1. RARE CASE OF MYXOPAPILLARY EPENDYMOMA FROM MEDULLA

2. Learning objectives Myxopapillary ependymoma (WHO Grade I ) is a rare variant of ependymoma; this tumor was originally defined by Kernohan and it occurs almost exclusively in the conus medullaris or filum terminale. Ependymomas have a wide morphologic spectrum and MPE constitutes a distinct clinico-pathological variant. MPE that occurs primarily in the cerebral hemisphere or brainstem is extremely rare with only seven cases having been reported in the literature, and all of them have occurred in young patients

3. background A 45 years old male patient presented with several episodes of syncopal attacks with right upper limb numbness Plain CT revealed a well defined ovoid heterogeneous mildly hypodense lesion measuring ~ 3 cm filling the cisterna magna with mass effect on adjacent cerebellar hemispheres and medulla Plain and contrast enhanced MRI revealed A well circumscribed heterogeneous lesion in the cisterna magna and inferior aspect of fourth ventricle causing compression of medulla and splaying of inferior cerebellar peduncle with minimal expansion of cervico medullary junction

4. CT PLAIN

5. MRI T1 WI

6. T2WI- AXIAL

7. MRI - CONTRAST SAGGITAL /CORONAL VIEW

8. Patient had an episode of cardiac arrest and was revived and taken up for emergency decompression surgery. Midline suboccipital craniectomy was performed The lesion was seen arising from medulla and upper part of cervical cord with soft fleshy wall and a cystic area containing mucinous material Partial resection of the lesion and cyst was achieved.

9. HISTO PATHOLOGY FINDINGS Pathological Findings: Microscopically, the peculiar histologic features were papillae or reticular structures formed by cuboidal or flat cells with regular nuclei, and there was an abundant stroma showing conspicuous mucinous change. The latter was strongly positive for alcian-blue and periodic acid-Schiff stain. Multifocal hemorrhagic necrosis with fibrosis were evident.

10. HPE..CONT The tumor cells showed strong diffuse positivity for GFAP in the majority of the neoplastic cells. Focal positive reactions were also identified for S- 100 protein and vimentin. However, the tumor cells were negative for cytokeratin. The Ki-67 labeling index was very low (<1%) and the tumor cells were negative for p53 protein. histopathological and clinicoradiologic studies confirmed that the primary MPE arising in the medulla.

11. GFAP S100

12. DISCUSSION Myxopapillary ependymoma is a sub-classification of ependymoma that is thought to be nearly exclusive to the conus medullaris or filum terminale. primary intracerebral or brainstem myxopapillary ependymomas are very rare only seven cases of primary intracranial MPE have been reported other regions where MPE presented six of these tumors were locatedsupratentorial tumor group, 2 occurred in the intraventricular, 2 were intraparenchymal, 1 was transependymal, and 1 was extra-axial. the infratentorial tumor was restricted to the 4 th ventricle.

13. We present here a case of 45 years old male with Mxyo papillary ependymoma of the medulla, and we also review the relevant literature. To the best of our knowledge, this is the second documented case of the literature Conclusion: Myxopapillary ependymoma thought to be nearly exclusive to the conus medullaris or filum terminale. but one should think about MPE intraparenchymal and brainstem and imaging/ histopathology helps us to treat the patient in advance Patient now on radiotherapy and check MRI done for drop metastasis

14. References