Two Rare Cases of Glioma in Total Spine with Metastasesto Brain

ABSTRACT

Objective: NA Background: Glioma classification evolved over the years but remains a diagnostic challenge. Primary spinal cord (PSC) glioblastoma is extremely rare and represents fewer than 1.5% of all spine tumors in adults. Presentation may mimic demyelinating or inflammatory disorders, but prognosis is significantly worse. We present two aggressive cases of extensive, total spinal cord gliomas with early metastases to brain. Design/Methods: NA Case #1 A 44-year-old woman with a diagnosis of demyelinating disorder with paraplegia, bladder and bowel incontinence presented with new appendicular ataxia. Previous MRI revealed unremarkable brain and hyperintensity in T7-10 concerning for multiple sclerosis. Empiric methylprednisolone and cyclophosphamide showed no improvement. Repeat MRI showed extensive intramedullary cystic lesions throughout cervical, thoracic, and lumbar spine, hyperintensities in the brainstem, and enhancing lesions in the corpus callosum and R frontal lobe. Biopsy revealed brain Glioblastoma, WHO grade IV, IDH wildtype. H3K27M test was not performed. Patient expired 13 months after initial symptom onset. Case #2 A 49-year-old man with a recent COVID-19 infection presented with 2 weeks of bilateral lower extremity numbness and weakness. MRI brain was unremarkable, and spine revealed intra-dural, extra-medullary nodular enhancing lesions throughout cervical and thoracic spine, and the cauda equina. Infectious, inflammatory, and rheumatologic causes were investigated until repeat imaging in 1 week (after a course of empiric methylprednisolone) demonstrated the rapid development of a non-enhancing expansile mass in the R temporal lobe. Biopsy revealed spinal Glioblastoma, WHO grade IV, IDH wildtype, negative for H3K27M mutation, and brain low grade glioma. The patient remains on palliative radiation with concurrent temozolomide and adjuvant temozolomide. Conclusions: Primary spinal cord glioblastomas are rare and devastating. Timely diagnosis remains a challenge since clinical and radiographic findings mimic demyelinating or inflammatory disorders. Our cases highlight the diagnostic challenge and importance of early suspicion in the diagnosis of malignant spinal glioma.