Ependymoma grade II, case 6

Clinical history
This 69-year-old patient is 10 years status post surgery for severe spinal stenosis including a C1-C2-C3 laminectomy followed a few weeks later by anterior interbody fusion of C5-C6. Clinical condition did not significantly improve. Presently the patient complains of sensory and motor deficit of both arms, predominating in the right hand. Weakness of the legs with gait disturbances appeared more recently.

MRI findings
MRI confirms not only severe spinal stenosis but discloses an intramedullary mass.
Image 1: Sagittal T1WI: Post-operative changes with anterior C5-C6 fusion and C1-C3 laminectomy. Persistent spinal stenosis. There is an ill defined low intensity area in the upper cervical cord.
Image 2: Sagittal T2WI: Extensive high signal area is seen involving the entire cervical spinal cord. Although high signal intensities may be found associated with severe spinal stenosis, the extent of the lesion is very large. No definite solid tumor lesion can be identified on those images.
Image 3: Sagittal Gd T1WI: A solid enhancing nodule is clearly visible at the level of C3-C4, located within the spinal cord as better shown on image 4: Axial Gd T1WI.

Surgery
Total excision of well delineated solid intramedullary tumor.

Histology
Ependymoma grade II.

Immediate post-operative MRI
Image 5: Sagittal T1WI and Image 6: Sagittal T2WI: new postoperative changes with an enlarged C2-C5 laminectomy.
Image 7: Sagittal Gd T1WI. Complete tumor removal is confirmed by the disappearance of contrast uptake.

Conclusion
This patient did not improve after multiple surgeries for spinal stenosis. Finally, besides sensory changes the patient developed progressive motor deficit of all four extremities. Clinical symptoms could not be explained by only cervical stenosis. Moreover, the high signal intensity lesion seen on T2 Weighted images was too extensive to be ascribed only to spinal stenosis. This case illustrates the usefulness of Gadolinium injection in order to achieve correct diagnosis.

Search also:
- Ependymoma

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