Spinal subarachnoid hemorrhage associated with neurofibroma of the cauda equina. Case report

Hydrocephalus and spinal cord tumors: a review

INTRODUCTION

Hydrocephalus secondary to intraspinal tumors is a well-known but rare condition since about 1% of patients with spinal cord tumors have various degrees of hydrocephalus at initial presentation.

DISCUSSION

The mechanism of development of intracranial hypertension and hydrocephalus in patients with spinal cord tumor is not exactly known. The problematic aspects of this condition, with regard to clinical presentation and pathophysiology, are discussed and the relevant literature is reviewed. This uncommon association should always be kept in mind in the differential diagnosis of hydrocephalus of unknown etiology for three main reasons: the possibility of neurological deterioration if the patient is shunted prior tumor removal, the possibility to treat the hydrocephalus without shunting by simply removing the tumor, and the possible role of hydrocephalus as an early sign of intracranial metastasis in patients previously operated upon for removal of intramedullary gliomas. Due to the very slow evolution of the disease, a careful and close clinical and neuroradiological follow-up are essential for many years afterward. The presence of intracranial hypertension in a patient previously operated for a spinal tumor should be considered and investigated as an early sign of neoplastic intracranial seeding.

Spinal cord changes after the evacuation of a spinal subdural haematoma

Spinal subdural haematoma is a rare entity. Only a few cases have been reported, mainly in patients with coagulopathies or bleeding diathesis, and also in patients undergoing anticoagulant therapy following surgery, trauma, or lumbar puncture. Symptoms of spinal cord compression produced by spinal subdural haematoma may progress rapidly causing complete and irreversible deficits. However, rapid diagnosis and surgical intervention can result in a good functional outcome for the patient. We report on a 41-year-old woman with a normal coagulation profile who developed a spinal subdural haematoma after a minor motor vehicle accident. Although initially asymptomatic, she developed a dense quadriparesis over a 36-h period. A magnetic resonance imaging study demonstrated a subdural mass compressing the spinal cord, and at surgery a spinal subdural haematoma was found. She was discharged to an inpatient rehabilitation facility. Follow-up at 1 year showed significant improvement in motor function, but absence of posterior column function. A follow-up magnetic resonance study demonstrated widening of the spinal cord, advanced myelomalacia and a large, central, multi-loculated syrinx.

Rare cause of subarachnoid hemorrhage: spinal meningeal carcinomatosis. Case report

Subarachnoid hemorrhage (SAH) of spinal origin is a rare entity accounting for approximately 1% of all cases of SAH. Its most frequent causes are trauma and vascular malformations. Although primary spinal tumors, especially ependymomas, are also relatively common causes, SAH secondary to a metastatic spinal tumor arising from outside the central nervous system is an extremely rare condition; only one case has been reported in the literature. The authors present a case of spinal meningeal carcinomatosis secondary to cutaneous malignant melanoma in which the patient presented with only symptoms of SAH. Although very rare, this case underscores several factors. 1) Spinal SAH due to spinal metastases should be considered in the differential diagnosis of patients with previously known malignancy. 2) Spinal SAH may manifest without paraparesis or sensory deficit. 3) Magnetic resonance imaging of the spinal cord may be important to determine the source of SAH in patients in whom four-vessel cerebral angiography demonstrates no abnormal findings.

Pseudoaneurysm of the thoracic radiculomedullary artery with subarachnoid hemorrhage

✓ The authors report a rare case of a patient with a left-sided T-5 radiculomedullary artery pseudoaneurysm who presented with spinal subarachnoid hemorrhage (SAH). The patient, a 71-year-old woman, was hospitalized for progressive paraplegia and sensory loss with bladder and rectal dysfunction. Computerized tomography scanning revealed an SAH at the posterior fossa. Spinal T2-weighted magnetic resonance imaging demonstrated SAH and an inhomogeneous and slightly low signal intensity mass at T4–5. Spinal angiography revealed a tiny masslike staining without arteriovenous shunting. The resected specimen, which caused the spinal SAH, was diagnosed as a pseudoaneurysm based on operative and pathological findings.

Spinal subarachnoid hematoma compressing the conus medullaris and associated with neurofibromatosis type 2

STUDY DESIGN

Report of a case of subarachnoid hematoma associated with neurofibromatosis type 2 (NF2) in a 10-year-old girl.

OBJECTIVE

To report a rare case of subarachnoid spontaneous hematoma associated with NF2, with no evidence of trauma.

SETTING

Gifu, Japan.

METHODS

The patient presented with severe leg pain. MRI revealed a subarachnoid hematoma at the level of L2 and a spinal cord tumor at the level of T6. The subarachnoid hematoma had low and high heterogeneous signal intensity on the T1-weighted image and low signal intensity on the T2-weighted image, indicating the presence of extracellular methemoglobin. The tumor and hematoma were resected.

RESULTS

Pathological analysis demonstrated that the surgical specimen removed from the area of L2 was a hematoma and the specimen from T6 was a neurinoma. At follow-up 1 year after surgery, the girl remained neurologically asymptomatic.

CONCLUSIONS

This rare case of spinal subarachnoid hematoma was associated with NF2. MRI was useful in establishing the diagnosis.

Cerebrovascular complications in cancer patients

Coagulation disorders are common in cancer patients. In patients with solid tumors, a low-grade activated coagulation can result in systemic and cerebral arterial or venous thrombosis. Cancer treatments may also contribute to this coagulopathy, which usually, but not exclusively, occurs in the setting of advanced malignant disease. There may be TIAs or cerebral infarctions. Because of the widespread distribution of cerebral thromboses, there may be a superimposed encephalopathy; sometimes this is the only sign. Concurrent systemic thrombosis is present in many patients and is a useful clue to the diagnosis. In cerebral venous occlusion, the initial symptom is usually a headache. Except for cerebral intravascular coagulation that is unassociated with NBTE, neuriomaging studies usually demonstrate one or more parenchymal infarctions. MRI or MRV may demonstrate venous thrombosis. The laboratory evidence of coagulopathy is difficult to distinguish from the asymptomatic coagulopathy that often accompanies advanced cancer, and the test results must be interpreted cautiously. NBTE can be diagnosed by transesophageal echocardiography. There is no established treatment for the thrombotic coagulopathy associated with cancer, but anticoagulation should be considered. In leukemia and lymphoma, the coagulopathy is typically acute DIC that can lead to systemic and brain hemorrhages. It is especially common in acute myelogenous leukemias. The clinical signs of cerebral hemorrhage are fulminant and may be fatal. The bleeding usually occurs in the brain or subdural compartment, and rarely in the subarachnoid space. The diagnosis can be suspected by the clinical setting and by systemic thrombosis or hemorrhage. It can be established by examination of the peripheral smear, the platelet count, and tests of coagulation function. Therapy of acute DIC is controversial and should be individualized for the clinical setting. Cerebrovascular disorders can complicate metastatic or primary tumor in the brain, skull, dura, or leptomeninges. The clinical signs of infarction are indistinguishable from other causes of stroke, except that tumor-related venous occlusion will usually first produce signs of increased intracranial pressure. The diagnosis of tumor-related infarction can usually be established by neuroimaging studies that show infarction and may show extracerebral sites of tumor. CSF examination is useful in diagnosing leptomeningeal metastasis. A search for lung or cardiac tumor should be performed when embolic tumor infarction is suspected. Primary or metastatic tumors in the brain or dura may hemorrhage, producing the initial clinical signs of the brain tumor or a change in chronic signs induced by the tumor. There are helpful clues to a neoplastic hemorrhage on brain CT or MRI scans. The brain hemorrhage may require evacuation and the underlying tumor will usually require additional antineoplastic treatment. Hyperleukocytosis (extreme elevation of the cell count) in acute myelogenous leukemia is a less common cause of brain hemorrhage in recent years because of improved methods to lower the cell count. Cerebral arterial or venous thrombosis is sometimes the result of cancer therapy. The attribution of thrombosis to chemotherapy in many published cases is only speculative, because carefully conducted prospective studies that include investigation for other thrombotic causes are not available. The best-known associations with thrombosis are L-asparaginase, which is typically used in the induction therapy of acute lymphocytic leukemia, and combination hormonal therapy and chemotherapy for breast cancer. Radiation to the head and neck, typically administered for head and neck epithelial cancers or lymphoma, may result in delayed carotid atherosclerosis. The distribution of stenosis or occlusion is within the radiation portal and is typically more extensive than is atherosclerosis that develops in the absence of radiation. Small clinical series suggest that surgical treatment is equally effective as in nonirradiated carotid atherosclerosis. In children, the cerebral vessels can be affected by brain radiation resulting in stenosis or occlusion. Brain hemorrhages can result from chemotherapy effects on the hemostatic system or a microangiopathic anemia. Hemorrhages from radiation-induced vascular abnormalities are rare. Opportunistic infections, especially fungal infections, can complicate cancer or its treatment. Septic cerebral emboli may result in focal cerebral signs, seizures, or encephalopathy. Sometimes there is an associated hemorrhagic vasculitis or cerebritis. Rarely, mycotic aneurysms may bleed. A high index of suspicion is needed to diagnose fungal infection because of the difficulty in culturing the organism from the blood or CSF. A clinician can usually establish the cause of stroke in the cancer patient by performing a careful review of the clinical setting--including the type and extent of cancer and the type of antineoplastic therapy--in which the stroke occurred. Systemic thrombosis, embolism, or hemorrhage can be a clue to the cause, and appropriate neuroimaging and coagulation studies to aid in the diagnosis are available. Therapy may ameliorate symptoms or prevent further episodes. The identification of one of these unusual stroke syndromes that leads to the diagnosis of an occult and treatable cancer can be particularly rewarding.

Mediastinal neurilemmoma complicated with spinal subarachnoid hemorrhage

A 28-year-old woman suffered severe back pain and headache during exercising on three occasions during the prior two-month period. On admission, the physical examination revealed symptoms of meningeal irritation, nuchal rigidity, severe headache, continuous nausea, and vomiting. Cerebral computed tomography of the intracranial subarachnoidal space revealed no subarachnoid hemorrhage. Her cerebrospinal fluid was bloody. Spinal magnetic resonance imaging identified a posterior mediastinal tumor adherent to the left side of the 5th thoracic vertebra and an abnormally expanded blood vessel near the mediastinal tumor. In addition, a high signal intensity lesion appeared to be present on the surface of the spinal cord. A mediastinal neoplasm was removed through standard thoracotomy. During surgery, marked enlargement was noted in some veins (hemiazygos and 5th intercostal veins) which apparently had been constricted by the mediastinal tumor. Surgical and radiological findings suggested a relationship between the constricted venous return due to the tumor and the patient's spinal subarachnoid hemorrhage.

Traumatic intratumoral hemorrhage as the presenting symptom of a spinal neurinoma. Case report

Intratumoral hemorrhage as the presenting symptom of spinal tumors is rare. The authors describe a patient who presented with rapidly progressing paraplegia 24 hours after sustaining a minor traumatic injury of the thoracic spine. Radiological evaluation demonstrated a low-thoracic intradural tumor that was resected and found to be a neurinoma in which severe intra- and peritumoral hemorrhage was revealed. The radiological, surgical, and pathological findings are presented and discussed.

Spinal subarachnoid hemorrhage attributable to schwannoma of the cauda equina

BACKGROUND

Cauda equina syndrome occurring as a result of spontaneous spinal subarachnoid hemorrhage (SAH) from a spinal tumor is reported to be rare.

CASE DESCRIPTION

A 28-year-old woman presented at our clinic with a history of severe back pain for 10 days, progressive paraparesis, and urinary retention. Her physical examination revealed a mass located intradurally at the level of L1-2 and a massive SAH. An L1-L2, laminectomy and a hemilaminectomy from D9 to D12 were performed and the SAH was evacuated and the cord was decompressed.

CONCLUSION

At the first year follow-up, her restricted dorsal and plantar flexion continued. Post-gadolinium magnetic resonance imaging revealed no mass.

Traumatic spinal subarachnoid hematoma: report of a case with MRI

BACKGROUND

Spinal subarachnoid hematoma (SAH) is uncommon following traumatic injury to the spine. There are few case reports of neurologic deficit secondary to traumatic spinal SAH.

CASE DESCRIPTION

This 6-year-old boy was injured in a vehicular accident from which he became paraplegic and presented to us 1 week later. Plain X rays were normal and a myelo-computed tomography (CT) scan demonstrated an irregular intradural lesion from D10-L2. The magnetic resonance imaging (MRI) revealed an SAH at D11-12 level, posterior to the cord, which was surgically evacuated. The patient did not improve neurologically.

CONCLUSION

Significant cord injury and neurologic deficit can occur without obvious abnormalities on plain X rays or CT scan. MRI is very useful in detecting these lesions and can help in their management.

Spontaneous spinal subarachnoid hematoma--case report

BACKGROUND

Spinal subarachnoid hemorrhage is unusual, and rarely results in spinal subarachnoid hematoma because the cerebrospinal fluid tends to dilute the blood and prevent the formation of clots. We describe a patient with spinal subarachnoid hematoma of unusual spontaneous origin.

CASE

A 66-year-old female presented with sudden onset of intense back pain with paraplegia. Magnetic resonance imaging demonstrated a mass lesion between T2 and T6, compressing the spinal cord anteriorly. Emergency osteoplastic laminotomy exposed a hematoma in the subarachnoid space from T2 to T6, but no source of the hemorrhage was found. The patient was able to walk by herself about 20 days after the operation.

CONCLUSION

The outcome is significantly influenced by the duration between onset and operation, preoperative neurologic status, and rapidity of symptom progression. Therefore, we emphasize the importance of early diagnosis, and rapid and complete operative removal of spinal subarachnoid hematoma in order to achieve the best outcome.

Spinal tumors and subarachnoid hemorrhage: pathogenetic and diagnostic aspects in 5 cases

The authors report 5 cases of spinal tumor associated with subarachnoid hemorrhage. Histologically, the tumor was an ependymoma in 2 cases, a neurinoma in 2 cases and a hemangioblastoma in 1 case. The pathogenetic and diagnostic characteristics of these 5 cases are analyzed in the light of other published reports.

Isolated aneurysm of a spinal radicular artery presenting as spinal subarachnoid haemorrhage

Images

Acute paraplegia resulting from haemorrhage into a spinal neurofibroma

Acute paraplegia due to the intratumour haemorrhage of spinal neurofibroma is a rare condition. We describe 2 patients with this unusual presentation. Surgical treatment was successful in both patients. These 2 cases are reported, and the literature is reviewed.

Spinal subarachnoid hemorrhage due to a filum terminale ependymoma

We present a case of spinal subarachnoid hemorrhage due to an ependymoma of the filum terminale in a 23-year-old male. Clinical signs indicating a spinal origin of the subarachnoid hemorrhage are discussed. Subarachnoid hemorrhages are only rarely caused by an intraspinal tumor, most of which are located in the cauda equina. Our findings in this case proved the value of MRI examination in tumors of the cauda equina.

Nontraumatic spinal cord compression

Nontraumatic spinal cord compression can have very dramatic clinical presentations with rapid onset of symptoms and quickly ensuing paralysis. The manifestations may be much more subtle. This text will discuss the four most common causes of myelopathy, including spinal canal hemorrhage, spinal abscess, compression by tumor, and skeletal disease. Compressive lesions to the spinal cord from other than these etiologies are rare.

A combined neurilemmoma and angioma of the parasellar region. Case report

A combined neurilemmoma and angioma of the parasellar region is presented that clinically simulated a pituitary tumor. The lesion produced increased intracranial pressure and subarachnoid hemorrhage (SAH). This neoplasm is believed to have originated from the leptomeninges or the perivascular neural elements, or both. The angiomatous network within the tumor could have been the source of the SAH.

Subarachnoid hemorrhage due to a spinal neurinoma

A rare observation of spinal neurinoma associated with subarachnoid hemorrhage is reported and the other 12 cases in the literature are reviewed. The extramedullary location of the tumor and the feeble arachnoidal attachments to the spinal cord favor subarachnoidal bleeding in these cases. When the meningeal signs are evident and signs of spinal cord impairment are still unclear, an intracranial origin of the bleeding must be excluded. In doubtful cases, selective spinal angiography is useful in the differential diagnosis between a bleeding spinal tumor and an arteriovenous malformation of the spinal cord.

Spontaneous spinal subarachnoid hemorrhage and subdural hematoma. Report of two cases

Two patients with spontaneous spinal subarachnoid hemorrhage are presented to emphasize the clinical and radiological features of this uncommon illness. Both had severe back pain at the onset. One patient had a subdural hematoma that compressed the conus medullaris and cauda equina, and was drained percutaneously; the other had clots in the subarachnoid space. The cerebrospinal fluid showed a polymorphonuclear pleocytosis that simulated septic meningitis. Complete spinal angiography failed to reveal a cause for the hemorrhages.

Subependymoma presenting as subarachnoid hemorrhage: case report

✓ Symptomatic subarachnoid hemorrhage (SAH) in a young patient originated in a non-obstructive lateral ventricular subependymoma. A brief review of brain tumors known to cause SAH is discussed. The computerized tomography scans are presented.

Subarachnoid hemorrhage and papilledema due to a cervical neurilemmoma. Case report

An unusual case of a cervical neurilemmoma is presented. A 67-year-old man developed papilledema on two occasions in association with the symptoms and signs of a subarachnoid hemorrhage (SAH). He proved to have an otherwise asymptomatic cervical neurilemmoma. It is suggested that both acute and subclinical bleeding from such tumors may sometimes underlie the development of raised intracranial pressure occasionally encountered. The clinical clue to the spinal origin of the SAH was an acute onset with root pain. This case is discussed with reference to similar cases in the literature.

Spinal subarachnoid hemorrhage during myelography. Case report

Neoplasms of the conus medullaris and cauda equina have been shown to cause subarachnoid hemorrhage (SAH). In such instances, the hemorrhage has been the presenting symptom. A patient with a neurofibrom at T12-L1 experienced spinal SAH during myelography for suspected lumbar disc disease. The roentgenograms showing the lesion itself first and the subarachnoid clot subsequently may be unique. The cause of hemorrhage in this patient may have been the shearing of bridging capsular veins because of diminished cerebrospinal fluid pressure below the almost obstructing lesion.

Subarachnoid hematoma following lumbar puncture causing compression of the cauda equina. Case report

✓ A case of conus and cauda equina compression caused by a subarachnoid hematoma is reported which was probably due to needle trauma during an attempted lumbar puncture.

Spontaneous subarachnoid hemorrhage associated with spinal cord tumor. Case report

✓ A rare case of spontaneous subarachnoid hemorrhage from an extramedullary upper thoracic astrocytoma is described. The differential diagnosis between cranial and spinal spontaneous subarachnoid hemorrhage is discussed.

Rupture of spinal cord ependymoma. Case report

✓ The rupture of an ependymoma of the cauda equina associated with trauma and subarachnoid hemorrhage is described. The clinical course of the patient is discussed, and the mechanism and significance of the rupture postulated.