Intracranial Ependymoma with Extracranial Metastases

John S. was first admitted to The Hospital for Sick Children on August ~5, 1965, at the age of ~ ye'~rs 5 months. His past history and development had been normal. He had been irritable for 6 months and had had intermittent unexplained vomiting for 4 months. A weakness of the right arm and leg had been noticed for 10 days. There was no history of headache or loss of vision. On examination irritability was noted and there was a right hemiparesis and hyporeflexia. The right plantar response was extensor. The right optic disc was blurred. He tended to fall to the right when sitting or walking. The blood and urine were normal. An electroencephalogram showed an active disturbance in the left parietal region consistent with an expanding lesion. Skull x-ray showed a split suture and a thinning of the skull bone in the left parietal area. A left carotid arteriogram and air-encephalogram showed a space-occupying lesion in the left parieto-occipital area. Six days after admission a second air-encephalogram was performed through a left parietal burr hole; prior to the injection of air 60 mls. of thick reddish-yellow fluid were aspirated. This fluid contained red blood cells, some polymorphonuclear cells and clusters of foamy macrophages. No malignant cells were seen. Operation. Two days later a left parieto-occipital craniotomy was performed and a soft hemorrhagic mass of tissue approximately 4.0)<3.0X~2.0 cm., with some scattered areas of grayish tumor, was removed. Microscopy showed a cellular tumor composed of columns and sheets of medium-sized round or oval cells with vesicular nuclei among which ran wide bands of a loosely cellular mesenchymal-like tissue. Mitotic figures were plentiful. There were also numerous vascular channels. In places the cells were more elongated and arranged in true rosettes and pseudo-rosettes around blood vessels (Fig. 1). It was concluded that this was an ependymoblastoma (ependymoma Grade IV). Postoperative Course. Beginning 8 weeks postoperatively the patient received 3,494 r over a course of 3 weeks. Throughout this time his temperature was up and down reaching peaks of 104~ A brain abscess was suspected. Second operation. On October ~0, 1965, a second craniotomy was performed in the left parieto-occipital area. Purulent material was aspirated which grew