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Ependymoma, case 2

 

Clinical history
A 36-year-old male presented with an 8 month history of pain and stiffness in the neck. Torticollis was the first clinical symptom. The patient noted progressive loss of sensation in both hands, as well as pain in the right arm. He also complained of loss of strength in the right hand. Clinical examination revealed that deep tendon reflexes were present, and no motor deficits or urinary disturbances were observed. Loss of sensation was confirmed by appropriate testing. McCormick scale of disability: grade I.

Pre-operative MRI
- Straightening of the cervical spine.
- Solid nodule markedly enhancing after gadolinium injection.
- Bulbar cyst.
- Small polar cyst at the inferior part of the tumor.

Images 1 - 3: Sagittal T1WI. Spinal cord enlargement from the craniocervical to the T1 level, with a well-delineated hypo-intensity at the C1 level, consistent with an intramedullary cyst.
Images 4 - 6: Sagittal Gd T1WI. Intense heterogeneous intramedullary enhancement at C2-C3 with better delineation of the superior polar cyst after Gd injection.
Image 7: Coronal T1WI.
Images 8 - 9: Coronal Gd T1WI.

Surgery
 Video 1: ependymoma
A clear cleavage plane could be found at surgery, allowing for total resection of an ependymoma Grade II.

Stage 1: Section of the pia mater between posterior columns.
Stage 2: Separation of the posterior columns and opening of a satellite cyst.
Stage 3: Biopsy.
Stage 4: Dissection of the tumor.
Stage 5: Complete removal of the tumor.
Stage 6: Suturing of the posterior pia mater.
Stage 7: Closing of the arachnoid.

Histology
Ependymoma Grade II.
Images 17 - 18: Perivascular pseudorosettes
Image 19: Anaplasia with nuclear atypia and mitosis

Post-operative clinical course
Immediately after surgery, the patient had a more pronounced loss of sensation, which improved over several weeks. No motor deficit developed and the patient was able to walk normally a few days after surgery.
McCormick scale: grade I at the time of discharge from the hospital, ten days after surgery.

Post-operative MRI
- Total removal of the solid nodule at C2-C3 level.
- Only a small cavity is observed at the site of tumor resection.
- Regression in size of the previously identified bulbar cyst.
- No enhancement noted after contrast injection.

Images 10 - 12: Sagittal T1WI. Laminectomy from C2 to C6 following complete tumor resection. Note the small post-operative intramedullary residual cavity at the C2-C3 level and the cervical kyphosis.
Images 13 - 15: Sagittal Gd T1WI. Slight enhancement at the C4 level, probably corresponding to post-operative changes.
Image 16: Axial Gd T1WI.

Late post-operative follow-up:
The patient developed a post-operative kyphosis that eventually necessitated orthopedic treatment. No late post-operative sensory deficit was observed, however, cervical pain persisted. No tumor recurrence was noted three years after surgery and the patient remains clinically stable.

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Fig. 1

Ependymoma, case 2, Fig. 1
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Ependymoma, case 2, Fig. 19