Spontaneous Hemorrhage of a Spinal Ependymoma: A Rare Cause of Acute Cauda Equina Syndrome

Tait, Matthew; Chelvarajah, Ramesh; Garvan, N; Bavetta, S

doi:10.1097/01.brs.0000143663.27275.7f

Cited by 36 publications

(25 citation statements)

References 11 publications

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“…6 Acute presentations with a sudden onset of severe pain are rare and related to tumor hemorrhages. 15,37 This was encountered in only 1 patient in this series.…”

Section: Discussion Clinical Presentation and Diagnosismentioning

confidence: 91%

Spinal ependymomas. Part 2: Ependymomas of the filum terminale

Klekamp

2015

FOC

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OBJECT Ependymomas of the filum terminale provide specific surgical challenges due to their often enormous size, contact with nerve roots of the cauda equina and conus, and potential for subarachnoid dissemination. This study presents treatment results for these tumors over a 30-year period. METHODS Among 1447 patients with tumors of the spinal canal treated between 1980 and 2014, 618 patients presented with extramedullary tumors. Of these, 42 patients (25 males, 17 females) demonstrated a myxopapillary ependymoma in the lumbosacral region. Thirty-four patients underwent 36 operations for 39 such tumors. The mean patient age was 38 ± 14 years (range 11−73 years), with an average clinical history of 37 ± 67 months. Patients were followed through outpatient visits and questionnaires, with a mean follow-up of 10 years (127 ± 100 months). Twenty-seven operations were performed to treat de novo tumors and the remainder were undertaken on recurrent tumors. Short-term results were determined for individual symptoms, and tumor recurrence rates were calculated with Kaplan-Meier statistical analyses. RESULTS Subarachnoid dissemination was observed in 11 patients and was related to previous surgery in 9 patients and associated with extensive tumors in 2 patients. Gross-total resections (GTR) were achieved in 28 operations (77.7%) and subtotal resections in the remainder. Subtotal resections were restricted to unencapsulated ependymomas (61.5%). Radiotherapy was employed after 6 operations on unencapsulated tumors, with 5 of these also demonstrating subarachnoid seeding. Permanent surgical morbidity affected 3 patients who experienced permanent worsening of bladder function, while 7 patients showed no postoperative changes, and the remaining 26 operations were followed by improvements. Long-term outcome depended on the amount of resection and the presence of a tumor capsule. Eight of 9 tumor recurrences affected unencapsulated tumors, of which 3 had undergone GTR. The overall recurrence rates were 6.6%, 19.0%, and 37.0% after 1, 10, and 20 years, respectively. For unencapsulated ependymomas, the corresponding rates were 15.6%, 32.5%, and 66.2% after 1, 10, and 20 years, respectively, with significantly lower rates of 9.1% after 10 and 20 years for encapsulated tumors. Postoperative radiotherapy tended to prolong the recurrence-free interval for patients with unencapsulated tumors. Five patient deaths occurred during follow-up, of which 2 deaths were tumor related and occurred at 216 and 287 months after surgery. CONCLUSION Extramedullary ependymomas are slow-growing tumors in the lumbosacral region, sometimes with an indolent course for long periods of time. Despite their delicate location and often enormous size, surgical morbidity in experienced hands is low, with good chances for postoperative clinical improvements and very low recurrence rates after GTR for encapsulated tumors. The role of postoperative radiotherapy remains controversial. Radiotherapy may be considered after incomplete resections of unencapsulated tumors and/or for patients with subarachnoid dissemination.

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“…6 Acute presentations with a sudden onset of severe pain are rare and related to tumor hemorrhages. 15,37 This was encountered in only 1 patient in this series.…”

Section: Discussion Clinical Presentation and Diagnosismentioning

confidence: 91%

Spinal ependymomas. Part 2: Ependymomas of the filum terminale

Klekamp

2015

FOC

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“…The clinical course is typical with low back pain, paresthaesias or sciatalgia. In addition to these symptoms, spontaneous subarachnoid and intratumoural haemorrhages are mainly confined to the myxopapillary type and seen infrequently [1,3,4]. The main Fig.…”

Section: Discussionmentioning

confidence: 99%

“…1 A well-demarcated intradural-extramedullary mass lesion at the level of the first lumbar vertebra was observed on gradientecho (flip angle 25°) magnetic resonance images reason for these types of haemorrhages is the relatively more vascular structure of myxopapillary ependymomas. However, there are other predisposing factors for spontaneous haemorrhages such as pregnancy, recent epidural anaesthesia or anticoagulation [3,4]. The treatment of choice is total excision of the tumour when possible.…”

Section: Discussionmentioning

confidence: 99%

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Posttraumatic intratumoural haemorrhage: an unusual presentation of spinal ependymoma

et al. 2007

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Ependymomas presenting with intratumoural and/or subarachnoid haemorrhages are seen rarely. These haemorrhages are mostly due to anticoagulation, epidural analgesia or pregnancy. A 62-year-old male farmer with cauda equina syndrome after a work-related trauma is presented. He was admitted to our hospital with paraparesis, faecal incontinance and sensory loss below the level of the lumbar-2 dermatome. Magnetic resonance imaging of the spine displayed an intradural mass lesion at the level of the first lumbar vertebrae. The lesion was excised totally via dorsal midline approach. Histopathologic examination revealed grade-3 ependymoma with intratumoural haemorrhage. The patient's symptoms were relieved completely on postoperative day 7. The patient was given information about periodical examination for recurrence and discharged on the third postoperative week. Asymptomatic spinal lesions should be considered for operation whenever detected because of unpredicted complications.

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“…Imaging typically shows a well-circumscribed neoplasm that may have cystic or hemorrhagic features. In the instance of hemorrhagic change, cauda equina syndrome may be the presenting feature (4).…”

Section: Introductionmentioning

confidence: 99%