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Ependymoma, case 5

 

Clinical history
This 44-year-old patient presented with five year history of cervico-thoracic pain radiating into the right arm.
At clinical examination, posterior cord type paresthesias were reported, with worsening of the pain at night. Bilateral loss of temperature and pain sensation was present at the T1-T3 level. More recently, urinary and sexual disturbances developed.
McCormick grade I disability.

Pre-operative MRI
Images 1 - 4: Sagittal T1WI. There is focal enlargement of the cervical and thoracic spinal cord at the C7-T2 level. Note the hypointense capping above and below the tumor.
Images 5 - 7: Sagittal PD image. The tumor is hyperintense to the spinal cord and the dark rim is better seen.
Images 8 - 10: Sagittal T2WI. Spinal cord edema is clearly visible.
Image 11: Sagittal Gd T1WI. No contrast enhancement is visible.
Image 12: Axial T1WI. The enlarged spinal cord fills the entire spinal canal.
Images 13 - 14: Axial and coronal T2WI. The tumor is hyperintense.

Surgery
A C6-T3 laminectomy was performed, and an easy cleavage plane found between normal spinal cord and the tumor, which was completely removed by CUSA. An associated hemorrhage was identified at the time of surgery.

Histology
Grade II ependymoma.

Post-operative clinical evolution
Immediately after surgery the patient's clinical condition worsened, although the patient could still ambulate (McCormick grade II).
After three months the patient improved (McCormick grade I), although the deficits in pain and temperature sensation persisted at the T1-T2, as did the thoracic pain.
One year after surgery, discrete spasticity was still present, as was dysuria, and three years post-op the patient's clinical condition remained stable (McCormick grade I).

Follow-up MRI
Images 15 - 18: Sagittal T1WI. The site of resection is clearly seen. The hypointense foci are still visible.
Images 19 - 20: Sagittal 3D T2WI.
Images 21 - 24: Axial T1WI. The spinal cord is flattened at the level of the tumor resection.

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Ependymoma, case 5, Fig. 24