Hemorrhagic Spinal Ependymoma: A Rare Case Presentation

Abstract

Introduction: Spinal ependymomas are the most common intramedullary spinal cord tumors in adults and the second most common in children, following astrocytomas (1,2). They most frequently occur in the cervical region, followed by the lumbar region, and are rare in the thoracic spine (3). Typical clinical manifestations include sensory deficits, motor weakness, and sphincter or sexual dysfunction (4). Hemorrhagic presentation is exceedingly rare and often associated with acute neurological deterioration due to intratumoral or subarachnoid bleeding (5,6). In severe cases, cranial extension of hematoma through the spinal canal may result in quadriplegia or respiratory compromise (7). Case Presentation: We report a case of a 16-year-old female, previously healthy, who presented with lower back pain and bilateral lower limb paresthesia lasting six days. She developed rapidly progressive ascending weakness, leading to inability to ambulate by day three and quadriplegia with complete loss of sensory and sphincter function by day five. Respiratory distress ensued, requiring intubation and ventilatory support. MRI of the spine demonstrated an intramedullary thoracic mass at T2 with T1 isointense and T2 mildly hyperintense signals, and heterogeneous post-contrast enhancement.  There was associated intratumoral hemorrhage extending cranially from T2 to C2 cervical cord with central canal expansion expansion. The patient underwent emergency T1–T3 laminectomy. Upon dural opening, a tense spinal cord was noted. Midline myelotomy revealed a small intramedullary mass and extensive heamtoma , which was gently evacuated, followed by complete excision of a small midline intramedullary tumor. The cord relaxed post-evacuation, and watertight duroplasty was performed. Postoperatively, patchy sensory improvement was observed by day two. Motor recovery remained limited. The patient was discharged after three weeks for home-based rehabilitation and physiotherapy. Discussion: Spinal ependymomas account for 60–70% of adult intramedullary tumors and are generally slow-growing (1,2). However, acute hemorrhagic presentation is rare, representing less than 1% of all spinal ependymoma cases (5,8). Hemorrhage may occur spontaneously or be precipitated by minor trauma or tumor vascularity (9).Emergency decompression and hematoma evacuation can prevent irreversible cord injury, although neurological recovery often depends on the extent of preoperative deficits (10,11). Histopathological confirmation and postoperative MRI surveillance are essential for long-term management. Adjuvant radiotherapy is recommended in cases of subtotal resection or recurrence (12). Conclusion: Hemorrhagic spinal ependymoma is a rare but life-threatening presentation requiring urgent diagnosis and decompressive surgery. Rapid recognition and multidisciplinary management are critical to optimize neurological outcomes and prevent permanent disability.