Neurofibroma manifested by spinal subarachnoid hemorrhage

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.

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.

A Rare Case of Pediatric Lumbar Spinal Ependymoma Mimicking Meningitis

Spontaneous acute subarachnoid hemorrhage (SAH) from lumbar ependymoma in children is rare. We report a case of a 14-year-old boy who developed sudden radicular low back pain while playing baseball. He was initially managed conservatively in a local hospital for suspected lumbar disc herniation, but he later developed meningeal symptoms and fever before being referred to our hospital. He underwent a diagnostic lumbar puncture in the emergency department; his cerebrospinal fluid suggested an SAH. Physical examination showed meningeal signs and cauda equina features. Cerebrospinal fluid analysis was negative for bacterial meningitis. Lumbar magnetic resonance imaging revealed a mass characterized as a hemorrhagic lesion. The patient had an emergent evacuation of the mass through the posterior approach. Postoperatively, his symptoms resolved completely. The histologic diagnosis was, surprisingly, an ependymoma (World Health Organization grade II). This case is particularly interesting because of its rarity in children, and its pattern of presentation. Although bacterial or viral meningitis is the most frequent cause of meningeal features in children, SAH from a hemorrhagic spinal tumor should be considered. Ultimately, a high index of suspicion is needed for prompt diagnosis.

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.

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.