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Ependymoma grade II, case 10

 

Clinical history
40-year-old female with:
- history of slowly progressive weakness and paresthesias of both legs;
- posterior cord type pain;
- degree of disability: McCormick grade I;
- minor sphincter disturbance.

Neurological examination
- hyperreflexia of both arms

Pre-operative MRI
Images 1 - 3: Sagittal T1WI.
Images 4 - 6: Sagittal Gd T1WI centered on the cervical spine.
Characterize the abnormalities seen on these images:
- Is the cord normal or enlarged?
- Are there cystic elements? What type of cyst are you dealing with?
- Look carefully at the C5-C6 disc.

Images 7 - 9: Complementary Sagittal Gd T1WI: Are these images helpful?
Images 10 - 11: Axial T1WI in the cervical region.
Image 12: Axial Gd T1WI in the cervical and upper thoracic region.

Post-operative MRI
Images 13 - 15: Sagittal T1WI.
Images 16 - 18: Sagittal Gd T1WI.
Images 19 - 25: Axial Gd T1W1: what is particularly well demonstrated in images 20 and 21?

DIAGNOSIS:

Ependymoma grade II

Pre-operative MRI
Shows an iso-intense tumor located at the cervico-thoracic level with an intensely and homogeneously enhancing solid component (C6-C7 to T2-T3), following Gadolinium injection. Associated cystic components are seen at both ends of the tumor, without mural enhancement.
Incidentally note the large C5-C6 disc herniation.

Surgery
Video 1: Ependymoma
Stage 1: Soft ependymoma.
Stage 2: The tumor is dissected from the normal spinal cord.
Stage 3: Coagulation of the anterior feeding arteries.
Stage 4: The tumor is completely removed.

Post operative MRI
Demonstrates total removal of the tumor.
Image 17: Postoperative syringomyelia at the site of tumor resection. The associated cystic components are already smaller. The C5-C6 disc herniation is unchanged.

Post-operative clinical course
The patient's neurological condition worsened immediately after surgery but eventually returned to the pre-operative neurological deficit.
Degree of disability: McCormick type I.

Comment
Worsening of the neurological status is often observed immediately after surgery. In our experience, three months after surgery 53% of patients improved, 37% remained stable and 10% deteriorated.
No patient paraplegic before surgery recovered, implying that tumors within the spinal cord must be operated upon while the patient can walk. The postoperative quality of life depends upon the preoperative neurological status.

 

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Fig. 1

Ependymoma grade II, case 10, Fig. 1
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Ependymoma grade II, case 10, Fig. 25