CASE 1242 Published on 17.01.2002

Supratentorial ependymoma

Section

Neuroradiology

Case Type

Clinical Cases

Authors

O. Kilickesmez , A. Y. Barut , M. H. Kucukislamoglu

Patient

17 years, male

Categories

No Area of Interest ; Imaging Technique MR

No Procedure ; No Special Focus ;

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Clinical History

The boy was presented with moderate left-sided motor weakness and progressive headache occurring over the last few months. The neurological examination on presentation showed mild ataxia. Routine blood examinations were unremarkable.

Imaging Findings

The boy was presented with moderate left sided weakness and progressive headache which was apparent for the last few months. The present neurological examination showed mild ataxia. Routine blood examinations were unremarkable. MRI study of the cranium was performed on a 1.5 T MR scanner, with SE T1, FSE PD-T2, post gadolinium SE T1 weighted sequences in three planes. MRI study revealed a heterogeneous mass centered in the right thalamus, exerting mass effect on the displaced and compressed third ventricle. Lateral ventricles are enlarged and there is evidence of transependymal flow of CSF, clearly seen on T2 WI as periventricular hyperintensities. On T2 WI hyperintensities seen in the mass are probable necrotic portions of the mass. Minimal edema in adjacent brain parenchyma is seen. The tumor was completely removed surgically. Histopathological examination confirmed the diagnosis of ependymoma .

Discussion

Ependymomas are the third most common brain tumour in the paediatric population. Over 90% of these cases are intracranial, while in adults most ependymomas occur in the spinal cord. Approximately 60% of ependymomas are infratentorial and 40% are supratentorial. 70% of supratentorial ependymomas are extraventricular in location, but they often arise close to the ventricular surface and extend into the ventricle. In children, most intracranial ependymomas are infratentorial, where their relationship to the floor of the fourth ventricle often makes complete resection difficult. Supratentorial ependymomas are thought to arise from periventricular ependymal cell rests.

These tumours are heterogeneous masses lying close to a ventricular surface. They enhance intensely in a moderate inhomogeneous pattern. On MRI these tumours demonstrate variable signal intensity on both T1 and T2 WI secondary to necrosis, haemorrhage and calcification. For optimal treatment total resection is extremely important, if possible. After incomplete resections postoperative radiation therapy is necessary. Radiation therapy has probable benefit for long-term survival. Chemotherapy has shown little benefit unless in helping to make the tumour more resectable in second-look surgery.

Differential Diagnosis List

Supratentorial extraventricular ependymoma

Final Diagnosis

Supratentorial extraventricular ependymoma

References

[1] Vinchon M, Soto-Ares G, Riffaud L, Ruchoux MM, Dhellemmes P. Supratentorial ependymoma in children. Pediatr Neurosurg. 2001 Feb;34(2):77-87. (PMID: 11287807)

[2] Palma L, Celli P, Mariottini A, Zalaffi A, Schettini G. The importance of surgery in supratentorial ependymomas. Long-term survival in a series of 23 cases. Childs Nerv Syst. 2000 Mar;16(3):170-5. (PMID: 10804053)

[3] Centeno RS, Lee AA, Winter J, Barba D. Supratentorial ependymomas. Neuroimaging and clinicopathological correlation. J Neurosurg. 1986 Feb;64(2):209-15. (PMID: 3944630)

[4] Schwartz TH, Kim S, Glick RS, Bagiella E, Balmaceda C, Fetell MR, Stein BM, Sisti MB, Bruce JN. Supratentorial ependymomas in adult patients. Neurosurgery. 1999 Apr;44(4):721-31. (PMID: 10201296)

[5] Furie DM, Provenzale JM. Supratentorial ependymomas and subependymomas: CT and MR appearance. J Comput Assist Tomogr. 1995 Jul-Aug;19(4):518-26. (PMID: 7622676)

Case information

URL:	https://eurorad.org/case/1242
DOI:	10.1594/EURORAD/CASE.1242
ISSN:	1563-4086

Figure 1

MR images

Axial T1 WI reveals a heterogeneous hypointense mass centred in the right thalamus, exerting mass effect on the displaced and compressed third ventricle. Lateral ventricles are enlarged.

Axial post-contrast T1 WI demonstrates heterogeneous strong enhancement of the mass.

Axial T2 WI reveals a heterogeneous mass centred in the right thalamus, exerting mass effect on the displaced and compressed third ventricle. Lateral ventricles are enlarged and there is evidence of transependymal flow of CSF, clearly seen on T2 WI as periventricular hyperintensities. Hyperintense focuses seen in the mass are probably the necrotic parts of the mass. Minimal oedema in adjacent brain parenchyma is seen.

Axial PD WI reveals a heterogeneous hyperintense mass centred in the right thalamus.

Figure 2

MR images

Sagittal post-contrast T1 WI demonstrates heterogeneous strong enhancement of the mass.

Coronal post-contrast T1 WI demonstrates heterogeneous strong enhancement of the mass.

Coronal T2 WI reveals a heterogeneous mass centred in the right thalamus, exerting mass effect on the displaced and compressed third ventricle. The necrotic focus is clearly seen.