Brain Tumor Res Treat.  2019 Oct;7(2):141-146. 10.14791/btrt.2019.7.e32.

Found at Old Age and Continuously Growing WHO Grade II Fourth Ventricle Ependymoma: A Case Report

• Park M
• Hong EK
• Lee SH
• Gwak HS

• KMID: 2461188
• DOI: http://doi.org/10.14791/btrt.2019.7.e32

Abstract

A 74-year-old woman presented with a month-long nausea and vomiting, then she could not take a meal. She had found an asymptomatic 4th ventricular mass 6 year ago as a preoperative work-up for ovarian cancer. And during the yearly follow-up, the mass had grown continuously over 6 years, and caused symptoms in the seventh year. MRI revealed a large ovoid extra-axial mass in the fourth ventricle compressing adjacent medulla and cerebellum. Surgery achieved near total resection since the tumor tightly adhered to the brain stem of 4th ventricle floor. The histological diagnosis was ependymoma (WHO grade II). She transferred rehabilitation facility for mild gait disturbance, hoarseness and swallowing difficulty. Fourth ventricle ependymoma in the elderly is extremely rare and the growth rate has not been reported. Here, we present a rare care of 4th ventricle ependymoma found asymptomatic at elderly but continuously grow to cause local pressure symptoms.

Keyword

Ependymoma; Grade II; Fourth ventricle; Elderly

MeSH Terms

Aged
Brain Stem
Cerebellum
Deglutition
Diagnosis
Ependymoma*
Female
Follow-Up Studies
Fourth Ventricle*
Gait
Hoarseness
Humans
Magnetic Resonance Imaging
Meals
Nausea
Ovarian Neoplasms
Rehabilitation
Vomiting

Figure

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  Fig. 1 Initial MRI at the time of diagnosis and retrospectively traced mass at 6 years ago MRI. A: Brain MRI revealed slightly high signal on T2-axial well-delinated ovoid mass in the 4th ventricle floor. B: The mass (arrow) was retrospectively found on MRI taken after aneurysmal clipping and ventriculo-peritoneal shunt 6 years ago. C: T1-sagittal MRI revealed, iso-signal intensity, and D: fuzzy enhancing mass after gadolinium enhancement.

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  Fig. 2 Serial yearly follow up MRIs from 2013 to 2017 (A–F) reveal continuous growing 4th ventricle tumor on T2 (left of each) and T1 gadolinium enhanced image (right of each). The largest tumor diameter increased from 9 mm to 30 mm in 6 years but she remained asymptomatic up to 6th year.

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  Fig. 3 Comparison of mass size on T1 gadolinium enhanced MR images between (A) the last year of patient being asymptomatic and (B) the 7th year of patient developing intolerable nausea and vomiting at the age of 74 years-old.

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  Fig. 4 Midline suboccipital craniotomy were used for resection of 4th ventricle tumor (A). The tumor was exposed between cerebellar tonsils. It was fragile and colored grey to purple (B). Using telovelar approach, we could easily dissect tumor from the cerebellum and the roof of 4th ventricle. We leaved small seam of tumor (arrows) adhered to dorsal lip of 4th ventricle, and near total resection of the tumor was achieved.

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  Fig. 5 Pathologic feature of ependymoma. A: This celluilar tumor is composed of small round cells. The tumor cells are arranged around blood vessels with intervening anucleate zones, forming perivascular pseudorosettes.(H-E, ×100). B: In close up view, tumor cell processes converge on the blood vessels creating fibrillar zone of pseudorosettes (H-E, ×200). C: True ependymal rosettes having luminal spaces are also noted (H-E, ×100). D: Dot-like perinuclear immunopositivity on EMA stain is characteristic. It indicates intracellular lumen of ependymal tumor cells (EMA, ×100). H-E, hematoxylin and eosin; EMA, epithelial membrane antigen.

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  Fig. 6 Postoperative MRI revealed total excision of enhancing mass with linear enhancement of surgical tract (A). The region demonstrates abnormally diffusion restricted and low apparent diffusion coefficient values explain transient postoperative neurological deficit of the patient (B).

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