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Ependymoma, case 4

 

Clinical history
This 62-year-old male presented with a five year history of recurrent lower back pain radiating into the left leg. Progressive left foot paresis occurred and urinary and sexual disturbances developed.

Neurological examination
Neurological examination showed atrophy of the muscles of the left leg, loss of knee and ankle jerks on the left, and diminished pain and temperature sensation.

Surgery (July 1990)
Based on a first MRI, not shown here, the patient underwent a first surgical intervention for a lower thoracic and conus medullaris tumor, for which the diagnosis of astrocytoma was suggested. At surgery only biopsy could be performed and an initial histological diagnosis of astrocytoma was made. After additional stains were performed, a final diagnosis of ependymoma II was made. Based on this information, the therapeutic strategy was to observe the patient and to re-intervene if new neurological deficits developed. The following is a series of follow-up MRIs, illustrating the natural history of this low grade ependymoma.

Follow-up MRI (October 1990)
Image 1: Sagittal T1WI. T10-L2 laminectomy. The lower thoracic spinal cord, as well as the conus are enlarged due to a partially cystic lesion. The solid components are slightly hyperintense.
Images 2 - 3: Sagittal and coronal Gd T1WI. Show heterogeneous intense contrast uptake within the tumor.

Second follow-up MRI (March 1991)
Image 4: Sagittal T1WI.
Image 5: Sagittal Gd T1WI.
Image 6: Coronal Gd T1WI.
The tumor appears to be stable and it exhibits a similar appearance compared to the October 1990 examination.

Third follow-up MRI (December 1991)
Image 7: Sagittal T1WI. The cystic component has become larger. Note the appearance of the cap sign at the lower margin of the tumor.
Images 8 - 10: Sagittal Gd T1WI. Persistent intense and inhomogeneous tumor enhancement is appreciated.
Images 11 - 12: Axial Gd T1WI.
Images 13 - 14: Coronal T1WI.

Follow-up clinical course
The paresis of the left leg worsened, as did the dysesthesia of the left foot. As there was clinical and radiological evidence of tumor progression, the patient was reoperated in February 1992 and total removal of the tumor was achieved.

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Fig. 1

Ependymoma, case 4, Fig. 1
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Ependymoma, case 4, Fig. 11
Ependymoma, case 4, Fig. 12
Ependymoma, case 4, Fig. 13
Ependymoma, case 4, Fig. 14