Ependymoma grade II, case 2

Clinical history
40-year-old female with:
- history of slowly progressive hypoesthesia of the right hand and arm evolving over one and one half year. Pain in the right hand was a major complaint. The patient more recently developed hypoesthesia of the right leg.

Neurological examination
- absence of motor deficits
- reflexes are present and brisk at all levels
- hypoesthesia of the right side more marked in the right upper extremity
- normal gait
- no urinary disturbances
- McCormick degree of disability grade I.

Pre-operative MRI
Images 1 - 3: Sagittal T1WI. What are the signal characteristics of the solid component of this cervical lesion? What kind of cystic component do you see? Note particularly the C5-C6 disc level.
Images 4 - 6: Sagittal T2WI. Again, observe the signal characteristics of the tumor and its components on this T2-weighted sequence. Is there associated edema?
Image 7: Two sagittal adjacent Gd T1WI. How would you characterize the contrast enhancement seen here?
Images 8 - 9: Axial Gd T1WI. Why are these images especially helpful?

DIAGNOSIS:

Ependymoma grade II

Pre-operative MRI
In this case the tumor is slightly hyperintense on T1-weighted images. At both ends of the lesion, a cystic component is seen with partially enhancing borders, following Gadolinium injection. This is clearly seen on the axial images. These intra-tumoral cystic components were indeed well identified at surgery. Moreover, note that the tumor enhancement is intense but heterogeneous. On T2WI, the tumor is iso-intense compared to the normal cord. Associated edema is moderate and seen in the upper cervical cord.

This is another patient who also presented with an incidental cervical disc herniation.

Surgery
Total removal of a dark brownish tumor was accomplished only after an arduous dissection, as a cleavage plane was difficult to identify during the early stages of the surgical procedure. During surgery, biopsy indicated that the surgeon was dealing with a low grade ependymoma. This information is of utmost importance as it encourages the surgeon to attempt total resection of the lesion.

Post-operative clinical course
No worsening of the neurological status was observed in this case, although the surgeon opened the spinal cord quite extensively and noted that he saw the anterior spinal artery while dissecting anteriorly within to the cord.
Still, hypoesthesia of the entire left body persisted up to the C4 level with associated hyperreflexia.

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