|Year : 2014 | Volume
| Issue : 1 | Page : 46-48
Low-grade dorsal spinal cord astrocytoma presented with paraplegia following minor trauma
Bander F Al-Dhafery, Abdullah S Al-Mulhim, Hossain A. A. Alola
Department of Radiology, King Fahd Hospital of the University, University of Dammam, Dammam, Saudi Arabia
|Date of Web Publication||7-Mar-2014|
Bander F Al-Dhafery
Department of Radiology, Vascular Interventional Radiologist, King Fahd Hospital of the University, University of Dammam, P.O. Box 40053, Al-Khobar 31952
Although they constitute about one third of spinal cord glial neoplasms, low-grade astrocytomas can present variably. Post-traumatic neurologic dysfunction due to low-grade spinal cord gliomas is an uncommon event. The authors report a case of paraplegia following minor traumatic event in an 18-month-old boy where subsequent imaging was directed to exclude intracranial hemorrhage. Upon further investigations which included spine-computed tomography and magnetic resonance imaging, a hemorrhagic intraspinal neoplasm was discovered and confirmed to be a low-grade astrocytoma. This case illustrates an instance of significant neurological deficit caused by intratumeral hemorrhage and swelling.
ملخص البحث :
تعنى هذه الحالة لطفل ادخل المستشفى أثر حادث بسيط وكان يعاني من شلل نصفي سفلي، ناتجاً عن ورم في الحبل الشوكي الظهري (أستروسايتوما). تشكل هذه الأورام ثلث أورام الحبل الشوكي ولكنها تختلف في كيفية ظهورها. ويعتبر الخلل العصبي الناتج عن حادث بسبب الأورام في الحبل الشوكي (أستروسايتوما) غير مألوف. توضح هذه الحالة مثالا هاما عن شلل نصفي ناتجا عن نزيف داخل الورم.
Keywords: Astrocytoma, magnetic resonance imaging, paraplegia
|How to cite this article:|
Al-Dhafery BF, Al-Mulhim AS, Alola HA. Low-grade dorsal spinal cord astrocytoma presented with paraplegia following minor trauma. Saudi J Med Med Sci 2014;2:46-8
|How to cite this URL:|
Al-Dhafery BF, Al-Mulhim AS, Alola HA. Low-grade dorsal spinal cord astrocytoma presented with paraplegia following minor trauma. Saudi J Med Med Sci [serial online] 2014 [cited 2019 Feb 23];2:46-8. Available from: http://www.sjmms.net/text.asp?2014/2/1/46/128453
| Introduction|| |
Although they are second in prevalence to ependymomas in adults, spinal cord astrocytomas are the most common intramedullary tumor in children and pain is the most common presenting symptom followed by motor-sensory dysfunction. Delay in the diagnosis in this case is thought to result from absent objective signs of neurological dysfunction. 
| Case Report|| |
An 18-month-old boy presented to our emergency service with acute onset of paraplegia following a minor traumatic event (falling from a Crip) and initial investigation was directed toward traumatic etiology where brain-computed tomography scan was essentially normal. A cervical and dorsal computed tomography scan was performed (SIEMENS SYMPHONY AS. multi-detector scanner) and images were obtained in three orthogonal scans with a slice thickness of 2 mm and bone algorithm was used. The scan showed mild expansion of the spinal canal with effacement of spinal canal epidural fat at D11 and D12 levels with no associated fractures or mal alignment [Figure 1].
|Figure 1: Axial non-enhanced CT scan with bone algorithm of the dorsal spine at the level of D11-D12 demonstrating mild effacement of the epidural fat and mild spinal canal expansion|
Click here to view
MRI of the thoracolumbar spine was obtained in sagittal T1 (TE14/TR406/SLICETHICKNESS 3MM), sagittal T2 (TE115/TR4000/ST3MM), axial T1WI (TE14/TR478/ST6MM), axial T2WI (TE147/TR4780/ST6MM), sagittal T1WI with fat suppression and intravenous contrast (TE10/TR511/ST3MM), axial TIWI with fat suppression and intravenous contrast (TE11/TR562/ST6MM) and sagittal gradient echo (TE18/TR600). The contrast used was Gadolinium based (MAGNEVIST. Dimeglumine gadopentetate, 469 mg, From Schering Pharma AG).
The images were evaluated by three consultant radiologists (using SEIMENCE SYNGO. PLAZA-viewer and EIZO 5 megapixel color LCD monitor). The MRI showed a long segment thoracic spinal cord intra medullary mass lesion that involved D11 and D12 segments consecutively and measured 5.6 × 1.16 × 1.56 cm in cranio-caudal, antero-posterior, and transverse dimensions respectively. It showed low signal intensity in T1WI and increased heterogeneous signal intensity in T2WI with associated syrinx that reaches the D1 level [Figure 2]. Gradient echo images showed a blooming artifact and postcontrast administration showed a faint enhancement pattern with associated hemorrhagic components indicating hematomyelia. A cerebrospinal fluid analysis revealed xanthochromia, increased protein level, and red blood cell count. The patient underwent dorsal laminoplasty and resection of the intramedullary tumor. Pathological correlation revealed low-grade glial neoplasm formed of dense meshwork of fibrillary background and focal breakdown foci. Immunohistochemical studies were also performed and a diagnosis of low-grade astrocytoma was made. The patient was vitally stable but in flaccid paralysis till the discharge date and he was under antibiotic coverage along with steroids. Physiotherapy follow-up in an outpatient basis was arranged.
A consent was obtained from the patient and permission from the ethical committee was obtained. This work was not supported by any funding agency and the authors have nothing to disclose.
|Figure 2: (a) Sagittal T1WI(TE14/TR406), (b) sagittal T2WI(TE115/TR4000), (c) axial T1WI(TE14/TR478), (d) axial T2WI(TE147/TR4780), (e) sagittal T1WI with fat suppression and intravenous contrast(TE10/TR511), (f) axial T1WI with fat suppression and intravenous contrast (TE11/TR562), and (g) sagittal gradient echo (TE18/TR600). They showed an intramedullary space occupying lesion that involves D11 and D12 segments consecutively and showed low-signal intensity in T1WI and increased heterogeneous signal intensity in T2WI with associated syrinx that reaches the D1 level. Post-contrast administration showed a faint enhancement pattern with associated hemorrhagic components that showed a blooming artifact indicating hematomyelia|
Click here to view
| Discussion|| |
Of all central nervous system (CNS) tumors, about 2-4% of CNS glial tumors are spinal intramedullary neoplasms. Spinal cord neoplasms constitute 35% of all intraspinal tumors in children. Ependymomas are the most common glial tumor in adults, whereas astrocytomas are the most common intramedullary tumors in children. Nonglial neoplasms, including hemangioblastomas, paragangliomas, metastases, lymphoma, and primitive neuroectodermal tumors (PNETs), are much less common. 
Spinal cord astrocytomas are most commonly located in the thoracic region, followed by the cervical cord, and rarely present as an isolated or focal lesion in the conus and based on the World Health Organization (WHO) scale, spinal cord astrocytomas are graded as low grade (WHO grade 1) to anaplastic or high grade (WHO grade 4). 
Spinal cord lesions often present with variable symptoms which might be sudden or slowly progressive. Delayed diagnosis is usually attributed to vague symptomatology. Back pain is the presenting symptom and might occur in an episodic manner over time. 
Typical magnetic resonance imaging findings are of fusiform expansion of the spinal cord, more common in the cervical followed by thoracic and lumbar spine. Nearly half of these tumors may have cysts or syringe hydromyelia. Mild-to-moderate enhancement is a known imaging feature for most of those lesions. Plain radiography is of limited diagnostic value. On occasion, widening of the spinal canal, widening of the interpedicular distance, and scalloping of the dorsal aspects of the vertebral bodies can be appreciated on plain radiographs as a late imaging finding. Typical and atypical scoliotic curvatures can be seen in patients with spinal cord tumors. Computed-tomography (CT) scanning is of limited value in the assessment of spinal cord tumors. CT scans may depict bony changes of the spine, which may occur as late secondary findings in patients with spinal cord tumors; such changes include pedicular erosion, widening of the spinal canal, and dorsal scalloping of the vertebral bodies. CT myelography is indicated in the workup of spinal cord tumors only if MRI is contraindicated. The spinal cord is typically enlarged at the level of tumor. This feature helps in differentiating spinal cord tumors from non-neoplastic diseases that may mimic a spinal cord neoplasm, such as inflammatory or demyelinating processes. ,
Paraplegia and tetraplegia with urinary and bowel disturbance were reported previously in a case of cervical intramedullary astrocytoma with hematomyelia in the adult age group. ,
The maximum of safe tumor resection should be the primary treatment objective for both low- and high-grade astrocytomas whether or not concomitant radio- and chemotherapy were implemented. Addressing the factors that influence prognosis may help in treatment planning with the goal of prolonging survival. 
The aimed message from this case report is to keep clinicians aware of possible unusual presentations of spinal cord astrocytoma and to have a low threshold to perform further advanced imaging in cases of discordant medical history and clinical examination.
| References|| |
|1.||Koeller KK, Rosenblum RS, Morrison AL. Neoplasms of the spinal cord and filum terminale: Radiologic-pathologic correlation. Radiographics 2000;20:1721-49. |
|2.||Chelcun JL, Pope RS. Spinal cord astrocytomas: Rare but life-threatening tumors in children. JAAPA 2009;22:37-41. |
|3.||Huisman TA. Pediatric tumors of the spine. Cancer Imaging 2009;9:S45-8. |
|4.||Smith AB, Soderlund KA, Rushing EJ, Smirniotopolous JG. Radiologic-pathologic correlation of pediatric and adolescent spinal neoplasms: Part 1, Intramedullary spinalneoplasms. AJR Am J Roentgenol 2012;198:34-43. |
|5.||Seo HS, Kim JH, Lee DH, Lee YH, Suh SI, Kim SY, et al. Nonenhancing intramedullary astrocytomas and other MR imaging features: A retrospective study and systematic review. AJNR Am J Neuroradiol 2010;31:498-503. |
|6.||Kawakami K, Kasai H, Yamada A, Numa Y, Sakai N, Kawamoto K. A case of spinal astrocytoma presenting spinal transverse sign due to hematomyelia. No Shinkei Geka 1995;23:327-31. |
|7.||Alberdi J, Eiras J, Gomez J, Carcavilla L, Cantero J, Gimenez J. Sudden tetraplegia caused by hemorrhage in a central-medullary astrocytoma. Neurochirurgie 1987;33:62-5. |
|8.||Benes V 3 rd , Barsa P, Benes V Jr, Suchomel P. Prognostic factors in intramedullary astrocytomas: A literature review. Eur Spine J 2009;18:1397-422. |
[Figure 1], [Figure 2]