Subarachnoid hematoma of the craniocervical junction and upper cervical spine after traumatic cerebral contusion: case report

Traumatic Spinal Subarachnoid Hemorrhage With Spinal Cord Compression: A Case Report and Literature Review

The occurrence of spinal hematoma is rare, and differentiation between subarachnoid hemorrhage and subdural hemorrhage on neuroradiological imaging can be challenging. Spinal subarachnoid hemorrhage (SSAH) is less frequently associated with trauma and can result in severe neurological impairment. We report the case of a 53-year-old man who presented with severe motor and sensory deficits primarily of the left arm without further neurological deficits in the other extremities after a fall from a height of six meters. Magnetic resonance imaging (MRI) showed an acute intradural hematoma at the C4-C6 level with significant spinal cord compression. Surgery revealed a hematoma enclosed by an arachnoid layer. Two months later, MRI showed complete resolution of spinal cord edema and avulsion of the left C6 and partially C7 nerve roots, corresponding to electromyography findings revealing a brachial plexus avulsion. Nine months after the accident and five months after surgical repair of the brachial plexus avulsion, there was a significant improvement in the sensory and motor functions of the left arm, allowing the patient to manage daily activities independently. Patients with neurological deficits following spinal trauma should be evaluated for spinal cord compression, such as intraspinal hematoma, as soon as possible to enable early spinal decompression. We describe a rare case of traumatic SSAH and brachial plexus avulsion following successful surgical decompression of the spinal cord without clinical postoperative myelopathy.

Perineural cyst with intracystic hemorrhage following aneurysmal subarachnoid hemorrhage: A case report

RATIONALE

Most perineural cysts are asymptomatic and discovered incidentally at the time of imaging. Although enlargement of the perineural cyst (PC) through a ball-valve mechanism and resultant compression of the adjacent neural or bony structures are known to be a source of pain in PCs, the reason why asymptomatic PCs become symptomatic is unclear. The authors report a case of PC, which was presumed to become symptomatic after subarachnoid hemorrhage without enlargement of the pre-existing PC.

PATIENT CONCERNS

A 47-year-old woman complained of lumbosacral pain after neck clipping for a ruptured cerebral aneurysm.

DIAGNOSES

Magnetic resonance imaging (MRI) revealed a PC with intracystic hemorrhage at the S2 level. In comparison with the size of the PC on computed tomography performed 3 years ago, there was no change in the size. Electrodiagnostic studies performed 6 weeks after the onset of the pain showed subacute right S2 radiculopathy.

INTERVENTIONS

With conservative treatment, her pain gradually diminished.

OUTCOMES

When the lumbosacral pain improved, follow-up MRI showed that a fluid-fluid level within the PC disappeared.

LESSONS

Hemorrhage from the subarachnoid space, such as spontaneous aneurysmal SAH, into the pre-existing PC can cause an asymptomatic PC to become symptomatic without getting enlarged. Stretching of the nerve root due to hemorrhage or irritation of the nerve root due to an inflammatory reaction to blood products can make asymptomatic PCs symptomatic without enlargement of PCs.

Brown-Séquard syndrome and cervical post-traumatic subarachnoid hematoma

Cervical Traumatic SSH are very rare in literature. They are usually caused by cardiopulmonary diseases that increase vascular pressure causing spinal vessels rupture. In thoracolumbar spine, the spinal puncture is the most common cause. The ventrolateral position is even more unusual. In traumatic brain injury (TBI), an abrupt extension-flexion movement could have caused the rupture of subarachnoid vessels. This, accompanied by the slowed blood "wash out" (probably due to the previous osteoarthrosis and spinal canal stenosis), led to the formation of an organized clot, which caused an acute spinal cord compression syndrome. Cervical subarachnoid spinal hematoma can present as Brown-Séquard syndrome. The treatment is prompt surgical removal and decompression. The posterior approach (partial hemilaminectomy with or without laminoplasty) with microsurgical technique is feasible, fast and simple to evacuate the hematoma with good results. Surgical nuances in posterior approach are: small spinal canal, difficulty in mobilizing the cervical cord, these haematomas are wrapped and attached to the spinal cord or nerve roots by multiple arachnoid bands, requiring techniques of Microdissection for its evacuation unlike the epidural and subdural haematomas that are easily aspirated. Here, we report a unique case of a ventrolateral SSH due to TBI.

Spinal Subarachnoid Hemorrhage Migrated from Traumatic Intracranial Subarachnoid Hemorrhage

Very rarely, spinal subarachnoid hemorrhage (SSAH) can occur without any direct spinal injury in patients with traumatic intracranial SAH. A-59-year-old male with traumatic intracranial subarachnoid hemorrhage (SAH) presented with pain and numbness in his buttock and thigh two days after trauma. Pain and numbness rapidly worsened and perianal numbness and voiding difficulty began on the next day. Magnetic resonance imaging showed intraspinal hemorrhage in the lumbosacral region. The cauda equina was displaced and compressed. Emergent laminectomy and drainage of hemorrhage were performed and SSAH was found intraoperatively. The symptoms were relieved immediately after the surgery. Patients with traumatic intracranial hemorrhage who present with delayed pain or neurological deficits should be evaluated for intraspinal hemorrhage promptly, even when the patients had no history of direct spinal injury and had no apparent symptoms related to the spinal injury in the initial period of trauma.