Cauda equina schwannoma presenting with intratumoral hemorrhage and intracranial subarachnoid hemorrhage

Intramedullary Schwannoma of the Spinal Cord: A Nationwide Analysis by the Neurospinal Society of Japan

OBJECTIVE

This study was aimed to report the clinical characteristics of intramedullary schwannomas and discuss imaging findings and treatment strategies.

METHODS

The inclusion criterion was consecutive patients with intramedullary schwannomas who were surgically treated at 8 centers between 2009 and 2020. Clinical characteristics included age, sex, clinical presentation, disease duration, and follow-up period. The modified McCormick scale was used to compare the preoperative and postoperative conditions. Pre- and postoperative magnetic resonance images (MRI) of each case were analyzed.

RESULTS

The mean age of the total 11 patients at the operation was 50.2 years. The mean duration of the symptoms was 23 months, with limb paresthesia being the most common clinical presentation. The cervical spine was the most common localization level of the tumor in 6 cases. The mean follow-up duration was 49.4 months. Gross total resection (GTR) and subtotal resection (STR) was achieved in 9 and 2 cases, respectively. According to the modified McCormick scale at 6 months postoperatively, 7 cases (63.6%) had improved and 4 cases (36.3%) had unchanged grades. Typical MRI findings of the intramedullary schwannoma included ring-like enhancement, syringomyelia, cystic formation, intramedullary edema, and hemosiderin deposition. Gadolinium enhancement was homogenous in 8 cases (72.7%). The tumor margins were well demarcated in all cases.

CONCLUSION

Intramedullary schwannoma should be considered when sharp margins and well-enhanced tumors are present at the cervical spine level and the initial symptoms are relatively mild, such as dysesthesia. When GTR cannot be achieved, STR for tumor decompression is recommended.

Acute Neurological Aggravation Caused by Intratumoral Hemorrhage of a Cervical Dumbbell Schwannoma: Report of a Rare Case and Literature Review

Schwannomas are one of the most common types of primary intraspinal tumors. We report a rare case of neurological aggravation due to the intratumoral hemorrhage of a cervical schwannoma. A 65-year-old man presented with lower extremity weakness developing gradually. Tumor resection was performed one week after neurological aggravation occurred. After surgery, he recovered dramatically. There are vascular and mechanical hypotheses for the etiology of intratumoral hemorrhage of schwannoma. In the present case, falling and antiplatelet drugs may have caused the intratumoral hemorrhage. Optimal surgical timing remains controversial. Some reports reveal patients recovered well after urgent surgery. However, even if urgent surgery is performed, some have neurological sequelae. Others reveal patients recovered well after elective surgery without any sequelae. Because previous reports reveal the surgical procedure may damage the spinal cord, urgent surgery may not be compulsory and elective surgery may be a better treatment option. Further investigation is needed to clarify the etiology and optimal timing for surgical treatment of intratumoral hemorrhage.

Cancer Related Subarachnoid Hemorrhage: A Multicenter Retrospective Study Using Propensity Score Matching Analysis

Objective

To investigate the clinical features, risk factors and underlying pathogenesis of cancer related subarachnoid hemorrhage (SAH).

Methods

Clinical data of SAH in patients with active cancer from January 2010 to December 2020 at four centers were retrospectively reviewed. Patients with active cancer without SAH were matched to SAH patients with active cancer group. Logistic regression was applied to investigate the independent risk factors of SAH in patients with active cancer, after a 1:1 propensity score matching (PSM). A receiver operator characteristic curve was configured to calculate the optimal cut-off value of the joint predictive factor for cancer related SAH.

Results

A total of 82 SAH patients with active cancer and 309 patients with active cancer alone were included. Most SAH patients with cancer had poor outcomes, with 30-day mortality of 41.5%, and with 90-day mortality of 52.0%. The PSM yielded 75 pairs of study participants. Logistic regression revealed that a decrease in platelet and prolonged prothrombin time were the independent risk factors of cancer related SAH. In addition, receiver operator characteristic curve of the joint predictive factor showed the largest AUC of 0.8131, with cut-off value equaling to 11.719, with a sensitivity of 65.3% and specificity of 89.3%.

Conclusion

Patients with cancer related SAH often have poor outcomes. The decrease in platelet and prolonged prothrombin time are the independent risk factors of cancer related SAH, and the joint predictive factor with cutoff value equal to 11.719 should hence serve as a novel biomarker of cancer related SAH.

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.

Hemorrhagic Schwannoma of the Cauda Equina: Case Report and Review of the Literature

Spinal intradural hemorrhage is a rare event; the most common causes of spinal bleeding are traumas, medical therapy with anticoagulants and thrombolytics, vascular malformations, and congenital defects of coagulation. Rarely, spinal cord tumors may cause hemorrhage. Herein, we report the case of a patient with acute and quickly worsening lumbar pain: the neurological examination revealed a flaccid paraplegia caused by an intradural lesion extending on the right side of the spinal cord from T1 to L2 vertebral level. Pathological examination revealed an hemorrhagic schwannoma. Acute spinal subdural hemorrhage caused by spinal schwannomas is a very rare occurrence (29 cases only have been previously reported). Review of the literature with clinico-diagnostic features is presented, surgical treatment is explained, and pathological findings with possible etiopathogenesis of hemorrhage are described.

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.

Acute paraplegia due to thoracolumbar schwannoma following trauma: A case report and literature review

Spinal schwannomas account for one third of primary spinal neoplasms. Clinical presentation is related to the tumor location. An atypical case of acute paraplegia following a fall, on the ground of a thoracolumbar schwannoma, without intratumoral hemorrhage, in a previously asymptomatic patient is reported. A 58-year-old male patient presented with acute paraplegia, and urinary and bowel incontinence, following a fall. The patient had no previous history of back and/or leg pain or neurological symptoms. Magnetic resonance imaging revealed a subdural mass, as well as a fracture of the right T12-L1 facet joint and the right transverse process. The patient underwent emergency T11-L1 wide laminectomy, exploration of the subdural space and T10-L2 posterolateral transpedicular stabilization and fusion. An intradural, extramedullary mass, causing severe cord compression, was found and excised. Pathology revealed schwannoma, without intratumoral hemorrhage. The patient recovered completely 6 months postoperatively. To the best of our knowledge, this is the first report of spinal intradural schwannoma causing sudden paraplegia in a previously asymptomatic patient in the setting of trauma, without intratumoral hemorrhage. Emergency canal decompression and complete excision of the tumor represent the optimal management of such cases.

Spontaneous Subarachnoid Haemorrhage in Spinal Hemangioblastoma: Illustrative Case and Discussion of a Pathophysiological Hypothesis

Spontaneous non-aneurysmal subarachnoid haemorrhage (naSAH) is an unusual finding that could be burdened by significant mortality and morbidity rates. Rare pathologies and delayed diagnosis could be advocated as responsible of unfavourable outcomes. Herein, we describe an exceedingly rare giant lumbar spinal hemangioblastoma (80 × 23 mm) presenting as an intracranial naSAH. Based on our radiological and clinical findings a pathophysiological hypothesis linking intracranial naSAH to venous hypertension was discussed for the first time even among lumbar spinal tumors. Although rare, unusual causes should be investigated in presence of radiological atypical finding as a prompt evaluation and treatment could be needed.

Spinal schwannoma causes acute subarachnoid haemorrhage: A case report and literature review

BACKGROUND

Spinal schwannomas that arise from spinal nerve root sheaths are the most common intradural extramedullary spinal tumours and are often accompanied by nerve roots or spinal cord irritation symptoms. The phenomenon of spinal schwannoma causing subarachnoid haemorrhage (SAH) is rare, with ependymoma of the conus medullaris accounting for most cases.

CASE REPORT

A 45-year-old man was admitted to our hospital due to progressive lower limb weakness and sudden back pain after hard physical work. The patient had not been able to walk for 2hours upon admission. An emergency magnetic resonance imaging (MRI) scan showed that the spinal cord at the C6-T4 level was severely compressed by a subdural mass. During the emergency operation, exploration of the dura and arachnoid mater revealed a fresh blood clot covering a tumour located on the ventral side of the spinal cord. The size of the tumour was approximately 3×2×1cm without adhesion to the surrounding tissue, but the drainage vein was ruptured. Postoperative pathology showed that the tumour was a schwannoma with areas of fresh haemorrhage and focal necrosis.

CONCLUSIONS

Spinal schwannomas presenting with SAH are rare events. In our opinion, spinal pathology with rapid progression of neurological symptoms requires early diagnosis and emergency management. Complete excision of haemorrhagic tumours is the goal of treatment to prevent recurrence, which can effectively avoid irreversible damage to the spinal cord resulting from spinal cord compression.

Natural reduction in acute intratumoral hemorrhage of spinal schwannoma in the cauda equina

A 58-year-old woman presented with acute pain in her back and her left leg. Magnetic resonance imaging (MRI) revealed an intradural schwannoma with an intratumoral hemorrhage between the lower L4 vertebra and L5/S1 disk level. A follow-up MRI after one month revealed that the tumor had regressed from the middle of L5 to the L5/S1 disk level. The tumor was totally resected. There have been several reports of intratumoral hemorrhage of spinal schwannomas occurring at the cervical, thoracic, and conus levels; however, there has been only one previous report of it being seen at the L2-3 middle lumbar level and none at all at lower lumbar levels. This is the first report of an intratumoral hemorrhage of a schwannoma in the lower lumbar area. Furthermore, natural regression of an intratumoral hemorrhage of spinal schwannoma at lower lumbar levels has not previously been reported.

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.

Spinal subarachnoid hemorrhage and aneurysms

Spinal subarachnoid hemorrhage (SAH) is a rare disease. Spinal aneurysms are even rarer and mostly undetected unless they rupture and become symptomatic. In this chapter we aim to review the available literature about spinal subarachnoid hematoma with special emphasis on spinal aneurysms. As most reports of spinal aneurysms describe a single case or a small case series, the diagnostic algorithm is often lacking. The outcome is also different based on the etiologies; therefore management strategy must be individualized. We addressed these issues in this chapter. The reported incidence of spinal SAH is less than epidural hematoma and more than subdural hematoma. Spinal aneurysms can present as isolated entity or can be associated with other vascular anomalies. Microsurgical clipping and/or resection is possible, especially when they are located dorsally or dorsolaterally. Endovascular approach is also a feasible option unless negotiation of microcatheter becomes difficult in tortuous small-caliber arteries. Successful obliteration leads to good outcome, especially when present in posterior spinal artery. A detailed knowledge of spinal SAH and spinal aneurysms is important to detect them in time. Clinicians must consider several factors to choose an appropriate treatment strategy to ensure the safety of their patients.

Hemorrhagic thoracic schwannoma presenting with intradural hematoma and acute paraplegia after spinal manipulation therapy

Hemorrhagic conversion of spinal schwannomas represents a rare occurrence; also rare is the development of a spinal intradural hematoma after spinal manipulation therapy. We report a unique presentation of paraplegia in a patient who underwent spinal manipulation therapy and was found to have a hemorrhagic thoracic schwannoma at time of surgery in the setting of anti-platelet therapy use. In patients with spinal schwannomas, tumor hemorrhage is a rare occasion, which can be considered in the setting of additive effects of spinal manipulation therapy and antiplatelet therapy.

Spinal Intradural Schwannoma with Acute Intratumoural Haemorrhage: Case Report and Review

Schwannomas account for around half of all intradural spinal tumours, with chronic progressive symptoms as the most common presenting features. Intratumoural haemorrhage as a presenting feature of spinal schwannoma is very rare and only 11 cases have been reported till date. Authors here report a previously asymptomatic 40-year-old male who presented with acute onset paraplegia 12 hours after a minor trauma. MR imaging revealed a C7-D3 intradural-extramedullary lesion with features of acute blood and showing no enhancement. Emergency laminectomy and complete removal of the mass was performed and histopathology revealed features of schwannoma with haemorrhage. Patient had modest improvement of his neurological deficits at a follow-up of 6 months. Pertinent literature is reviewed in brief.