Spontaneous Hemorrhage of a Spinal Ependymoma: A Rare Cause of Acute Cauda Equina Syndrome

In Brief Study Design. An interesting case of spontaneous bleeding from an ependymoma of the filum terminale is presented. Objectives. To document a rare case of rapid neurologic deterioration as a consequence of spinal tumoral hemorrhage and to highlight important issues regarding tumor histologic subtype and the impact of anticoagulation that have emerged from an illuminating review of the literature. Summary of Background Data. To our knowledge, there have been only 8 reported cases of hemorrhage from an ependymoma of the filum terminale or conus medullaris causing acute cauda equina syndrome. Bleeding is described in the pathology texts as being a consequence of the vascular architecture of the myxopapillary subtype and so postulated to be more common in this group. Anticoagulation is recognized to increase the frequency of tumoral bleeding, but no studies report its effect of severity of clinical presentation. Methods. We report the case of a 57-year-old woman who developed nontraumatic acute cauda equina syndrome, including sphincter compromise. She underwent a lumbosacral laminectomy for evacuation of a hematoma, at which stage a filum terminale ependymoma was excised. Histopathologic analysis demonstrated it to be of a nonmyxopapillary subtype. Results. The patient demonstrated gradual improvement of the neurologic deficit. At 12-month follow-up, her saddle area sensory deficit has resolved, her right lower limb is much stronger allowing her to walk long distances, and she is successfully performing intermittent self-catheterization of her bladder. Conclusions. The possibility of an underlying tumor should always be borne in mind so that adequate preoperative planning can be undertaken. The presence of the myxopapillary subtype should not prevent a clinician from excluding other reasons for hemorrhage, and counseling when reinstituting anticoagulation must include warning against a worse prognosis from any future hemorrhage. Rapid neurologic deterioration as a consequence of spinal tumoral hemorrhage is rare. The authors describe the ninth reported case of a patient presenting with acute cauda equina syndrome caused by spontaneous bleeding from an ependymoma of the filum terminale. This patient was receiving warfarin. The significance of ependymomal histologic subtype and anticoagulation in relation to the clinical presentation, risk, and severity of tumoral hemorrhage is discussed.