Ependymoma, case 1

Clinical history
This 64-year-old male had been operated on for carpal tunnel syndrome one year before, without clinical improvement. In fact, the symptoms progressively worsened and he became unable to handle small objects. He also had loss of temperature sensation, resulting in burns to the right hand.
On neurological examination, bilateral pyramidal syndrome and loss of pain and temperature sensation in the right hand were found.

Pre-operative MRI
Images 1 - 4: Sagittal T1WI. Spinal cord enlargement is noted from the C4 to C7 level, with a well delineated intramedullary oval hypointense lesion from C5 to C7. Note the small intramedullary hypointense focus at the inferior pole of the tumor (see -->).
Image 5: Sagittal T2WI. An intramedullary cyst is seen from C5 to C7, with moderate intramedullary hyperintensity at the C4 level at the superior pole of the cyst, corresponding to associated edema. Note the hypointense rim at the superior and inferior pole of the cyst, corresponding to hemosiderin and ferritin deposits, a "cap sign" better demonstrated on this imaging sequence. This finding results from old hemorrhage, and should suggest the diagnosis of ependymoma.
Images 6 - 8: Sagittal Gd T1WI. No enhancement is seen.
Image 9: Axial T1WI shows the spinal cord enlargement.
Image 10: Axial Gd T1WI.

Post-operative MRI (16 days later)
Images 11 - 13: Sagittal T1WI. Posterior laminectomy was performed from the C3 to C7 level, with a post-operative cavity seen at C5-C7. Note also a new hyperintense focus at the superior pole of the cavity, corresponding to a small hemorrhage.
Image 14: Sagittal gradient echo T2WI.
Images 15 - 17: Axial gradient echo T2WI.
The post-surgical cavity is well demonstrated. The gradient echo sequence better shows the hypointense focus at the lower part of the cyst, corresponding to hemosiderin and ferritin deposits.

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- Ependymoma

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