Teaching NeuroImage: Hemorrhagic ependymoma in the elderly
A rare cause of headache and gait imbalance
N. Montano, MD,
P. De Bonis, MD,
F. Doglietto, MD,
A. Cianfoni, MD,
R. Pallini, MD,
L. Lauriola, MD and
G. Maira, MD
From the Institute of Neurosurgery (N.M., P.D.B., F.D., R.P., G.M.), Institute of Radiology (A.C.), and Institute of Pathology (L.L.), Catholic University School of Medicine, Rome, Italy.
Address correspondence and reprint requests to Dr. Pasquale De Bonis, Institute of Neurosurgery, Catholic University School of Medicine, Largo Agostino Gemelli, 8, 00168 Rome, Italy debonisvox{at}gmail.com
A 73-year-old man presented with headaches, vomiting, and gaitimbalance. Neurologic examination demonstrated bilateral papilledemaand positive Romberg sign. Neuroimaging showed a posterior fossalesion with calcifications and intratumoral hemorrhage associatedwith obstructive hydrocephalus (figure 1, A through D). Grosstotal resection was performed (figure 2, A and B). Histologicexamination documented ependymoma (figure 2, C through E).
Nonenhanced CT (A), MRI with axial T2-WI (B), sagittal non-enhanced (C) and enhanced (D) T1-WI, showing a heterogeneous, solid-cystic, hemorrhagic and calcific mass in the cisterna magna and in the inferior portion of the fourth ventricle. A blood-fluid level is visible in the cystic portion (arrow) and contrast enhancement is evident in the solid intraventricular portion. The mass obstructed the fourth ventricle with resulting hydrocephalus.
(A, B) Intraoperative view confirming the hemorrhagic component of the lesion (A) and documenting the floor of the fourth ventricle free of disease at the end of tumor removal (B). (C–E) Histologic examination showed monomorphic cells with regular round nucleus and dispersed chromatin; tumor cells of the perivascular area were arranged radially around the vessels, forming perivascular pseudorosettes, with prominent perivascular immunoreaction for glial fibrillary acid protein (D) and epithelial membrane antigen (E). Mitoses and necrosis were absent. Diagnosis: WHO grade II ependymoma.
Ependymoma typically affects children and rarely occurs in elderlypatients.1 It is most frequently located in the posterior fossaand presents with cerebellar compression and intracranial hypertension.On MRI it appears as a T1-hypointense, T2-hyperintense, homogeneouscontrast-enhancing mass that may fill and expand the fourthventricle; heterogeneous enhancement due to calcifications andcystic components may be seen.2 Intratumoral hemorrhage hasbeen reported and rarely causes an acute presentation.3 Hemorrhagicependymoma should be considered in the differential diagnosisof hemorrhagic posterior fossa lesions in adults.
Honda M, So G, Kaminogo M, Abe K, Nagata I. Massive intratumoral hemorrhage of ependymoma of the fourth ventricle. Childs Nerv Syst 2005;21:926–929.[Medline]
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