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

I Barone, B.M. and Elvidge, A.R. (1970) Ependymomas: a clinical survey. J. Neurosurg.. 33: 428438. 2 Fokes. E.C. and Earle. K.M. (1969) Ependymomas: clinical and pathological aspects. J Neurosurg.. 30: 585-594. 3 Hoogen Esch. R.J. and Staal, M.J. (1988) Tumors of the cauda equina: the importance of an early diagnosis. Clin. Neurol. Neurosurg., 90: 343- 348. 4 Rivierez. M., Oueslati. S.. Philippon. J. et al. (1990) Les ependymomes du filum terminal intradural chez adulte. Neurochirurgie (Paris), 36: 96- 107. 5 N&Strom, C., Kernohan, J. and Love, J. (1961) One hundred primary caudal tumors. JAMA 178: 1071 1077. F., Schaeffer, H. and de Martel, T. (1930) 6 Andr&Thomas, Syndrome d’h&morragie mCning&e r&ah+ par une tumeur de la queu de cheval. Paris Med., 77: 292 -296. 8 Vernet, 0.. Alhila, R. and de Tribolet, N. (1986) Les hkmorragies sous-arachnoidiennes spinales. Schweiz. Med. Wschr., 116: 781-784. 9 Neau. J.. Lefkvre, J.. Gil. R. et al. (1983) Hkmorragies mkningees spinale d’origine tumorale. Sem. Hop. Paris. 59: 5-11. R.. Nowak. G. et al. (1990) 10 Herb, E., Schwachenwald. Acute bleeding into a filum terminale ependymoma. Neurosurg. Rev.. 13: 243-245.

Merrit, H., Antunes, J. (1979) Spinal tumors. In: Merrit. H.H. (Ed.), A Textbook of Neurology, 6th edn., Lea & Febinger, Philadelphia, pp. 300-30 1. Djindjan, M., Djindjan, R., Houdart, R. et al. (1978) Subarachnoid hemorrhage due to intraspinal tumors. Surg. Neurol., 9: 223-229. Fincher, E.F. (1951) Spontaneous subarachnoid hemorrhage in intraspinal tumors of the lumbar sac. J. Neurosurg.. 8: 576-584.

14 Perel, Y.. Got, H., Dufillot, Y. ct al. (IYXS) Hemorr-agte meningee, symptome revelateur d’une tumeur spinale. chc/ l’enfant. Pediatric, 8: 645- 65 I. 15 Prieto, A. and Cantu, R. (1967) Spinal subarachnoid hemorrhage associated with neurofibroma of the caudo equina. Case report. J. Neurosurg: 1967: 63 69. 16 Ilgren, E., Stiller, C., Hughes, J. et al. ( 1984) Ependymomas: a clinical and pathological study. Part II. Survival features. Clin. Neuropathol.. 3: 122 127.

Spinal subarachnoid hemorrhage due to a filum terminale ependymoma.

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 spi...
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