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

Spinal schwannoma and ependymoma: a diagnosis that shouldn't be missed in SAH - literature review and case report

BACKGROUND

The incidence of subarachnoid hemorrhage (SAH) is around 9/100 000 people annually, with 15-37% having no identifiable vascular source on angiography. This study aimed to define criteria to identify patients with a possible spinal origin of SAH. We present a literature review and a case of a 61-year-old patient with SAH due to lumbar spinal schwannoma.

METHODS

A literature search and review were conducted according to the PRISMA-P 2020 guidelines. We performed a restricted search using the keywords "SAH" and "Spinal Schwannoma"; "SAH" and "Ependymoma".

RESULTS

Out of 297 articles, 32 were included between 1951 and 2023 for a total of 44 cases with SAH of spinal origin. Fourteen schwannomas (31.8%) and 30 ependymomas (68.2%) were included in the review. Men represented 77% of the schwannoma and 64% of the ependymoma cohort. The median age was 45 years in the schwannoma vs 29 years in the ependymoma group. Ependymomas were predominantly located in the lumbar spine (85%). Localised spinal symptoms were present in 65% of schwannoma cases, encompassing radicular pain (28%), motor deficit (22%), and incontinence (14.5%). This was 93% in ependymomas, with symptoms being radicular pain (40%), motor deficit (20%), and incontinence (17%). Lumbar punctures diagnosed 86.5% of SAHs, while only 18.2% had subarachnoid bleeding found on a cerebral CT or MRI.

CONCLUSION

In SAH patients lacking a vascular bleeding source, any spinal symptom must prompt a complete examination of the spinal axis (i.e. MRI). Without spinal symptoms, SAH associated with spinal tumors will likely be missed.

Cervical dumbbell-type tumor spontaneously shrinking following an ischemic stroke

Background

Asymptomatic cervical dumbbell-type tumors can be incidentally diagnosed. Notably, the chronological changes in the size of these tumors have not been satisfactorily described.

Case Description

A 57-year-old man was clinically followed for an asymptomatic cervical dumbbell-type tumor that had the appearance of a schwannoma on magnetic resonance (MR) images obtained over a 7-year period. Notably, the tumor compressed both the spinal cord and the right vertebral artery. At the end of the 7-year period, the patient sustained a cerebral infarction due to atherosclerosis of the right vertebral artery; the angiogram revealed both atherosclerosis and the tumor compressing the right vertebral artery. After the stroke/ischemic event, the tumor progressively shrunk on MR images obtained for the following 4 years, and the spinal cord compression was similarly relieved.

Conclusion

Here, we report on a 57-year-old man with cervical MR images revealing that a cervical dumbbell schwannoma was progressively compressing both the spinal cord and the right vertebral artery. However, following a cerebral infarction, the tumor underwent spontaneous shrinkage over the next 4 years, thus relieving the compression.

Hemorrhagic Schwannoma of the Cauda Equina: Case Report and Review of the Literature

Spinal intradural hemorrhage is a rare event; the most common causes of spinal bleeding are traumas, medical therapy with anticoagulants and thrombolytics, vascular malformations, and congenital defects of coagulation. Rarely, spinal cord tumors may cause hemorrhage. Herein, we report the case of a patient with acute and quickly worsening lumbar pain: the neurological examination revealed a flaccid paraplegia caused by an intradural lesion extending on the right side of the spinal cord from T1 to L2 vertebral level. Pathological examination revealed an hemorrhagic schwannoma. Acute spinal subdural hemorrhage caused by spinal schwannomas is a very rare occurrence (29 cases only have been previously reported). Review of the literature with clinico-diagnostic features is presented, surgical treatment is explained, and pathological findings with possible etiopathogenesis of hemorrhage are described.

Increased Intracranial Pressure Without Hydrocephalus Associated With Spinal Cord Tumor: Literature Review

ABSTRACT

Spinal cord tumors (SCTs) may rarely cause increased intracranial pressure without hydrocephalus (IICPWH). A review of the English literature published after 1970 revealed 29 cases of IICPWH secondary to SCT. The following data were acquired: demographics, tumor characteristics, ophthalmic and neurological manifestations, and cerebral spinal fluid (CSF) features. We summarize the existing literature regarding various theories of pathophysiology, spinal imaging recommendations, and treatment modalities used in managing such patients. Patients with papilledema who also have neurological signs or symptoms of myelopathy or elevated CSF protein particularly in the setting of an atypical demographic for pseudotumor cerebri should raise a suspicion for a spinal tumor and prompt further investigation with a spinal MRI.

Cervical C2 to C4 schwannoma with intratumoral hemorrhage presenting as acute spastic quadriparesis: A rare case report

Background

Spinal schwannomas are slow growing, benign nerve sheath tumors. These may be asymptomatic or may present as backache with radicular pain, slowly progressive neurological deficits, but rarely with acute spastic quadriparesis attributed to intratumoral hemorrhage.

Case Description

A 38-year-old male presented with the chief complaint of neck pain radiating to the left upper extremity for the last 8 months. On admission, he exhibited diffuse hyper-reflexia but had no motor or sensory deficit. Magnetic resonance imaging showed a solid-cystic intradural extramedullary (IDEM) C2 to C4 mass severely compressing the spinal cord. The same day the patient acutely developed a spastic quadriparesis. Immediately, a partial C2, C3, and C4 laminectomy was performed for tumor excision; within 5 postoperative days, he fully regained neurological function. The final histopathology was consistent with a "schwannoma showing areas of congestion and hemorrhage."

Conclusion

Spinal schwannomas rarely present with intratumoral hemorrhage and acute spastic quadriparesis. Immediate operative decompression may lead to excellent postoperative neurological recovery.

Spinal Schwannoma with Intradural Intramedullary Hemorrhage

Patients with spinal abnormalities infrequently present with intradural intramedullary bleeding. The more common causes include spinal trauma, arteriovenous malformations and saccular aneurysms of spinal arteries. On occasion, spinal cord tumors either primary or metastatic may cause intramedullary bleed with ependymoma of the conus medullaris. Spinal nerve sheath tumors such as schwannomas only rarely cause intradural intramedullary bleed, especially in the absence of spinal cord or nerve root symptoms. We report a case of spinal intradural schwannoma presenting with acute onset of quadriparesis. Cerebral angiography studies were negative but magnetic resonance imaging (MRI) of the spine revealed a large hemorrhagic tumor in the thoracolumbar junction. However, we suggest that the patients with intradural intramedullary bleed should be evaluated for underlying spine disease.

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.

Idiopathic spontaneous spinal subarachnoid hemorrhage

INTRODUCTION

Spontaneous spinal subarachnoid hemorrhage (SAH) occurs in less than 1% of all cases of SAH, and idiopathic spontaneous spinal SAH is even more rare.

METHODS

A 48-year-old man presented with a sudden onset of low back pain without any neurological deficit. There was no history of either trauma or the use of anticoagulants. Magnetic resonance (MR) imaging of the lumbar spine revealed an intradural linear mass from T12 to L3, ventral to the conus medullais and cauda equina. The mass was of iso-signal intensity in T2-weighted images, of high signal intensity in T1-weighted images, and was not enhanced following injection of gadolium. Lumbar tapping revealed bloody cerebrospinal fluid, confirming SAH. At 1 month after the onset of symptom, his pain subsided spontaneously and no vascular abnormality was found by spinal angiography. Follow-up MR imaging confirmed the complete resolution of the SAH.

CONCLUSION

We report a case of idiopathic spontaneous spinal SAH at the lumbar level in a 48-year-old man.

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.

Increased intracranial pressure in a case of spinal cervical glioblastoma multiforme. Analysis of these two rare conditions

The authors describe a rare case of increased intracranial hypertension consequent to a spinal cervical glioblastoma multiforme in a young patient. They analyse the physiopathology of intracranial hypertension in spinal tumors and the rarity of such kind of tumor in this location, and its clinico-pathological aspects.

Spinal subarachnoid haemorrhage from an "ancient" schwannoma of the cervical spine

A case of spinal subarachnoid haemorrhage secondary to degenerative changes in a cervical schwannoma is presented. The problems associated with diagnosis as well as the possible mechanisms resulting in haemorrhage from spinal tumours are reviewed.

Papilledema and spinal cord tumors

Two cases of cervical schwannoma associated with papilledema and dementia are described and the pertinent literature is reviewed. It is very important to conduct complete spinal surveys when patients suffer dementia and papilledema and the cerebrospinal fluid protein is elevated.

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.

Recurrent spontaneous subarachnoid haemorrhage due to spinal haemangioblastoma

Images

Spinal subdural hematoma, neurilemmoma, and acute transverse myelopathy

A 74-year-old woman had acute cervical transverse myelopathy from a neurilemmoma. Although extremely rare, the possibility of tumor should be recognized in patients with apparently spontaneous spinal subdural hematoma. As in other cases of compressive myelopathy, early operation is essential for recovery of neurological deficit.

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.

Hydrocephalus and dementia complicating spinal tumor. Case report

Hydrocephalus and dementia associated with spinal mass lesions are well recognized. Removal of the spinal mass has sometimes resulted in relief of the dementia. This case demonstrates that the ventricular size may also become smaller after removal of the spinal mass.