - 10: Sagittal Gd T1WI. How would you characterize Gadolinium enhancement within the upper cervical cord?

Follow-up MRI (August 1991)
Images 11 - 13: Sagittal T1WI.
Image 14: Sagittal PD image.
Image 15: Sagittal T2WI.
Image 16: Sagittal Gd T1WI.
Image 17: Axial Gd TIWI.
What is your opinion about the surgical result? Compare these studies with a late follow-up MRI, performed in 1995.

Follow-up MRI (1995)
Images 18 - 22: Sagittal T1WI.
Images 23 - 24 : Sagittal T2WI.
Images 25 - 27: Sagittal Gd T1WI.
Images 28 - 35: Axial Gd T1WI.

DIAGNOSIS:

Astrocytoma grade II

Pre-operative MRI (December 1990)
The examination revealed a ill-defined, partially cystic and eccentrically located infiltrating tumor at the C1-C2 level, involving the bulbo-medullary junction. Associated edema extends down to C6.
As no clear delineation between normal cord and tumor was seen on MRI, prognosis about the surgical outcome was difficult to establish and total resection of the tumor was considered unlikely.

Surgery
Video 1.
Total removal of the tumor was achieved. This demonstrates that radiologists should be careful about any prognosis.

Stage 1: Commencing the surgical procedure.
Stage 2: Cleavage plane is identified.
Stage 3: Debulking with CUSA (Cavitron Ultrasonic Surgical Aspirator).
Stage 4: Dissection of the tumor.
Stage 5: Dissection with cottonoid.
Stage 6: The tumor is completely removed.

First follow-up MRI (February 1991)
Confirms total removal of the tumor. Still, there is a questionable focus of contrast enhancement at the C1 level.

Serial follow-up MRI (August 1991 - August 1995)
Secondary kyphosis has developed. Non-enhanced images are important here, as they show small artifacts at the posterior surface of the upper cervical cord, which are not to be confused with areas of contrast enhancement after Gadolinium injection. Total removal of the tumor is still noted and no tumor recurrence was identified.

 

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Fig. 1

Astrocytoma grade II, Fig. 1
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Astrocytoma grade II, Fig. 35