C’liniccrlNwrolog~ 0
und Nw~~surger~,
1992 Elsevier Science Publishers
CLINEU
69
94 (1992) 69-72 B.V. All rights reserved
0303-8467/92/S
05.00
00178
Case report
Spinal subarachnoid
hemorrhage due to a filum terminale ependymoma
P. Admiraal”, G.J. Hazenberga, P.R. Algrab, W. Kamphorst” and J.G. Wolbersd “Departments
qf “Neurology,
‘Rudiology,
‘Pathology
and ‘Neurosurgery,
(Received (Revised,
24 September,
received
(Accepted
Key ,~orcls;
Ependymoma;
Filum terminale;
The Nether1and.s
1991)
I I December.
16 December,
subarachnoid
Free University Hospitul, Amsterdam,
1991)
1991)
hemorrhage:
MRI
Summary
We present a case of spinal subarachnoid hemorrhage due to an ependymoma of the filum terminale in a 23-year-old male. Clinical signs indicating a spinal origin of the subarachnoid hemorrhage are discussed. Subarachnoid hemorrhages are only rarely caused by an intraspinal tumor, most of which are located in the cauda equina. Our findings in this case proved
the value of MRI examination
in tumors
of the cauda equina.
Introduction
Case report
Tumors of the cauda equina are uncommon, representing 1% of the central nervous system tumors [l 11. The occurrence of ependymomas in the filum terminale varies according to the different published series [l-5]. Of the 100 filum terminale tumors reported by Ntir-
A 23-year-old male carpenter was referred to our hospital because of otitis media. In the course of a number of
Strom, 89 were ependymomas [6]. The symptomatology often lacks characteristic features, because it can mimic
cholesteatoma. Two weeks earlier he had done some heavy work with much lifting. After this he suffered from
more common sciatic syndromes. Only on rare occassions does an intraspinal tumor cause a subarachnoid
headache. had fever and general malaise. Also he experienced backache and much pain in both upper legs, which
hemorrhage. Demonstrating a clinical pletely different to that of an intracranial
typically became worse upon biking. The bladder and bowel functions were normal. On examination the body temperature was 38.5”C, with normal pulse and blood pressure. Conciousness was clear, slight nuchal rigidity was present, in supine position, on lifting his head. Fun-
picture, comsubarachnoid
hemorrhage [7,8.13]. Since the original report by And+ Thomas in 1930, 54 cases of subarachnoid hemorrhage caused by a filum terminale the literature [7- lo].
tumor have been reported
in
years he had been operated 4 times for a benign cholesteatoma in the right middle ear. On admission the ENT specialist found no signs of otitis media or
doscopic examination ties. Straight-leg-raising 10”. Strength,
Corrrspondmce IO: P. Admiradl, University Netherlands
Hospital,
De Boelelaan
of Neurology,
Free
1117. 1081 HV Amsterdam,
Department
The
of the eyes showed no abnormalitests were positive bilaterally at
sensation,
coordination
and
reflex
re-
sponses were normal, and routine laboratory tests of blood and urine showed no abnormalities. Lumbar puncture at L4iL5 level yielded blood-stained cerebrospinal fluid in 4 consecutive tubes. A CT scan of the
Fig. 1, Metrizamide myelography. Round filling defect at Ll/ L2 level (arrow). Compatible with an intradural mass lesion.
brain revealed no signs of SAH. A myelogram of the whole spinal cord, showed a round filling defect at the Ll/L2 level (Fig. 1). The subsequently performed spinal angiogram, including all feeding vessels, showed no evidence of a spinal arteriovenous malformation. MRI examination of the whole spinal cord was done. It showed at the lumbar spine, in sagittal and coronal planes, an intradural, extramedullary mass, just caudal to the conus medullaris (Figs. 2, 3). On T,- weighted images there was an increased signal from the tumor, following the intravenous injection of 0.1 mmol/kg gadolinium-DTPA (Fig. 4). Ependymoma or neurofibroma was entertained as diagnosis. Laminectomy Ll and L2 revealed an intradural brown-coloured tumor with distended veins running over it, just caudal to the epiconus. The tumor was adherent to the filum terminale, and the spinal roots were not involved. With transection of the filum terminale the tumor could be removed in toto. Pathological examina-
Figs. 2 and 3. MRI, T,-weighted images (3hOiN msec: 11111x sagittal plane of the lumbar spine show the lumor caudal Irom the epiconus and contrast enhancement al’ the tumor .~f~erI 1’. injection of 0. I mmol./kg g,doiirtium-DTPA.
tion revealed on ependymoma, benign cellular variant, grade I. There were focally necrosis and siderophages.
Discussion Subarachnoid hemorrhage (SAH) may follow physical exertion. especially in the case of an intracranial aneurys-
71 preceded
the onset of symptoms.
be that the heavy manual led to venous mechanism ultimate
One explanation
labor performed
stasis in the veins draining
the tumor,
that caused the tumor ischaemic
necrosis
proved
to be diagnostic
and
most of the time
[10,15]. As is well known
(as also in our patient).
examination
to metrizamide
was superior
in respect to locating
the tumor
the patient
yielded
showed
MRI
myelography
and establishing
to the conus medullaris
gery is the treatment control
a
bleed. In the case of a spinal tumor metrizamide
myelography
tionship
may
by our patient
its rela .-
and cauda equina.
Sut cIf
of choice. Four years follow-up no complaints
no recurrence.
or symptoms.
We conclude
MR I
when co11
fronted with a case of SAH, unexplained by CT scannin g or angiography of the brain, fresh attention should be paid to the clinical
picture.
If clinical
signs point
to a
spinal origin of the SAH, non-invasive MRI of the myelum is the modality of choice. otherwise a complete myFig. 4. MRI, T,-weighted image (360120 msec) in coronal plane of the lumbar spine after i.v. injection of 0.1 mmolikg gadolinium-DTPA shows the tumor with contrast enhancement.
elography
should
be performed.
If MRI
examination
and/or a myelography are not diagnostic, a spinal angiogram should be performed, to pertain the possibility of an
arterio-venous
malformation
as the
cause
of the
bleed. matic rupture [12]. Our search for an intracranial aneurysm was negative. The percentage of SAH without explanation visible at CT scanning or angiography of the
brain varies from 20 to 37% [8,12]. A spinal origin of the SAH is rarely encountered, ranging from 0.6 to 1.0% [14]. Prieto and Cantu
described
the signs which point to
a spinal origin of the SAH [ 151: (1) backache and radicular pain, which are more severe than the headache. (2) Resolution symptoms.
of the headache with worsening of the spinal (3) No impairment of conciousness. (4) Dys-
function which can be located at the level of the myelum or spinal roots. Symptoms 1-3 were present in our patient. According to Djindjan et al. [12] a spinal arteriovenous malformation is the most frequent cause of a spinal SAH. bleeding occurred 43 times (26%), among 170 instances of spinal AVM [12]. In our patient, however. the normal spinal angiogram excluded this diagnosis. Another explanation for a spinal SAH, that is a spinal tumor,
has been reported
54 times. The majority
among
them were ependymomas (59%). 80% of which were located in the cauda equina 18,141. Other tumors included neurinoma (18%), and exceptionally a meningioma, schwannoma, astrocytoma or cavernous hemangioma [14]. SAH caused by a filum terminale ependymoma is a rare event; of the 73 cases reported in different series, one bleed was found [ 1~51. In one-third of the cases of spinal SAH due to a tumor, trauma or physical stress directly
References
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