Syringomyelia with syringobulbia presenting only with paralysis of 9th and 10th cranial nerves

Rapid progression of acute cervical syringomyelia: A case report of delayed complications following spinal cord injury

Context: Post-traumatic syringomyelia treatment usually focuses on restoring normal cerebrospinal fluid (CSF) flow. Herein, the first-reported case of delayed post-traumatic syringomyelia associated with an L2 compression fracture 30 years prior to syringomyelia symptoms that rapidly progressed to the brainstem within 5 months, leading to respiratory and circulatory impairments, is summarized. The improvement in symptoms and significant decrease in size of the syringomyelia/syringobulbia achieved in this patient suggest that the initial treatment of choice in such acute cases should be posterior fossa decompression (PFD). Intradural exploration in order to restore the normal CSF flow at the level of trauma can then be planned in a later time.Findings: A retrospective analysis of clinical manifestations and findings obtained from magnetic resonance (MR) imaging, including pre-operative and post-operative follow-up data acquired 6 months later, provided adequate comparisons of the neurological deficits and syrinx size. Interestingly, serial MR images showed that a cervical syrinx acutely progressed to the brainstem within 5 months. PFD and sectioning of the thick veil completely obstructing the foramen of Magendie resulted in partial resolution of the neurological deficits and syringomyelia regression after surgery.Conclusions: To our knowledge, this is the first case report to summarize the delayed complications of a spinal cord injury and acute syringomyelia progression to the brainstem in a short period. The symptoms were relieved by an emergency PFD, chosen due to the rapid progression of symptoms. An atypical treatment strategy is described for extremely rare cases, but with a good short-term prognosis.

Silent post-traumatic syringomyelia and syringobulbia

INTRODUCTION

Post-traumatic syringomyelia is a complication of traumatic spinal cord injury consisting in the development of a cavity within the spinal cord. Once considered an uncommon complication, its diagnosis has increased due to increased attention and advances in medical technology. Common symptoms of the syrinx are a sensory loss of the dissociated type with pain and temperature loss and the preservation of fine touch and vibratory sensation. Eventually, a deterioration of motor function with muscle wasting may occur.

CASE PRESENTATION

We present the case of a 36-year-old woman who sustained a sport accident in 1996, resulting in AIS A, T7 paraplegia. She underwent a magnetic resonance imaging (MRI) examination because of neck and left shoulder pain that resolved after a short anti-inflammatory treatment. The MRI showed a large cavity involving the cord beneath T6 and the medulla. Septations were present at both the spinal cord and medulla levels. With regard to vertebral status, the MRI showed the presence of severe kyphosis at the fracture level together with spinal cord compression. The neurological examination was normal except for the pre-existing paraplegia and of a slight heat and pain sensation deficit in the C8 dermatome.

DISCUSSION

We discuss the need of regular follow-up examinations as even large syrines with involvement of the brainstem may be asymptomatic. We also discuss the possible pathogenetic factors including the type of treatment of the vertebral lesion.

Syringobulbia in Patients with Chiari Malformation Type I: A Systematic Review

This study aimed to summarize the clinical features, diagnosis, and treatment of Chiari malformation type I- (CM-1-) associated syringobulbia. We performed a literature review of CM-1-associated syringobulbia in PubMed, Ovid MEDLINE, and Web of Science databases. Our concerns were the clinical features, radiologic presentations, treatment therapies, and prognoses of CM-1-associated syringobulbia. This review identified 23 articles with 53 cases. Symptoms included headache, neck pain, cranial nerve palsy, limb weakness/dysesthesia, Horner syndrome, ataxia, and respiratory disorders. The most frequently involved area was the medulla. Most of the patients also had syringomyelia. Surgical procedures performed included posterior fossa decompression, foramen magnum decompression, cervical laminectomy, duraplasty, and syringobulbic cavity shunt. Most patients experienced symptom alleviation or resolution postoperatively. A syringobulbic cavity shunt provided good results in refractory cases. Physicians should be aware of the possibility of syringobulbia in CM-1 patients, especially those with symptoms of sudden-onset brain-stem involvement. The diagnosis relies on the disorder's specific symptomatology and magnetic resonance imaging. Our review suggests that the initial therapy should be posterior fossa decomposition with or without duraplasty. In refractory cases, additional syringobulbic cavity shunt is the preferred option.

Signs consistent with syringobulbia may be detected in dogs undergoing MRI

Syringobulbia is a pathologic condition characterized by one or more fluid-filled cavities within the brainstem. This retrospective case series describes observations in eight dogs with syringobulbia diagnosed during MRI. All dogs were adult, small-breed dogs with concurrent syringomyelia and neurologic deficits localized to sites rostral to the spinal cord, which cannot be explained by syringomyelia (eg, six dogs had vestibular signs). On MRI, the fluid-filled cavities had signal intensity characteristics like cerebrospinal fluid, were in the medulla oblongata, and were solitary in each dog. Initially, the shape of the cavity was a slit in five dogs and bulbous in two dogs. Magnetic resonance imaging was repeated in five dogs (6-55 months of age). One dog had progression of syringobulbia from slit-like to bulbous, and four dogs had unchanged slit-like syringobulbia. One dog developed slit-like syringobulbia after cranioplasty. A variety of medical and surgical treatments were performed with improvement of some but not all clinical signs. One dog died following surgery due to cardiopulmonary failure and the other seven dogs were alive at least 1 year after the initial diagnosis, which was the least time of follow-up. One surviving dog developed a unilateral hypoglossal nerve deficit 2 months after the initial diagnosis and megaesophagus 14 months later. In conclusion, detecting a fluid-filled cavity in the medulla oblongata consistent with syringobulbia is possible in dogs undergoing MRI. The cavity is likely acquired, slit-like or bulbous, progressive, or static, and might be associated with breed size and neurologic signs localized to the medulla oblongata.

Syringobulbia in pediatric patients with Chiari malformation type I

OBJECTIVE Syringobulbia (SB) is a rare entity, with few cases associated with Chiari malformation type I (CM-I) in the pediatric population. The authors reviewed all pediatric cases of CM-I-associated SB managed at their institution in order to better understand the presentation, treatment, and surgical outcomes of this condition. METHODS A prospectively maintained institutional database of craniovertebral junction abnormalities was analyzed to identify all cases of CM-I and SB from the MRI era (i.e., after 1984). The authors recorded presenting symptoms, physical examination findings, radiological findings, surgical treatment strategy, intraoperative findings, and outcomes. SB cases associated with tumors, infections, or type II Chiari malformations were excluded. RESULTS The authors identified 326 pediatric patients with CM-I who were surgically treated. SB was identified in 13 (4%) of these 326 patients. Headache and neck pain were noted in all 13 cases. Cranial nerve abnormalities were common: vagus and glossopharyngeal nerve dysfunction was the most frequent observation. Other cranial nerves affected included the trigeminal, abducens, and hypoglossal nerves. Several patients exhibited multiple cranial nerve palsies at presentation. Central sleep apnea was present in 6 patients. Syringomyelia (SM) was present in all 13 patients. SB involved the medulla in all cases, and extended rostrally into the pons and midbrain in 2 patients; in 1 of these 2 cases the cavity extended further rostrally to the cerebrum (syringocephaly). SB communicated with the fourth ventricle in 7 of the 13 cases. All 13 patients were treated with posterior fossa decompression with intradural exploration to ensure CSF egress out of the fourth ventricle and through the foramen magnum. The foramen of Magendie was found to be occluded by an arachnoid veil in 9 cases. Follow-up evaluation revealed that SB improved before SM. Cranial nerve palsies regressed in 11 of the 13 patients, and SB improved in all 13. CONCLUSIONS The incidence of SB in our surgical series of pediatric patients with CM-I was 4%, and all of these patients had accompanying SM. The SB cavity involved the medulla in all cases and was found to communicate with the fourth ventricle in 54% of cases. Posterior fossa decompression with intradural exploration and duraplasty is an effective treatment for these patients.

Syringohydromyelia in association with syringobulbia and syringocephaly: case report

The authors present the case of a 14-year-old boy with holocord syringohydromyelia extending into the brainstem, cerebral peduncle, internal capsule, and cerebral cortex. At the posterior fossa exploration, an opaque thickened arachnoid with occlusion of the foramen of Magendie was encountered. Careful documentation of postoperative regression of the syringocephaly, syringobulbia, and syringohydromyelia was made. The pathophysiology is discussed.

Syringobulbia in a Pediatric Population

OBJECTIVE:

To better understand the presentation, management, and outcome of syringobulbia in the pediatric age group.

METHODS:

The University of Iowa pediatric neurosurgery database was searched for patients under the age of 18 with a diagnosis of syringobulbia. The patients' records were retrospectively reviewed for demographic data, chief complaint and presenting symptoms, neurological and radiographic findings, treatment, outcome, and complications. Children with open neural tube defects and Chiari II malformations were excluded.

RESULTS:

Six pediatric patients were identified as meeting inclusion criteria. The average age at time of surgery was 14.8 years. The chief complaints were vision impairment in three children and numbness, gait instability, and headache worsened with Valsalva in one patient each. Other prominent symptoms included sleep apnea and weakness. All patients showed at least one cranial nerve dysfunction. Radiographs revealed hindbrain herniation and associated syringomyelia in all cases. Two patients had scoliosis. Treatment was posterior fossa decompression with cerebellar tonsillar shrinkage, opening of foramen of Magendie, and duraplasty. Two patients also required concomitant ventral decompression. The cavity of syringobulbia communicated with syringomyelia and the fourth ventricle in most children but was distinct from the fourth ventricle. Two patients received fourth ventricle to subarachnoid shunts. Follow-up averaged 3.2 years, and all patients clinically improved after surgery. Magnetic resonance imaging documented resolution of syringobulbia in all cases, with syringomyelia improving in all cases. There was no permanent morbidity or mortality in the series.

CONCLUSION:

Syringobulbia is strongly associated with Chiari malformation and syringomyelia, and patients often present because of cranial nerve palsies. Posterior fossa decompression is a safe and effective treatment.