Conus Medullaris Teratoma with Utilization of Fiber Tractography: Case Report

Abstract

Objective Conus medullaris teratomas are very rare tumors. Traditional preoperative diagnosis depended on the findings from magnetic resonance imaging (MRI). Tractography is a novel technique that has recently been utilized to diagnose spinal cord lesions. This case report shows that fiber tractography has great potential in preoperative diagnosis and postoperative follow-up of teratomas of the conus medullaris.

Methods A 50-year-old man with a conus medullaris teratoma underwent tractography with the aim of visualizing the tumor in relation to the white matter tracts. The patient underwent a T12–L2 laminectomy, and the lesion was resected. The histopathology diagnosis was of a mature teratoma.

Study Design Case report.

Results Diffusion tensor imaging (DTI) and tractography provide more details about the white matter tracts in relation to space-occupying lesions that may be more sensitive than conventional MRI and have recently been utilized in spinal cord lesions. Fiber tracking has the ability to visualize the integrity of the white matter tracts at the level of the conus medullaris in relation to the lesion. The tracts appeared to be displaced by the lesion at the conus medullaris. Tractography also showed no white matter tracts within the lesion. Such findings are consistent with the characteristics of a benign lesion. Exploiting tractography in this case was helpful in predicting the nature of the lesion preoperatively and in planning the surgical intervention.

Conclusions Conus medullaris teratomas mostly affect adults. Patients generally present with a long history of clinical symptoms prior to diagnosis. Surgery is required for diagnosis, and the goal should be complete tumor excision without sacrificing any neurologic functions. The use of DTI and tractography, in addition to conventional MRI, has the potential to be very valuable for the diagnosis, surgical planning, and follow-up of patients with conus medullaris teratomas.

Keywords

conus medullaris - teratoma - intramedullary tumor - diffusion-weighted images - tractography

• References

• 1 Kahilogullari G, Erdem A, Heper AO, Erden E. Intramedullary mature cystic teratoma of the conus medullaris. A case report. J Neurosurg Sci 2006; 50 (2) 55-58
• 2 Mut M, Shaffrey ME, Bourne TD, Jagannathan J, Shaffrey CI. Unusual presentation of an adult intramedullary spinal teratoma with diplomyelia. Surg Neurol 2007; 67 (2) 190-194
• 3 Ak H, Ulu MO, Sar M, Albayram S, Aydin S, Uzan M. Adult intramedullary mature teratoma of the spinal cord: review of the literature illustrated with an unusual example. Acta Neurochir (Wien) 2006; 148 (6) 663-669 ; discussion 669
• 4 Ates O, Cayli SR, Koçak A, Alkan A, Onal C, Usta U. Mature spinal teratoma associated with thickened filum terminale. Neurol Med Chir (Tokyo) 2005; 45 (7) 375-378
• 5 Bloch I, Varga Z, Benini A. Teratoma of the conus medullaris. J Clin Neurosci 1999; 6 (3) 249-252
• 6 Caruso R, Antonelli M, Cervoni L, Salvati M. Intramedullary teratoma: case report and review of the literature. Tumori 1996; 82 (6) 616-620
• 7 Caruso R, Colonnese C. Intramedullary teratomas: Two case reports and a review of the literature. Zentralbl Neurochir 2006; 67 (4) 213-218
• 8 Eide PK, Skullerud K. Teratoma of the medullary cone as a cause of peripheral polyneuropathy [in Norwegian]. Tidsskr Nor Laegeforen 1994; 114 (10) 1185-1186
• 9 Elmaci I, Dagcinar A, Ozgen S, Ekinci G, Pamir MN. Diastematomyelia and spinal teratoma in an adult. Case report. Neurosurg Focus 2001; 10 (1) ecp2
• 10 Fernández-Cornejo VJ, Martínez-Pérez M, Polo-García LA, Martínez-Lage JF, Poza M. Cystic mature teratoma of the filum terminale in an adult. Case report and review of the literature. Neurocirugia (Astur) 2004; 15 (3) 290-293
• 11 Hader WJ, Steinbok P, Poskitt K, Hendson G. Intramedullary spinal teratoma and diastematomyelia. Case report and review of the literature. Pediatr Neurosurg 1999; 30 (3) 140-145
• 12 Hejazi N, Witzmann A. Spinal intramedullary teratoma with exophytic components: report of two cases and review of the literature. Neurosurg Rev 2003; 26 (2) 113-116
• 13 Mohindra S, Chhabra R, Gupta R, Dass Radotra B. Cystic, exophytic teratoma of conus medullaris presenting with chronic renal failure. Surg Neurol 2008; 69 (1) 81-83 ; discussion 84
• 14 Natarajan M. Conus medullaris teratoma presenting as myokymia. Neurol India 1999; 47 (3) 251
• 15 Nicoletti GF, Passanisi M, Platania N, Lanzafame S, Albanese V. Intramedullary spinal cystic teratoma of the conus medullaris with caudal exophytic development: case report. Surg Neurol 1994; 41 (2) 106-111
• 16 Rosenbaum TJ, Soule EH, Onofrio BM. Teratomatous cyst of the spinal canal. Case report. J Neurosurg 1978; 49 (2) 292-297
• 17 Yu J, Qu LM, Li Y, Huang H. Coexistence of spinal teratoma of the conus medullaris and arteriovenous malformation in an adult: a case report. Turk Neurosurg 2012; 22 (4) 510-514
• 18 Ducreux D, Fillard P, Facon D , et al. Diffusion tensor magnetic resonance imaging and fiber tracking in spinal cord lesions: current and future indications. Neuroimaging Clin N Am 2007; 17 (1) 137-147
• 19 Thurnher MM, Law M. Diffusion-weighted imaging, diffusion-tensor imaging, and fiber tractography of the spinal cord. Magn Reson Imaging Clin N Am 2009; 17 (2) 225-244
• 20 Poeze M, Herpers MJ, Tjandra B, Freling G, Beuls EA. Intramedullary spinal teratoma presenting with urinary retention: case report and review of the literature. Neurosurgery 1999; 45 (2) 379-385
• 21 Monajati A, Spitzer RM, Wiley JL, Heggeness L. MR imaging of a spinal teratoma. J Comput Assist Tomogr 1986; 10 (2) 307-310
• 22 Vargas MI, Delavelle J, Jlassi H , et al. Clinical applications of diffusion tensor tractography of the spinal cord. Neuroradiology 2008; 50 (1) 25-29
• 23 Tsuchiya K, Fujikawa A, Honya K, Nitatori T, Suzuki Y. Diffusion tensor tractography of the lower spinal cord. Neuroradiology 2008; 50 (3) 221-225
• 24 Ozanne A, Krings T, Facon D , et al. MR diffusion tensor imaging and fiber tracking in spinal cord arteriovenous malformations: a preliminary study. AJNR Am J Neuroradiol 2007; 28 (7) 1271-1279