Ependymoma grade II, case 3

Clinical history
60-year-old male patient with a history of progressive loss of sensation and motility of the right hand over a 2 year period.

Neurological examination
Disclosed bilateral Babinski sign and clear sensory and motor deficit of the right hand.

Preoperative MRI
Image 1: Sagittal T1WI. Cord expansion by tumor infiltration at the level of C5-C6-C7 is demonstrated. The lesion is slightly hypointense.
Image 2: Sagittal T2WI. On those T2WI, the lesion appears to be better delineated. It is hyperintense surrounded by an hypointense hemosiderin rim. Edema is present at both ends and seen as mildly hyperintense ill defined areas.
Image 3: Sagittal Gd T1WI. After Gadolinium injection, only moderate and irregular contrast enhancement is seen at the periphery of the lesion.
Image 4: Axial Gd T1WI confirm the cord enlargement and mild irregular tumor enhancement.

Comments
This is again, in our experience a typical example of an ependymoma since the lesion is limited, shows a "cap sign" (hemosiderin deposits) and is well delineated. Still, mild contrast enhancement is less frequently seen in ependymoma.

Surgery
Complete resection of a well defined tumor was achieved. After surgery, the patient still experienced hypoesthesia of the three first fingers of the right hand as well as hypoesthesia of the last two fingers of the left hand. Moreover, the patient complained after surgery from hypoesthesia of the lower limbs which were attributed to surgical displacement of the posterior columns. No permanent motor deficit was observed.

Histology
Grade II ependymoma.

Late control postoperative MR examination (4 years after surgery)
Image 5: Sagittal T1WI. Postoperative changes include focal thinning of the cord at the C5 to C7 level with syringomyelia.
Image 6: Sagittal T2WI. Thinning of the cord is equally well shown and previous hemosiderin deposits are still clearly visible.
Image 7: Sagittal Gd T1WI. No abnormal contrast enhancement is shown. No evidence of tumor recurrence.
Image 8: Additional axial Gd T1WI show posterior adherence of the cord to the posterior wall of the cervical canal. These images confirm the postoperative cavity and no tumor recurrence.
Image 9: Sagittal gradient echo T2WI. Thanks to this particular pulse sequence, the hemosiderin deposits are more clearly visualized, seen as low signal intensity areas.

Clinical evolution
Persistence of paresthesia of both forearms and dysesthesia.

Search also:
- Ependymoma

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