Myxopapillary ependymoma with hemorrhage
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Intradural and extramedullary enhancing lesion at L3/4 causes severe narrowing of the vertebral canal, and compression of the nerve roots of the cauda equina. Associated subdural hemorrhage up to L1.
Changes at the more inferior aspect of the thecal sac are suspicious for drop metastases, although a prior tumoral subarachnoid hemorrhage with resultant arachnoiditis could result in a similar appearance.
The bladder is markedly distended suggesting a neurogenic bladder.
Appearance is highly suggestive of a myxopapillary ependymoma with hemorrhage.
The patient went on to have a resection.
Sections show a tumor with a pseudopapillary and microcystic architecture with a prominent myxoid background. Occasional perivascular pseudorosettes are present. The tumor cells are plump with oval nuclei. Areas of hemorrhage and necrosis are present, however, mitoses are very rare (fewer than one mitosis per ten high power fields). There is no atypia or microvascular proliferation. By immunohistochemistry, tumor cells are positive for GFAP.
FINAL DIAGNOSIS: myxopapillary ependymoma, WHO grade I.
Although uncommon, hemorrhage is a recognized presentation of these tumors.