PMC5422745_01
Presurgical MRI images at the diagnosis of a left temporal lobe GBM, 13 months before the presentation of spinal metastases (a). Immediately after tumor removal, MRI scans show a minimal residual contrast-enhancing lesion on the left temporal lobe (b). Brain MRI performed 13 months later, at the moment of diagnosis of spinal intramedullary metastasis, showing no evidence of intracranial recurrence (c).
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F1
The patient had been diagnosed 13 months before with a temporal lobe GBM (Fig. 1a). She had undergone surgical gross total tumor resection and postoperative MRI scans had revealed a very small residual contrast-enhancing abnormality (Fig. 1b). Brain MRI at the time of consultation due to paraparesis showed no evidence of a local intracranial recurrence (Fig. 1c).
Spinal MRI images obtained at the moment of presentation of progressive paraparesis 13 months after intracranial tumor removal followed by adjuvant therapy. T1 contrast-weighted images (a) and T2 sequences (b) reveal a large intraspinal tumor at the level of Th8/9, corresponding to intramedullary metastasis of temporal lobe GBM.
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F2
However, MRI of the spine demonstrated a homogeneous contrast-enhancing mass within the spinal canal at the Th8/9 level causing significant spinal cord compression (Fig. 2).
Surgical approach to the spinal tumor through a laminectomy performed at the Th8/9 level. Spinal canal exposure revealed no macroscopic infiltration of the dura mater (a). After durotomy, an infiltrating, highly vascularized intradural intramedullary tumor lacking recognizable edges in regard to the normal tissue was observed (b, c). A biopsy was carefully performed and further histological examination confirmed the diagnosis of GBM metastasis (c). Duroplasty using a graft interposition was performed with the aim of widening the spinal canal and ameliorate the local compressive effect induced by the tumor (d).
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F3
After opening the dural sack, an intradural intramedullary high vascularized infiltrating tumor was identified (Fig. 3a, b). Due to its adherent and infiltrating pattern with no recognizable edges to the normal tissue, it was unreasonable to attempt a radical tumor excision so we carefully performed a biopsy and interposed a dural graft to expand the spinal canal, therefore reducing the pressure against the spinal cord (Fig. 3c, d).