Bilateral papilloedema as the initial manifestation of spinal ependymoma

Spinal paraganglioma presenting with raised intracranial pressure: a note on the diagnosis and post-operative management

BACKGROUND

Spinal paragangliomas are tumors of neuroendocrine origin that present with symptoms of mass effect or neurosecretion but rarely involve the central nervous system. Raised intracranial pressure and papilledema are therefore unusual presentations of a spinal paraganglioma.

METHODS

We review the case of a 54-year-old man who presented with headache and visual disturbance. Fundoscopy confirmed papilledema with normal intracranial imaging. Neuraxis imaging revealed a lumbar intradural extramedullary tumor and pathological analysis confirmed a WHO Grade I spinal paraganglioma. The tumor was resected and post operatively his vison improved with resolution of optic disc swelling.

CONCLUSIONS

Raised intracranial pressure and papilledema are unusual clinical manifestations of spinal tumors and imaging the entire neuraxis can be valuable.

Atypical presentation of spinal intramedullary astrocytoma in a patient presenting with isolated signs of intracranial hypertension

INTRODUCTION

Intramedullary spinal tumors are rare entities that typically present with signs of spinal cord dysfunction including myelopathy, weakness, hypoesthesia, or bladder dysfunction. However, they can present in more insidious ways without signs of spinal cord dysfunction, as we will discuss in this case. Our patient presented with isolated signs of intracranial hypertension including headache and progressive vision loss. Although idiopathic intracranial hypertension (IIH) is significantly more common than spinal cord tumors, a full evaluation to rule out other diagnoses should always occur, as this is an exclusionary diagnosis.

CASE PRESENTATION

We describe an interesting case of an obese, middle-aged female who presented with signs and symptoms of elevated intracranial pressure (ICP) including progressive headache, visual changes, and papilledema. This led to a presumptive diagnosis of idiopathic intracranial hypertension (IIH). However, a careful review of her cerebrospinal fluid (CSF) analysis revealed a significantly elevated protein level. This prompted a more thorough workup, including a spinal MRI, that revealed an intramedullary astrocytoma. On her presenting physical exam, she had no upper or lower motor signs, no weakness, and no pathological reflexes.

DISCUSSION

In the evaluation of a patient with isolated signs of increased ICP concerning for IIH, it is important to conduct a thorough workup as this remains a diagnosis of exclusion. Many intracranial and intraspinal pathologies can manifest with similar vague neurological symptoms and masquerade as a more benign disease as shown in our patient who, unfortunately, died from a spinal astrocytoma.