Spinal Cord Ependymoma Presenting with Neurological Deficits in the Setting of Trauma

Abstract

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 REPORTA 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. Th e patient's neurologic defi cit resolved within 24 hours. Th e 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. DISCUSSIONEpendymomas are the most common intramedullary neoplasm in adults and represent 60% of all intramedullary tumors. Th ey arise from ependymal cells lining the central canal of the spinal cord. Th ese tumors have a mean age of presentation of 38.8 years and a slight male predominance (57.4%) (1, 2). Th e 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 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 postoper...

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