Baylor University Medical Center Proceedings July 2014 - (Page 213)
Spinal cord ependymoma presenting with neurological
deficits in the setting of trauma
Amin F. Saad, MD, Larry T. Nickell, MD, S. Sam Finn, MD, and Michael J. Opatowsky, MD, MBA
Ependymomas represent 4% of all primary central nervous system
neoplasms in adults, with 30% occurring in the spinal cord. We
describe a young man with neurological deficits following a motor
vehicle accident who was found to have an intramedullary cervicothoracic ependymoma.
CASE REPORT
A previously healthy 18-year-old man presented to the
emergency department following a motor vehicle accident.
All four extremities were weak immediately following the accident, with right-sided weakness noted on initial physical
examination. Head and cervical spine computed tomography
(CT) revealed no abnormalities. Cervical spine magnetic resonance imaging (MRI) revealed an expansile intramedullary
mass at the cervicothoracic junction (Figures 1a, 1b) and mild
interspinous ligament sprain. The patient's neurologic deficit
resolved within 24 hours. The patient underwent laminectomy and laminoplasty with complete resection of the mass
(Figure 1c) and had an uncomplicated postoperative course.
Neurological examination immediately following surgery revealed decreased right lower extremity proprioception, 2+/5
strength at the right L2 to L3 levels, and 4/5 strength at the
right L4 to S1 levels.
DISCUSSION
Ependymomas are the most common intramedullary
neoplasm in adults and represent 60% of all intramedullary
tumors. They arise from ependymal cells lining the central
canal of the spinal cord. These tumors have a mean age of
presentation of 38.8 years and a slight male predominance
(57.4%) (1, 2). The clinical presentation of ependymoma is
similar to that of other intramedullary lesions, with a prolonged history of slowly worsening myelopathic symptoms
prior to diagnosis.
MRI evaluation is the imaging modality of choice in the patient with suspected cord neoplasm. Ependymomas are typically
iso- to hypointense relative to the spinal cord on unenhanced
T1-weighted images, with the vast majority exhibiting at least
some degree of enhancement following intravenous gadolinium
administration (1, 3, 4). T2-weighted images usually reveal a
Proc (Bayl Univ Med Cent) 2014;27(3):213-214
hyperintense intramedullary lesion. Ependymomas may cause
hematomyelia as well as subarachnoid hemorrhage, with 20%
to 33% of lesions displaying a "cap sign" of signal hypointensity at the lesion margins secondary to hemosiderin deposition
from intralesional chronic microhemorrhages. Cysts are often
associated with ependymomas, with the majority representing
nontumoral (polar) cysts at the margins of the lesion. True tumoral cysts (surrounded by enhancement) arise less frequently
(1, 3, 4).
The preferred treatment for spinal cord ependymomas
is complete surgical resection. Current advances in microsurgical technique and intraoperative monitoring enable
frequent complete resection without worsening postoperative neurologic function (5). In a series of 31 cases described
by Chang et al (5), only 10% of cases were associated with
worsening neurological function, while 26% showed improvement and the rest remained stable. The preoperative
neurologic status of the patient is the greatest predictor of
postoperative functional outcome (2, 5). Radiation therapy
delays disease progression in patients treated with subtotal
resection.
1.
2.
3.
4.
5.
Koeller KK, Rosenblum RS, Morrison AL. Neoplasms of the spinal cord
and filum terminale: radiologic-pathologic correlation. Radiographics
2000;20(6):1721-1749.
Hanbali F, Fourney DR, Marmor E, Suki D, Rhines LD, Weinberg
JS, McCutcheon IE, Suk I, Gokaslan ZL. Spinal cord ependymoma: radical surgical resection and outcome. Neurosurgery
2002;51(5):1162-1172.
Fine MJ, Kricheff II, Freed D, Epstein FJ. Spinal cord ependymomas:
MR imaging features. Radiology 1995;197(3):655-658.
Kahan H, Sklar EM, Post MJ, Bruce JH. MR characteristics of histopathologic subtypes of spinal ependymoma. AJNR Am J Neuroradiol
1996;17(1):143-150.
Chang UK, Choe WJ, Chung SK, Chung CK, Kim HJ. Surgical outcome
and prognostic factors of spinal intramedullary ependymomas in adults.
J Neurooncol 2002;57(2):133-139.
From the Departments of Diagnostic Radiology (Saad, Nickell, Opatowsky)
and Neurosurgery (Finn), Baylor University Medical Center at Dallas.
Corresponding author: Amin F. Saad, MD, Department of Diagnostic Radiology,
Baylor University Medical Center at Dallas, 3500 Gaston Avenue, Dallas, TX 75246
(e-mail: amin.saad@baylorhealth.edu).
213
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