This Ought to Be a Spinal Reflex!

Spinal tumor is an important cause of bilateral papilledema and secondary intracranial hypertension. The proposed mechanisms include high protein content in cerebrospinal fluid(CSF) which impairs CSF absorption, mechanical obstruction to CSF drainage by the tumor or neoplastic arachnoiditis or meningeal tumoral infiltration.

Poster 133 This ought to be a spinal reflex! Shruthi Harish Bindiganavile1, Nita Bhat1, Jason Huse2, Andrew Whyte2, Andrew Lee1, Nagham Al- Zubidi2 1 Houston Methodist Hospital, Houston, Texas, USA, 2MD Anderson Cancer Center, Houston, Texas, USA Introduction: Spinal tumor is an important cause of bilateral papilledema and secondary intracranial hypertension. The proposed mechanisms include high protein content in cerebrospinal fluid(CSF) which impairs CSF absorption, mechanical obstruction to CSF drainage by the tumor or neoplastic arachnoiditis or meningeal tumoral infiltration. Description of Case(s): A 23-year-old obese female presented with headache, transient visual obscurations, pulse synchronous tinnitus, and intermittent binocular horizontal diplopia alongwith numbness in her legs and back pain over the last 2 months. On exam, vision was 20/30 OU, pupils were brisk and she was noted to have bilateral disc edema. Visual field testing revealed enlarged blind spots and superonasal field defect in both eyes. MRI of the brain and orbit with contrast and MR venogram (MRV) were normal. A lumbar puncture(LP) was schedule and there were four unsuccessful attempts. A fifth LP attempt now showed an opening pressure of 10 cm H2O, elevated CSF cell counts and protein. Patient was started empirically on Diamox. The patient then developed symptoms of cauda equina syndrome with acute onset rectal incontinence. An MRI of the lumbar spine showed a large intradural extramedullary mass with leptomeningeal spread along thoracic and cervical spinal cord. She underwent surgical resection of the tumor with L3-L5 laminectomy and tumor debulking. Biopsy revealed myxopapillary ependymoma, with immunohistochemistry positive for mucin (Periodic Acid Schiff) and S100. Conclusions, including unique features of the case(s): This young obese female presented with symptoms of raised intracranial pressure with normal MRI brain, orbits with normal MR Venogram of the brain. Multiple attempts at spinal tap were unsuccessful accounting for the false low opening pressure. Spinal fluid showed elevated protein and CSF pleocytosis. The patient then developed symptoms of cauda equina syndrome with acute onset rectal incontinence. MRI of the spinal axis revealed a myxopapillary ependymoma. Spinal tumor is an important cause of bilateral papilledema and secondary intracranial hypertension. References: Marzban AN, Saxena A, Bhattacharyya D, Ivanov M. Hydrocephalus and Papilledema in Spinal Cord Tumors: A Report of Two Cases. Surg J (N Y). 2016;2(2):e51-e58. Published 2016 Jun 29. doi:10.1055/s-0036-1584584 Keywords: Tumors, High intracranial pressure/headache, Neuroimaging, Pseudotumor cerebri, Miscellaneous Financial Disclosures: The authors had no disclosures. Grant Support: None. Contact Information: None provided. 186 | North American Neuro-Ophthalmology Society