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Ependymoma grade II, case 7

 

Clinical history
50-year-old female with a history of severe cervical pain of sudden onset in the absence of any history of trauma.

Neurological examination
Hyperreflexia of both lower limbs. Absence of sensory changes.
Slight motor deficit of the left arm with a discrete pyramidal syndrome of the right arm.

MRI findings(1996)
Image 1: Sagittal T1WI. Partially cystic enlargement of the cervical cord.
Image 2: Sagittal T2WI. A typical "cap sign" is seen at the lower margin of the lesion (arrow) suggesting the diagnosis of ependymoma.
Image 3: Axial T2WI (Gradient echo sequence) Serial axial cuts are useful to analyze this complex lesion: (a) cut through the normal cord at C1 (b) hyperintense cystic component (c) lower cystic element (d) inferior margin showing hypointensity due to hemosiderin deposits (Cap sign) (e) Pure central hypointense component is best seen thanks to this T2 gradient echo sequence.
Image 4: Axial T1WI (a,b,c,d). The cystic components are centrally located and show clear borders. The solid component (c) is almost iso-intense to the cord and ill defined on this pulse sequence.
Image 5: Sagittal Gd T1WI and image 6: Axial Gd T1WI. The solid part enhances heterogeneously.

Surgery
Partial removal of an infiltrating ill defined tumor.

Histology
Ependymoma grade II

Clinical follow-up
Impairment of deep tendon sensation on the left, hyperreflexia of right body, hypoesthesia of left body. Minimal motor deficit of left lower limb.

No radiotherapy was given.

Immediate post-operative MRI
Image 7: Sagittal T1WI and image 8: Sagittal T2WI post-operative changes with persistent cord enlargement and heterogeneous resection site. Low signal areas are due to the presence of some residual air.
Image 9: Sagittal Gd T1WI and image10: Axial Gd T1WI. Irregular contrast enhancement is observed at the edges of the area of resection.

Conclusion
Subtotal removal of the tumor. This first postoperative MRI serves as a baseline study for assessing subsequent progression of the lesion. Follow-up MRI was ordered every six months.

Follow-up MRI (1998)
The control MRI obtained two years later is shown here: the residual tumor is relatively small and only very slow progression is observed. In fact, as the efficacy of radiotherapy has not been conclusively demonstrated the policy chosen in our institution is to follow up these patients and carry out repeat surgery if necessary.
Image 11: Sagittal T1WI. The spinal cord is slightly irregular in shape and a few hypointense areas are shown.
Image 12: Sagittal T2WI. Irregular, hyperintense appearance of the site of previous surgery. At the periphery, areas of decreased signal are still visible (arrow), even slightly increased in size.
Image 13: Axial T1WI shows a small cyst (arrow) located in the center of the cord in a moderately uniformly expanded cord.
Image 14: Axial T2WI demonstrate the central hyperintense cyst and the deposits of hemosiderin seen as low signal intensity areas at both ends of the lesion (arrows).
Image 15: Sagittal Gd T1WI and image 16: Axial Gd T1WI. The size of the residual tumoral tissue is best evaluated after contrast administration. It has been stable for the last year.

Clinically, the patient's condition remains unchanged with only cervical pain.

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Ependymoma grade II, case 7, Fig. 1
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Ependymoma grade II, case 7, Fig. 7
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Ependymoma grade II, case 7, Fig. 9
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Ependymoma grade II, case 7, Fig. 14
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Ependymoma grade II, case 7, Fig. 16