Ependymoma grade II, case 5

Clinical history
This 28-year-old female presents with slowly progressive paresthesia of the left hand and left shoulder pain, progressing to quadriparesis with predominant weakness of the left hand.

Neurological examination
At neurological examination, a minor quadriparesis with hyporeflexia was observed.

MRI findings
Image 1: Sagittal T1WI. Cord expansion involves the cervical and upper thoracic level. An isointense solid nodule (arrow) is seen at C3-C5 with low signal areas at both ends corresponding to associated edema.
Image 2: Sagittal T2WI. The solid component is isointense to normal cord with few small hyperintense cystic elements. The associated edema is well demonstrated as ill defined extensive hyperintense areas seen at both ends involving the upper cervical cord (arrow) as well as the lower cervical and upper thoracic cord extensive to the level of Th2 (arrow).
Image 3: Sagittal Gd T1WI and image 4: Coronal Gd T1WI: The tumor enhances intensely but somewhat heterogeneously. Tumor delineation is well shown after contrast injection: the lesion appears sharply circumscribed.
Image 5: Axial Gd T1WI: The axial images demonstrate symmetric cord expansion, typical for ependymoma.

Surgery
Total resection of the lesion was achieved.

Histology
Ependymoma grade II

Immediate post-operative control MRI
Image 6: Sagittal T1WI: C2-C5 laminectomy. Cord expansion is still present. Heterogeneous appearance of the site of tumor removal. Small area of high signal intensity corresponding to hemorrhage (arrow). Air is present and seen as a low signal intensity area (arrowhead).
Image 7: Sagittal T2WI. On this pulse sequence, the post-operative cavity is better appreciated. There is evidence of total removal.
Image 8: Sagittal GdT1WI: After gadolinium injection, faint, linear contrast enhancement is seen at the upper border of the operation cavity.

Clinical follow-up
Immediately after surgery, the patient was quadriplegic. After 4 hours, she recovered partially from the motor deficit. Progressively after intensive therapy, the patient could walk again normally. Finally, the patient went back to work.
Two years after surgery, persistent sensory changes of the left hand are noted by the patient.

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- Ependymoma

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