Case contributed by Dr Bruno Di Muzio


Headache. CT brain showing hydrocephalus.

Patient Data

Age: 50 years
Gender: Male

MRI Brain

There is a solid frond-like mass occupying and expanding the inferior aspect of the fourth ventricle, with the tumor extending through the right foramen of Luschka and inferiorly through the foramen of Magendie and causing mild hydrocephalus. The caudal extent of the tumor reaches the level of C1-C2. This tumor has low T1 signal and increased T2/FLAIR signal, with heterogeneous though not intense contrast enhancement, and multiple small susceptibility foci consistent with microhemorrhages. It does not cause restricted diffusion compared to the brain parenchyma. There is a mass effect with anterior displacement of the medulla oblongata on the right. Associated cerebellar descent below the foramen magnum. The remainder of the brain appears normal, there is no transependymal edema surrounding the hydrocephalus. No evidence of leptomeningeal/CSF seeding within the brain or imaged upper cervical spine.


Sections showing moderately cellular tumor with a fibrillary background forming prominent perivascular pseudorosettes and focal ependymal canals.

Case Discussion

Imaging characteristics are most consistent with an ependymoma, although the location of the tumor is less typical in this age group. A choroid plexus papilloma is felt less likely given the not so vivid enhancement. 


MICROSCOPIC DESCRIPTION: 1-2. Sections show a moderately cellular tumor with a fibrillary background forming prominent perivascular pseudorosettes and focal ependymal canals. No true ependymal rosettes are seen. Tumor cells demonstrate mildly enlarged elongated nuclei and small nucleoli. No mitoses, necrosis or microvascular proliferation are seen. Immunohistochemically tumor cells stain:

  • GFAP+
  • ATRX+
  • IDH1-
  • p53-
  • EMA-.
  • Ki67 proliferation index is approximately 5%.

DIAGNOSIS: 1-2. Brain, 4th ventricle lesion: Ependymoma (WHO Grade II)

Slide images courtesy of the RMH Pathology Department. 

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Case information

rID: 55003
Published: 20th Aug 2017
Last edited: 14th Aug 2019
Tag: rmh
Inclusion in quiz mode: Included

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