Intracranial subarachnoid hemorrhage resulting from non-cervical spinal arteriovenous lesions: Analysis of possible cause of bleeding and literature review

Glomus Cervical Arteriovenous Malformation Presenting with Intracranial Subarachnoid Hemorrhage: Clinical Case and Pial Resection Surgical Technique Description

Spinal intramedullary arteriovenous malformations (AVMs) can present with spinal hemorrhage. However, some of them occasionally can be the cause of angiographically negative intracranial subarachnoid hemorrhage, thus requiring a more comprehensive diagnostic approach to detect the possible source of bleeding. Nidal or arterial feeder aneurysms are widely considered high-risk rupture portions of the spinal AVM and recognized as a major cause of bleeding. Due to the tight eloquent confines within the thecal sac and the higher annual rupture risk after the initial bleeding, recurrent hemorrhage may have catastrophic outcomes. Hence the goal of management is to obliterate the spinal AVM preserving neurologic function and preventing future hemorrhagic events. Unlike cerebral AVMs, partial treatment of spinal intramedullary AVMs has been documented to be effective to improve the patients' prognosis dramatically. Microsurgical resection with or without adjuvant embolization has been considered the mainstay treatment for symptomatic glomus spinal intramedullary AVMs. The case of a 25-year-old man with acute cerebral subarachnoid hemorrhage caused by intranidal aneurysm rupture of cervical glomus-type AVM is presented here. The patient was surgically treated by C3-C4 laminectomy and AVM excision by pial resection technique. Thereby, the pial resection technique helps in providing subtotal AVM nidus resection, minimizing parenchymal dissection but effectively devascularizing glomus AVMs with satisfactory long-term results.

Spinal dural arteriovenous fistula rupture after Rathke's cleft cyst endoscopic resection: Case report and literature review

Background:

Spinal dural arteriovenous fistula (SDAVF) is the most frequent vascular malformation of the spine and accounts for approximately 70% of all vascular spinal malformations. In rare cases, SDAVF rupture and subsequent subarachnoid hemorrhage or intramedullary hematoma may occur. The aim of this article is to present a fatal case of SDAVF rupture after a Rathke’s cleft cyst (RCC) endoscopic resection.

Case Description:

An 80-year-old female was referred to our hospital with a clinical presentation of bilateral reduction in visual acuity, bitemporal hemianopsia, and sellar magnetic resonance imaging (MRI) highly suggestive of RCC. After the first endonasal endoscopic surgery, the cyst was partially removed and vision improved. No signs of cerebrospinal fluid (CSF) leak were observed. After 1 year, the patient returned because of RCC recurrence and decreased visual acuity. In the second procedure, the lesion was totally resected and CSF leak was observed. A nasoseptal flap was rotated to cover the skull base defect. The patient developed subtle paraparesis followed by paraplegia on the 4^th postoperative day. The dorsal spine MRI revealed a T3-T4 intramedullary hematoma. A dorsal laminectomy was performed and a SDAVF was observed. During microsurgery, at the right T3 nerve root level, an arteriovenous shunting point was identified, coagulated, and divided. The intramedullary hematoma was evacuated. The patient developed neurogenic and septic shock and died.

Conclusion:

Venous hypertension, venous wall fragility, and venous thrombosis seem to be the main factors involved in SDAVF rupture. In this particular case, reduction of the extravascular pressure and sudden variation in the pressure gradient caused by sustained CSF leak, also appeared to play an important role in SDAVF rupture. It may represent one more complication related to radical resection of RCC.

Not All Subarachnoid Hemorrhages in Pregnancy Are Intracranial in Origin: A Case Report

Subarachnoid hemorrhage is uncommon in pregnancy and may be caused by intracranial aneurysms, arteriovenous malformations, venous thrombosis, or preeclampsia. We present an unusual case of subarachnoid hemorrhage in a term parturient where the bleeding originated from an extracranial source, namely a cervicothoracic arteriovenous malformation. This case highlights the challenge of diagnosing this condition when the initial presentation may be nonspecific, lacking in neurologic deficits, and confounded by the simultaneous presence of preeclampsia.

Intracranial Subarachnoid Haemorrhage Caused by Cervical Spinal Dural Arteriovenous Fistulas: Case Report

Cervical spinal vascular abnormalities commonly present with progressive myelopathy as a result of venous congestion. They are not very prone to bleed and tend to be underdiagnosed due to their subtle clinical presentation. We came across a rare case of intracranial subarachnoid haemorrhage caused by cervical spinal dural fistula in the Imperial College Healthcare NHS Trust Hospitals/UK in June 2020. We diagnosed the patient under strict evidence base medicine guidance, which otherwise would have been missed. We discussed the case in several multidisciplinary team (MDT) meetings, and patient was treated under the joint care of the neurology and neurosurgical teams. Patient made a full recovery and discharged home with no neurological defects or complications. Here, we reported this case with all the evidence we gathered from our MDT discussion. We hope our experience would help improve the diagnosis and management protocol for future patients with a similar condition.

Repeat Catheter Angiography in Patients with Aneurysmal-Pattern Angiographically Negative Subarachnoid Hemorrhage

BACKGROUND

A significant proportion of patients with subarachnoid hemorrhage have a normal cerebral angiogram. Patients with angiographically negative subarachnoid hemorrhage (anSAH) with either perimesencephalic- (panSAH) or aneurysmal-pattern hemorrhage (aanSAH, also known as diffuse anSAH) have an excellent prognosis, but only if underlying vascular abnormalities are completely excluded. The rate of occult aneurysms in patients with aanSAH varies widely across studies. The purpose of this study was to quantify the value of repeat DSA in these patients.

METHODS

We reviewed the records of all patients initially diagnosed with aanSAH after a screening DSA at a single tertiary neurovascular referral center from January 2006-April 2018. Patients with panSAH and traumatic SAH were excluded. We also performed a systematic review and meta-analysis of positive second DSAs in previously published case series of patients with aanSAH who underwent two serial DSAs. For meta-analysis, PubMed Central, MEDLINE and Cochrane Library databases were searched for pertinent studies up to November 2019. The rate of aneurysm detection on repeat angiography was extracted from each study. Pooled rates for positive second angiogram were calculated as untransformed proportions in a binary random-effects model meta-analysis. Inter-study heterogeneity was calculated using an I² statistic.

RESULTS

Three of 27 patients (11.1%) with aanSAH and at least two DSAs were subsequently found to have a cerebral aneurysm in our institutional dataset. Twenty-six studies in our systematic review met inclusion criteria, and the pooled rate of positive second angiogram was 10.4% (95% CI 7.3%-13.5%, P < 0.001). Substantial inter-study heterogeneity was observed in the meta-analysis (I² = 61.7%, P < 0.001).

CONCLUSIONS

One in 10 patients with aanSAH has an occult ruptured aneurysm. A second-look DSA should be strongly considered in these cases.

Ruptured Thoracolumbar Perimedullary Arteriovenous Fistula during Pregnancy Complicated by Cerebral Subarachnoid Hemorrhage and Brainstem Hematoma: A Case Report

Intradural spinal arteriovenous fistulas (sAVF) are spinal vascular lesions that usually manifest due to myelopathy or local symptoms caused by venous congestion and ischemia. In addition, perimedullary arteriovenous fistulas (PMAVF) in particular may rupture and cause subarachnoid or intramedullary hemorrhage along with relevant symptoms. Subarachnoid hemorrhage (SAH) can propagate into cranial space with clinically dominant symptoms and signs of typical aneurysmal intracranial SAH. The standard workup for cerebral SAH, after excluding an intracranial source of hemorrhage, is usually limited to a cervical spine MRI; therefore, thoracolumbar sources of hemorrhage can be missed, or their diagnosis may be delayed. Here we present a case of a pregnant patient who presented with cerebral SAH. The source of hemorrhage was not initially identified, leading to a presumptive diagnosis of benign pretruncal non-aneurysmal SAH. The correct diagnosis of spinal thoracolumbar PMAVF was revealed 2.5 months later due to the progression of local symptoms. While the diagnosis was being refined and endovascular treatment was being planned (but delayed due to pregnancy), there was a recurrence of intraconal hemorrhage followed by brainstem hemorrhage. This led to significant clinical deterioration. The PMAVF was then treated microsurgically and the patient experienced partial recovery.