Acute neurological deterioration as a result of two synchronous hemorrhagic spinal ependymomas

Development of a novel prediction model for differential diagnosis between spinal myxopapillary ependymoma and schwannoma

Spinal myxopapillary ependymoma (MPE) and schwannoma represent clinically distinct intradural extramedullary tumors, albeit with shared and overlapping magnetic resonance imaging (MRI) characteristics. We aimed to identify significant MRI features that can differentiate between MPE and schwannoma and develop a novel prediction model using these features. In this study, 77 patients with MPE (n = 24) or schwannoma (n = 53) who underwent preoperative MRI and surgical removal between January 2012 and December 2022 were included. MRI features, including intratumoral T2 dark signals, subarachnoid hemorrhage (SAH), leptomeningeal seeding, and enhancement patterns, were analyzed. Logistic regression analysis was conducted to distinguish between MPE and schwannomas based on MRI parameters, and a prediction model was developed using significant MRI parameters. The model was validated internally using a stratified tenfold cross-validation. The area under the curve (AUC) was calculated based on the receiver operating characteristic curve analysis. MPEs had a significantly larger mean size (p = 0.0035), higher frequency of intratumoral T2 dark signals (p = 0.0021), associated SAH (p = 0.0377), and leptomeningeal seeding (p = 0.0377). Focal and diffuse heterogeneous enhancement patterns were significantly more common in MPEs (p = 0.0049 and 0.0038, respectively). Multivariable analyses showed that intratumoral T2 dark signal (p = 0.0439) and focal (p = 0.0029) and diffuse enhancement patterns (p = 0.0398) were independent factors. The prediction model showed an AUC of 0.9204 (95% CI 0.8532-0.9876) and the average AUC for internal validation was 0.9210 (95% CI 0.9160-0.9270). MRI provides useful data for differentiating spinal MPEs from schwannomas. The prediction model developed based on the MRI features demonstrated excellent discriminatory performance.

A Case of Spinal Ependymoma Developed in the Extramedullary Location: A Case Report and Literature Review

Intradural extramedullary (IDEM) ependymoma except for tumors originated from the filum terminale or conus medullaris is rare. The present study showed a case of IDEM ependymoma. A 16-year-old boy was referred to our hospital with a complaint of right hypochondriac pain and motor weakness in his right leg. MRI revealed a solitary intradural tumor at Th5–8 level with syringomyelia at Th2–4 level. Microscopic total tumor resection was performed with right hemi-laminectomy of Th4–9. Histological diagnosis was ependymoma (WHO grade 2). Although his leg weakness was worsened transiently, he showed improvement in leg weakness being able to go up and down the stairs 1 month after the surgery. There was no tumor recurrence until now, 7 years after the surgery, without any adjunctive therapies. A total of 44 cases of IDEM ependymoma had been reported in the past literatures. They are thought to arise from ependymal cells which remained during the process of neural tube closure. Like intramedullary ependymomas, most of the IDEM ependymomas have clear border to surrounding tissue and often removed completely. However, a small number of recurrences and malignant transformations had been reported after complete resections despite benign histological features tumors. In the case of totally resected low grade IDEM ependymoma, it is thought to be reasonable to perform long-term periodical radiographic follow-up without postoperative adjunctive therapy.

Atypical Imaging of Hemorrhagic Lumbosacral Myxopapillary Ependymoma with Histopathological Correlation: A Case Report

Patient: Male, 16-year-old

Final Diagnosis: Hemorrhagic myxopapillary ependymoma • myxopapillary ependymoma

Symptoms: Gait abnormality • pain in lumbar region

Medication: —

Clinical Procedure: Resection of intraspinal mass

Specialty: Neurosurgery • Radiology

Cervicomedullary Ependymoma with Hemorrhage: A Case Report and Review of Literature

Ependymoma is a rare tumor central nervous system that arises from the ependymal lining of the ventricles or the central canal of the spinal cord. They are of neuroectodermal in origin and constitute about 30%–86% of tumors arising in the spinal cord. The occurrence of these tumors in the cervicomedullary region is very rare. Sudden symptomatic neurologic presentations due to hemorrhage in cervicomedullary ependymoma is very rare and so far have never been reported. Mostly presenting as neurologic deficits involving limbs, these tumors pose a technical challenge in their removal. We present a patient who presented with sudden-onset dysesthesia of the upper and lower limbs. On imaging, he was found to have a cystic medullary tumor extending to the cervical region with hemorrhage. We discuss the epidemiology, surgical challenges, and outcome along with review of literature of these rare tumors located in this precarious location.

Factors predicting outcome of surgical treatment of spontaneous spinal hematomas: a retrospective cohort study in four tertiary reference centers

BACKGROUND

Spontaneous spinal extradural hematoma (SSEH) is a rare but disabling disorder. Most of the previous assumptions regarding the factors that contribute to poor neurological recovery from SSEH are based on small case samples or conditions with similar clinical presentations but different physiopathologies. Our goal was to find the most relevant prognostic factors for neurological recovery in patients suffering SSEH treated with surgical evacuation.

METHODS

From a retrospective database of 29 surgical patients with SSEH, several clinical and radiological variables were recorded. These variables were compared between patients with good and poor neurological recovery, considering good as an improvement by at least one point in the ASIA Scale.

RESULTS

Among the patients included, morbidity and mortality rate was 6.9% and 3.4%, respectively, with a mean follow-up of 7.1 months. Neurological full recovery was experienced by 33% of the patients included, and 86% of individuals had an improvement in their neurological condition at last follow-up. Lesser intramedullary lesions were significantly associated with greater chances of improvement in ASIA Scale at discharge and at follow-up. Surgical decompression within the first 24 hours of onset of symptoms were correlated with better neurological outcomes at follow-up.

CONCLUSIONS

MRI is a powerful tool to predict the neurological outcome in SSEH patients, and it should be considered as an another resource to better know the patients with greater chances of having neurological recovery, especially in cases where the neurological examination is not reliable at the initial exam.

A Rare Case of Pediatric Lumbar Spinal Ependymoma Mimicking Meningitis

Spontaneous acute subarachnoid hemorrhage (SAH) from lumbar ependymoma in children is rare. We report a case of a 14-year-old boy who developed sudden radicular low back pain while playing baseball. He was initially managed conservatively in a local hospital for suspected lumbar disc herniation, but he later developed meningeal symptoms and fever before being referred to our hospital. He underwent a diagnostic lumbar puncture in the emergency department; his cerebrospinal fluid suggested an SAH. Physical examination showed meningeal signs and cauda equina features. Cerebrospinal fluid analysis was negative for bacterial meningitis. Lumbar magnetic resonance imaging revealed a mass characterized as a hemorrhagic lesion. The patient had an emergent evacuation of the mass through the posterior approach. Postoperatively, his symptoms resolved completely. The histologic diagnosis was, surprisingly, an ependymoma (World Health Organization grade II). This case is particularly interesting because of its rarity in children, and its pattern of presentation. Although bacterial or viral meningitis is the most frequent cause of meningeal features in children, SAH from a hemorrhagic spinal tumor should be considered. Ultimately, a high index of suspicion is needed for prompt diagnosis.

Acute Paraplegia as a Result of Hemorrhagic Spinal Ependymoma Masked by Spinal Anesthesia: Case Report and Review of Literature

Ependymomas are the most common intramedullary spinal cord tumors in adults. Although a hemorrhage within spinal ependymoma on imaging studies is not uncommon, it has rarely been reported to bea cause of acute neurological deficit. In the present report, we describe a case of a 24-year-old female patient who developed acute paraplegia as a result of hemorrhagic spinal ependymoma immediately after a cesarean delivery under spinal regional anesthesia. We review the literature of hemorrhagic spinal ependymomas presenting with acute neurological deficit and discuss the most appropriate treatment for a good neurological recovery.

Spontaneous Hemorrhage of a Spinal Ependymoma in the Filum Terminale Presenting with Acute Cauda Equina Syndrome: Case Report

We present a rare case of spontaneous hemorrhage of a spinal ependymoma in the filum terminale presenting with acute cauda equina syndrome. A 16-year-old male presented with a sudden onset of severe back pain that began 10 days before hospitalization. This symptom progressed, followed by development of decreased sensation in the lower extremities, bladder dysfunction, and motor weakness that advanced to an inability to walk. Spinal magnetic resonance imaging revealed a hemorrhagic mass from Th12 to L2 and L4 to L5, and clinical signs indicated acute cauda equina compression. One day after admission to the hospital, emergency surgery was performed. A spinal tumor in the conus portion with a spinal subarachnoid hemorrhage was seen. Gross total excision of the massive hematoma mixed with the underlying tumor was performed. Pathological findings of the excised tumor demonstrated a WHO Grade II cellular ependymoma of the non-myxopapillary type. The patient made a significant recovery. The ability to walk was restored, and impaired bladder function improved at follow-up. Early diagnosis and suitable treatment are associated with a more favorable outcome.

Concomitant Double Tumors of Myxopapillary Ependymoma Presented at Cauda Equina-Filum Terminale in Adult Patient

A 32-year-old man presented with gradually increasing bilateral buttock pain. He had intermittent claudication. Multiple, homogenously enhanced intradural extramedullary lesions at L2-L3 and L5-S1 levels were observed on magnetic resonance imaging. The tumors were debulked and were removed in piecemeal pattern until they had completely been resected. Histopathological examination of the surgical specimens confirmed that both tumors were myxopapillary ependymomas (MPE). MPE presenting as concomitant double tumor at conus-cauda-filum level are very rare. This kind of presentation could not be directly considered as dissemination, since both tumors were in the site of classical origin of MPE. Ten cases of double spinal MPEs have been reported to date. Including the present case, analysis of the 11 patients revealed some facts. There is a male predominance, which is opposite to the ependymomas that are commonly observed in females. Median age at presentation is 15 years. Most pronounced symptom is low back pain that sometimes radiates to lower extremities. Surgical approach was aimed in all tumors, which could be succeeded in all tumors except one. Adjuvant radiation therapy was applied in 5 patients. No recurrences have been reported after surgery or surgery + radiotherapy regimens.

The nature of double concomitant myxopapillary ependymoma: report of a case

Myxopapillary ependymomas are almost exclusively seen at the conus medullaris/filum terminale/cauda equina region, usually as solitary space-occupying lesions. The authors report the case of a 14-year-old boy with double concomitant myxopapillary ependymoma, proximal and caudal on the filum terminale in which a totally gross removal was achieved in two stages. This presentation is rare and, so far, we have known just three similar cases that were previously reported in children. The true nature of these lesions is controversial, and while some argue that they are related to metastatic seeding, others consider them independent lesions developing synchronously. A review on dissemination of spinal myxopapillary ependymomas was done.

Multiple primary intramedullary ependymomas: a case report and review of the literature

BACKGROUND CONTEXT

Intramedullary ependymomas constitute the most frequent type of intramedullary tumor. In patients with neurofibromatosis type 2 (NF2), multiple intramedullary ependymomas are known to occur. In the non-NF2 population, however, the presence of multiple synchronous intramedullary ependymomas is exceedingly rare.

PURPOSE

In this article, the authors report the second case in the literature of multiple primary synchronous intramedullary ependymomas. To the best of the authors knowledge, this report represents the first to provide a detailed pathology of all lesions, thereby giving an added level of confidence on the primary synchronous nature of the lesions. The authors have also performed a review of the literature regarding multifocal intramedullary ependymomas.

STUDY DESIGN

A review article and case report.

CONCLUSIONS

The concomitant localization of two primary intramedullary spinal cord ependymomas in the setting of nongenetic predisposition is an uncommon phenomenon. In this article, the authors present the second report of multiple, synchronous intramedullary ependymomas. A detailed review of the literature reveals that the presence of multiple intramedullary lesions in non-NF2 patients is both rare and deserving of further study.

Utilization of intraoperative electromyography for selecting targeted fascicles and determining the degree of fascicular resection in selective tibial neurotomy for ankle spasticity

BACKGROUND

Selective tibial neurotomy (STN) is an effective neurosurgical intervention for treating ankle spasticity. The authors use intraoperative electromyography (EMG) for selecting targeted fascicles and determining the degree of fascicular resection in STN. This study reports surgical techniques and outcomes of the operation.

METHODS

Participants who underwent STN with utilization of intraoperative EMG were recruited. Modified Ashworth Scale (MAS), passive range of motion (PROM) of the ankle in plantar flexion and dorsiflexion, Massachusetts General Hospital Functional Ambulatory Classification (MGHFAC) and ability to attain full plantigrade stance were assessed pre- and postoperatively.

RESULTS

Twenty-one STNs were performed in 15 patients. The mean pre- and postoperative MAS and PROM were 2.8 and 0.4 (p < 0.001), 39.5(o) and 66.0(o) (p < 0.001), respectively. The mean level of MGHFAC was improved from 3.3 preoperatively to 4.9 postoperatively (p < 0.01). Six non-ambulators had significant amelioration in MGHFAC level. Postoperatively, 19 of 21 lower limbs achieved full plantigrade, and 6 patients could perform selective voluntary motor control of the ankle.

CONCLUSION

STN is an effective procedure for spastic ankle in well-selected cases. Intraoperative EMG helps in selection of targeted fascicles, increases objectivity in neurotomy and prevents excessive denervation.

Anaplastic ependymoma with holocordal and intracranial meningeal carcinomatosis and holospinal bone metastases

BACKGROUND AND IMPORTANCE

Ependymomas are the most frequent intramedullary neoplasms in adult patients. Anaplastic histology, extramedullary location, meningeal dissemination at initial diagnosis, and extraneural metastases are rare findings. We describe a case of extramedullary anaplastic ependymoma that presented with holocordal and intracranial leptomeningeal carcinomatosis and bone metastases in all the vertebral bodies and the sternum. Such an aggressive dissemination at initial diagnosis has not been previously reported.

CLINICAL PRESENTATION

A 36-year-old woman presented with headache, multiple cranial nerve palsies, visual hallucinations, confusion, hemiparesis, hemihipoestesia, episodes of disconnection, and toxic syndrome. Magnetic resonance imaging and positron emission tomography scan revealed leptomeningeal carcinomatosis in the brainstem, the cerebellum, and along the whole spinal cord. Various nodular, intradural extramedullary lesions were present at multiple dorsal and lumbar levels. Metastatic bone disease affected all the vertebral bodies and various extraspinal bones. An intradural and bone biopsy was performed at L4, providing the diagnosis of anaplastic ependymoma (World Health Organization grade III) with focal neuronal differentiation. Despite chemotherapy, the patient's symptoms quickly progressed, and she died 7 weeks after diagnosis.

CONCLUSION

To our knowledge, there are no previous descriptions of ependymomas with this extensive leptomeningeal, spinal, intracranial, and extraneural dissemination at clinical onset. Bone metastases in spinal ependymoma have not been previously reported.