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

Spinal intradural schwannoma presenting with acute subarachnoid hemorrhage: a case report and review of published reports

Acute subarachnoid hemorrhage (SAH) presentation is a very rare occurrence in spinal schwannomas. We report a case of lumbar schwannoma in a patient presenting first with acute SAH. A 40-year-old man was referred to our department 7 days after the sudden onset of headache, neck pain, and fever. SAH was suspected; however, head computed tomography (CT) findings were normal. A lumbar puncture indicated blood-stained cerebrospinal fluid (CSF). Moreover, the CSF pressure changed from 200 mmH₂O to 90 mmH₂O after drainage of 10 mL of CSF indicating a blockage of CSF. Subsequent magnetic resonance imaging (MRI) confirmed an intradural tumor with SAH, which also caused blockage of the CSF circulation. The patient underwent immediate surgery and fully recovered. In conclusion, the early diagnosis and total removal of the tumor and blood clot significantly improved the patient’s outcome. There is a high index of suspicion for spinal tumors resulting in SAH when there is a CSF pressure change after lumbar puncture in an SAH patient.

Cauda equina schwannoma presenting with subarachnoid and subdural hemorrhage: Its underlying mechanism

Background

A patient presented with a spinal subarachnoid hemorrhage (SAH) and subdural hematoma (SDH) attributed to a spinal schwannoma at the T12-L1 level.

Case Description

A 67-year-old male acutely presented with severe back pain and L1 paraparesis/sensory loss, with urinary incontinence. CT/MR studies showed a spinal SAH and SDH within a likely T12-L1 schwannoma. At surgery, the hemorrhage within the tumor was continuous through the lower pole of the tumor into the subarachnoid and subdural spaces; tumor was dissected away from the surrounding tissues and totally removed. The postoperative course was uneventful, and the preoperative neurological deficits gradually resolved. Histopathologically, the lesion was a schwannoma with intratumoral hemorrhage.

Conclusion

This case demonstrates the rare acute presentation of a T12-L1 schwannoma with an accompanying intratumoral hemorrhage resulting in both a SDH/SAH.

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.

Primary spinal atypical teratoid/rhabdoid tumour presenting with hematomyelia and subarachnoid haemorrhage-a case report

Atypical teratoid/rhabdoid tumours (AT/RTs) are highly aggressive and uncommon malignant tumours of the central nervous system (CNS) affecting children younger than 3 years of age. Primary spinal cord involvement is an extremely rare presentation. AT/RTs show necrosis and haemorrhages on histopathology frequently. However, spinal atypical teratoid/rhabdoid tumour (AT/RT) with hematomyelia and spinal subarachnoid haemorrhage (SAH), as seen in our case, has never been reported in the literature in the paediatric age group. We report a case of primary spinal AT/RT in a 3-year-old male child presenting acutely with hematomyelia and spinal SAH and try to elucidate its pathophysiological basis.

Intralesional and subarachnoid bleeding of a spinal schwannoma presenting with acute cauda equina syndrome

We present an unusual case of spinal neurinoma with intralesional and subarachnoid bleeding with acute cauda equina syndrome. A 38-year-old man was admitted to our department after a minor thoracic spinal trauma with right lower limb plegia and urinary retention. MRI showed a T11 intradural tumour with intralesional and subarachnoid haemorrhage. The patient was operated of spinal cord decompression and complete tumour resection. The histological examination documented a schwannoma with large haemorrhagic intratumoural areas. A full neurological recovery was documented at 6-month follow-up.

A Rare Case of Spinal Schwannoma in a Child Presenting with Subarachnoid Hemorrhage: A Case Report with Review of Literature

Pediatric spinal schwannomas/neurofibromas constitute only 2.5%–4% of all pediatric spinal tumors. However, subarachnoid hemorrhage (SAH) because of spinal pathologies is very rare, representing 1.5% of all cases of SAH. Spinal nerve sheath tumors such as schwannomas rarely present with SAH, especially before the appearance of overt signs of spinal cord or root compression. We report a case of dorsolumbar schwannoma in an 11-year-old girl presenting clinically with signs and symptoms mimicking meningitis, but meningeal signs later proved to be due to SAH associated with spinal (D12-L1) schwannoma and hydrocephalus. Mass was excised and ventriculoperitoneal shunt was inserted. In our clinical practice, we may sometimes come across some uncommon diseases with even more uncommon presentations as happened with us at our institute. We must always consider that there is a possibility of SAH owing to silent spinal lesion in patients with angiographic negative intracranial SAH as in this case.

MRI-detection rate and incidence of lumbar bleeding sources in 190 patients with non-aneurysmal SAH

BACKGROUND

Up to 15% of all spontaneous subarachnoid hemorrhages (SAH) have a non-aneurysmal SAH (NASAH). The evaluation of SAH patients with negative digital subtraction angiography (DSA) is sometimes a diagnostic challenge. Our goal in this study was to reassess the yield of standard MR-imaging of the complete spinal axis to rule out spinal bleeding sources in patients with NASAH.

METHODS

We retrospectively analyzed the spinal MRI findings in 190 patients with spontaneous NASAH, containing perimesencephalic (PM) and non-perimesencephalic (NPM) SAH, diagnosed by computer tomography (CT) and/or lumbar puncture (LP), and negative 2nd DSA.

RESULTS

190 NASAH patients were included in the study, divided into PM-SAH (n = 87; 46%) and NPM-SAH (n = 103; 54%). Overall, 23 (22%) patients had a CT negative SAH, diagnosed by positive LP. MR-imaging of the spinal axis detected two patients with lumbar ependymoma (n = 2; 1,05%). Both patients complained of radicular sciatic pain. The detection rate raised up to 25%, if only patients with radicular sciatic pain received an MRI.

CONCLUSION

Routine radiological investigation of the complete spinal axis in NASAH patients is expensive and can not be recommended for standard procedure. However, patients with clinical signs of low-back/sciatic pain should be worked up for a spinal pathology.

Sudden post-traumatic sciatica caused by a thoracic spinal meningioma

Spinal meningiomas usually present with slowly progressive symptoms of cord and root compression, while a sudden clinical onset is very rare. A 35-year-old previously symptom-free woman presented sudden right sciatica and weakness of her right leg following a fall with impact to her left foot. A neurological examination showed paresis of the right quadriceps, tibial and sural muscles, increased bilateral knee and ankle reflexes and positive Babinski sign. Magnetic resonance imaging (MRI) revealed the presence of a spinal T11 meningioma in the left postero-lateral compartment of the spinal canal; at this level, the spinal cord was displaced to the contralateral side with the conus in the normal position. At surgery, a meningioma with dural attachment of the left postero-lateral dural surface was removed. The intervention resulted in rapid remission of both pain and neurological deficits. Spinal meningiomas may exceptionally present with sudden pain and neurological deficits as result of tumour bleeding or post-traumatic injury of the already compressed nervous structures, both in normal patients and in those with conus displacement or tethered cord. In this case, the traumatic impact of the left foot was transmitted to the spine, resulting in stretching of the already compressed cord and of the contralateral lombosacral roots. This case suggests that low thoracic cord compression should be suspected in patients with post-traumatic radicular leg pain with normal lumbar spine MRI.

Cauda equina schwannoma presenting with intratumoral hemorrhage and intracranial subarachnoid hemorrhage

The authors report the case of a spinal intradural schwannoma presenting with intracranial subarachnoid hemorrhage (SAH). Cerebral angiography did not show any intracranial lesion; however, MRI revealed two separate tumors in the lower segment of the spinal cord. The proximal lesion arising from the conus medullaris was well circumscribed and homogeneously enhanced, whereas the tumor in the cauda equina revealed hemorrhagic signals on MRI. This case also illustrates an unusual presentation of intracranial SAH simultaneously with intratumoral hemorrhage in a spinal cord schwannoma. The absence of hemorrhagic changes in the lesion arising proximal to the cauda equina region supports the mechanical theory proposed for the pathogenesis of hemorrhagic complications in spinal cord tumors.

Anaplastic medullary ependymoma presenting as subarachnoid hemorrhage

A-41-year old man presented with violent thunderclap headache and a bilateral proprioceptive sensibility deficit of the upper limbs. Cerebral CT scan and MRI were negative. Lumbar puncture confirmed subarachnoid hemorrhage (SAH), but cerebral angiography was negative. Three months later, the patient presented with paraparesis, and a thorough work-up revealed a diffuse, anaplastic extramedullary C7-D10 ependymoma with meningeal carcinomatosis considered the source of hemorrhage. The patient went through a D5-D8 laminectomy, temozolomide chemotherapy, and radiotherapy. The situation remained stable for a few months. In this paper, we would like to emphasize that spinal masses should be considered in cases of SAH with negative diagnostic findings for aneurysms or arteriovenous malformation.

[A case of lumbar myxopapillary ependymoma discovered due to headache]

A 23-year-old man was admitted to our hospital with lumbago about two weeks previously, and headache six days previously. Brain MR imaging revealed no remarkable findings except for left ethmoid sinusitis; both MR angiography and venography showed no vascular abnormalities. On the day after admission, lumbar puncture was performed because right homonymous hemianopsia and nuchal stiffness developed. The cerebrospinal fluid appeared bloody, and the source of bleeding was searched for. MR images of the lumbar spine demonstrated an intradural tumor with heterogenous contrast enhancement, and this tumor was considered to be the source of the bleeding. Tumor resection was performed, but some parts of the tumor could not be resected because of adhesion to the cauda equina. The pathological findings of the tumor demonstrated myxopapillary ependymoma. Radiation therapy was added to treat the residual tumor because myxopapillary ependymoma tended to recur in spite of the benign nature of the tumor. Spinal myxopapillary ependymoma is rare, but it causes subarachnoid hemorrhage. Subarachnoid hemorrhage from spinal tumor should be suspected when headache accompanied with severe low back pain are present even in the absence of spinal signs.

Cervical schwannoma presenting with acute intracranial subarachnoid hemorrhage

A subarachnoid hemorrhage (SAH) associated with negative finding on four-vessel angiography is seen in 5 to 30% of patients with intracranial SAH. A previously silent lesion in the spinal canal may be responsible for the angiographically negative finding for cause of intracranial SAH. We report a case of upper cervical (C1-2) intradural schwannoma presenting with acute intracranial SAH. Repeated cerebral angiographic studies were negative, but cervical magnetic resonance imaging study and tissue pathology revealed a intradural-extramedullary schwannoma in C1-2 level. This case illustrates the importance of a high index of clinical suspicion for spinal disease in angiographically negative intracranial SAH patients.

SPONTANEOUS INTRAMEDULLARY HEMORRHAGE OF SPINAL HEMANGIOBLASTOMA

OBJECTIVE

Spontaneous hemorrhage of a spinal hemangioblastoma is a rare event. With limited reports in the literature, the risk of acute hemorrhage associated with these lesions is poorly understood.

METHODS

A 39-year-old man presented with paraplegia and bilateral upper-extremity weakness related to an acute intramedullary hemorrhage from a thoracic spinal hemangioblastoma. Magnetic resonance imaging revealed an intramedullary hemorrhage from T3 to T6 with prominent flow voids along the dorsal aspect of the spinal cord from T6 to T10. Magnetic resonance angiography of the thoracic spine indicated a prominent enhancing vessel along the dorsum of the thoracic cord.

RESULTS

An emergency T3 to T8 laminoplasty was performed for evacuation of the hematoma and gross total resection of the lesion. Pathological analysis of the tumor biopsy confirmed the diagnosis of hemangioblastoma.

CONCLUSION

The risk of spontaneous hemorrhage from a spinal hemangioblastoma is low. Spinal hemangioblastomas presenting with intramedullary hemorrhage tend to cause severe neurological deficits and have a poorer long-term prognosis compared with subarachnoid hemorrhage and nonhemorrhagic lesions.

Intrasyrinx hemorrhage associated with hemangioblastoma in epiconus

BACKGROUND CONTEXT

Hemangioblastomas in the central nervous system are highly vascular lesions, but have low risk of hemorrhage. In spinal lesions, there are a few rare cases of intramedullary hemorrhages associated with hemangioblastoma, and their prognoses were very severe.

PURPOSE

This is the first case of an intrasyrinx hemorrhage associated with hemangioblastoma in epiconus. We report this rare case and discuss the clinical manifestations of intrasyrinx hemorrhage caused by hemangioblastoma in epiconus.

STUDY DESIGN

A case report.

METHODS

This case report presents a 45-year-old woman with intrasyrinx hemorrhage caused by hemangioblastoma in epiconus. The patient presented with a sudden onset of burning bilateral leg pain and rectal/bladder dysfunction, indicating conus medullaris syndrome. Initial magnetic resonance imaging revealed an intramedullary nodular lesion in the epiconus and holocord syringomyelia. However, follow-up magnetic resonance imaging showed intramedullary hemorrhage.

RESULTS

The patient underwent surgery, and an intrasyrinx hematoma was evacuated and the tumor was completely removed. Histological diagnosis was hemangioblastoma. Three months after surgery, the patient recovered from neurological deficits.

CONCLUSIONS

We present this rare case, and emphasize hemangioblastoma as the differential diagnosis in hemorrhagic spinal lesion.

Ependymoma of conus medullaris presenting as subarachnoid haemorrhage

Subarachnoid haemorrhage (SAH) due to spinal ependymoma is very rare. We report a 37 year old man who presented with typical clinical signs of SAH. Lumbar puncture confirmed SAH but cerebral angiography was negative, and further diagnostic work-up revealed an ependymoma of the conus medullaris as the source of the haemorrhage. A comprehensive review of the literature was conducted. Only 17 patients with spontaneous SAH due to a spinal ependymoma have been reported since 1958. However, in cases of SAH and negative diagnostic findings for cerebral aneurysms or malformations, this aetiology should be considered and work-up of the spinal axis completed.

Risk of hemorrhage in hemangioblastomas of the central nervous system

OBJECTIVE

Hemangioblastomas are benign vascular tumors of the central nervous system. Several cases of spontaneous hemorrhage within these tumors have been reported. However, the risk of hemorrhage in these tumors remains unknown.

METHODS

To clarify the incidence of hemorrhage in hemangioblastomas, we reviewed our large clinical database of 277 patients with central nervous system hemangioblastomas for the incidence of spontaneous or perioperative hemorrhage. Clinical characteristics such as tumor size, tumor location, von Hippel-Lindau disease status, and clinical symptoms before hemorrhage were correlated with hemorrhage risk. Furthermore, we reviewed the literature for cases of spontaneous hemorrhage from hemangioblastoma.

RESULTS

Among all patients in our series, we observed seven cases of spontaneous hemorrhage from a hemangioblastoma within the summarized follow-up time. Thus, we calculate a spontaneous hemorrhage probability of 0.0024 per person per year. The average diameter of tumors that bled was 3 cm in our series and 2.3 cm in the literature review, whereas the average diameter of hemangioblastomas in major series ranges from 0.8 to 1.1 cm. Furthermore, we have observed severe postoperative hemorrhage in two extraordinarily large solid hemangioblastomas (4 and 5 cm).

CONCLUSION

The overall incidence of hemorrhage in patients with hemangioblastoma is low. An important indicator for the probability of hemorrhage is tumor size, as spontaneous or postoperative hemorrhage occurred exclusively in extraordinarily large tumors. Hemangioblastomas smaller than 1.5 cm (the vast majority of these tumors) harbor virtually no risk of spontaneous hemorrhage.

Atypical presentations of conus medullaris and filum terminale myxopapillary ependymomas

Out of 27 cases of spinal ependymomas seen during a 21 year period (1978-1999), we observed three out of 12 myxopapillary tumours of the conus medullaris and filum terminale with atypical presentations. All the three cases presented with subarachnoid haemorrhage and intracranial hypertension. In addition, the second patient developed persistently low CSF sugar, while the third patient developed hydrocephalus, acute autonomic crisis and SIADH. Although subarachnoid haemorrhage (SAH), intracranial hypertension and hydrocephalus were previously scarcely reported in the literature, the low CSF sugar, acute autonomic crisis and SIADH were never reported singly or in combination. Up to our best knowledge, this is the first report that clearly outlines all these atypical manifestations in this particularly interesting neoplasm. Hence, the above challenging clinical presentations should be borne in mind with cryptic presentations of lower spinal cord and filum terminale ependymomas. A proposal of the mechanism of their production is suggested.

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.