Case Report

ERA’S JOURNAL OF MEDICAL RESEARCH

VOL.5 NO.1

INTRACYSTIC BLOOD MIMICKING RECURRENT EPIDERMOID OF

CONUSMEDULLARIS: A CASE REPORT

Mohd Iqbal, Sumaiya Irfan*, Hukum Singh

Departments of Neurosurgery , Departments of Pathology*

Jawaharlal Institute of Postgraduate Medical Education and Research

Era's Lucknow Medical College & Hospital, Sarfarazganj, Lucknow, U.P., India-226003.*

 

Received on : 27-03-2018

ABSTARCT

Accpected on : 21-05-2018

Spinal epidermoid are rare lesion of spine. We report a case of 12 year

Address for correspondence

 

old female who presented with difficulty in walking and weakness in left

Dr. Sumaiya Irfan

lower limb. MRI spine showed epidermoid at level of L1-L2.

Department of Pathology

Laminectomy and surgical excision of the cystic lesion was planned

Era’s Lucknow Medical College &

.Intra operativelya pearly white tumor adherent to cord was found and

Hospital, Lucknow-226003

excised. Histopathological examination confirmed the diagnosis of

Email: sumaiyairfan09@gmail.com

epidermoid cyst. One year after surgery she again came with complaint

Contact No: +91-9005417006

of pain at the site of surgery following which MRI was done which

 

 

showed recurrence of epidermoid, intra operatively it was found that it

 

 

 

 

was a cystic cavity filled with hemolyzed blood mimicking as recurrent

 

 

epidermoid radiologically.

 

 

 

 

 

Keywords: Spinal Epidermoid, MRI, Laminectomy.

 

INTRODUCTION

 

 

 

 

 

white, non vascular and non suckable, capsulated

Spinal

epidermoidare

cystic

lesions

lined

by

adherent to cord and one of the nerve root. A small part

which was adherent to nerve root was left behind.

squamous epithelium they account for less than1%of

Histopathological examination was consistent with the

spinal

lesion.

They

were first

described

as

tumeursperlées

(pearly

tumors)

by

Cruveilhier

in

diagnosis of epidermoid cyst and showed cyst wall

lined by stratified squamous epithelium and abundant

1835.Epidemoid can be congenital or acquired. They

keratinous material (figure 1).

can be extradural, intradural or extramedullary, or

intramedullary in the spine. Spinal epidermoids

 

present with non-specific symptoms ,MRI is helpful in

 

arriving at diagnosis. Reoccurrence of epidermoid

 

cyst are rare but are not uncommon after incomplete

 

surgical excision of capsule.

 

 

 

 

 

CASE REPORT

 

 

 

 

 

 

We report a case of 12 year old female who presented to

 

our hospital with history of trauma to back 3 years back

 

and complaints of difficulty in walking and pain in back

 

since 2 year along with weakness of left lower limb with

 

foot drop since 1 year. Neurological examination

 

revealed 4/5 power in left lower limb ,power at ankle

 

2/5 with foot drop. Upper limb had normal power. Rest

 

of the neurological examination was within normal

 

limits. MRI spine was ordered which showed T1,

Fig :1 H & E,10X view Epidermal inclusion cyst

T2hyperintense lesion at level of L1& L2 -

likely of

(cyst wall lined by stratified squamous epithelium

epidermoid cyst was made. She underwent L1-L2

& abundant keratin)

laminectomy along with surgical decompression of the

The patient was discharged after uneventful hospital

sac. Intra operatively tumour was present just below the

dura along with lipomatous tissue which was pearly

stay. The patient came to neurosurgery OPD after 1

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INTRACYSTIC BLOOD MIMICKING RECURRENT EPIDERMOID OF CONUSMEDULLARIS: A CASE REPORT

year with the complaints of pain over the same site of surgery since 1 month. Again MRI was done with radiological appearance (figure:2)

Fig 2: MRI: T1,T2 hyperintense lesion at L1& L2

Showing recurrence of epidermoid. Re exploration of the earlier postoperative site with excision of recurrent epidermoid was planned . Intra operatively it was found that cystic cavity filled with hemolyzed (motor oil like fluid) was present, it was conclude that intracystic blood was mimicking as recurrent epidermoid.

DISCUSSION

Congenital epidermoid occur as a result of inclusion of ectodermal tissue within the neural canal at the time of neural tube closure at fourth to fifth week of intrauterine life .Congenital epidermoids are usually associated with spinal dysraphisms such as syringomyelia, dermal sinus and spina bifida. Acquired epidermoid cysts are mostly iatrogenic occur as a result of implantation of ectodermal cells in spinal cord during surgery or spinal procedures like lumbar puncture or during trauma to spine.Very few cases of post traumatic epidermoid cyst have been reported in literature. , Shengreported a case of spinal epidermoid following burst fracture of lumbar vertebra.

The symptomatology in case of spinal epidermoid is non -specific and confusing .Patients generally present

with non-specific features of numbness, weakness, spasticity, paraparesis of lower extremities and defecation disorders pose challenges in pre-operative diagnosis. Differential diagnosis in such cases include ependymomas, metastasis, astrocytomas and dermoid cysts. MRI is useful in differentiating epidermoid from ependymoma, astrocytoma and metastasis. A histopathological examination is necessary to confirm the diagnosis of dermoid cyst.

Intra operatively epidermoid can be ruled out by its gross appearance. Epidermoid cysts are grossly pearly white cysts filled with characteristics keratinous content. Total surgical excision is treatment of choice for epidermoid cyst but sometimes it is difficult to remove cyst in Toto due to adhesion of capsule to spinal cord and nerve roots. In such cases a sub total excision of cyst is done. Recurrence of spinal epidermoid is not uncommon after incomplete resection .Fleming reported a case in which he described recurrence of epidermoid cyst seven times at the same location ,cases with symptomatic reoccurrence should be retreated with surgery but surgery is often difficult due to formation of scar tissue. Delayed postoperative haemorrhage is seen as a complication of spinal epidermoid .Multiple relapse of epidermoid cyst have been satisfactorily treated in a case with radiotherapy. Recurrent cases can be managed by radiotherapy but is not used routinely in recurrent cyst cases, this modality of treatment is reserved for cases who refuse surgery or are inoperable due to medical reasons.

CONCLUSION

Spinal epidermoid are rare, recurrence is rare but can occur before considering it as a case of reoccurrence complications associated postoperatively with epidermoid must be evaluated. As in our case it was delayed postoperative haemorrhage. MRI is helpful in arriving at the diagnosis .Surgical removal of cyst is treatment of choice.

REFERENCES

1.Amato VG, Assietti R, Arienta C: Intramedullary

epidermoid cyst: preoperative diagnosis and surgical management after MRI introduction. Case report and updating of the literature. J Neurosurg Sci. 2002, 46: 122-126.

2.Cruveilhier J: Anatomie Pathologique. 1835,

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4.Pear BL: Iatrogenic intraspinal epidermoid

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5.Green AJ, Roberts DR, Swanson RA: Post- traumatic epidermoid cyst presenting with headache. Neurology 2005 ,64(9):1657.

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How to cite this article : Iqbal M., Irfan S., Singh H., Lal N., Intracystic Blood Mimicking Recurrent Epidermoid Of Conusmedullaris: A

Case Report. EJMR2018;5(2):1-3

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