Syringomyelia and spinal arachnoiditis resulting from aneurysmal subarachnoid hemorrhage: Report of two cases and review of the literature

Delayed spinal arachnoiditis with syringomyelia following aneurysmal subarachnoid haemorrhage: a case report with patient experience

BACKGROUND AND IMPORTANCE

Syringomyelia, or the formation of fluid-filled cysts within the spinal cord, associated with delayed spinal arachnoiditis is an uncommon complication of aneurysmal subarachnoid haemorrhage. To date, about 18 cases have been reported in medical literature, with just two reported in patients under the age of 35 years.

CLINICAL PRESENTATION

A 27-year-old female patient complained of sudden, severe headaches in the occipital region, nuchal rigidity, and drowsiness when she presented at our institution. A head computed tomography scan revealed intraventricular bleeding in the lateral and fourth ventricles with more extensive haemorrhaging in the frontal horns. A left posterior inferior cerebellar artery (PICA) aneurysm was confirmed via digital subtraction angiogram, and endovascular embolization was done. Two years later, the patient reported intense pain in the lower back along with symptoms suggestive of spinal cord compression. Spinal magnetic resonance imaging (MRI) showed spinal adhesions from C1 to L4, syringomyelia with some vasogenic oedema extending from T3 to T9 level, and a cyst in the lumbar region. Consequently, a right hemilaminectomy was performed along with microsurgical release of arachnoid adhesions and placement of a subdural drain. Radiological and symptomatic improvements were observed. Since then, the patient's clinical condition has remained stable during the past three years of follow-up visits.

CONCLUSIONS

Literature on optimal treatment modalities and patient prognosis is scarce and debated. The time for symptom improvement depends on the level and extent of spinal cord involvement. Rehabilitation may be required for most patients, as complete symptomatic recovery may not be attainable.

Craniovertebral and spinal adhesive arachnoiditis: a late complication of ruptured vertebral and posterior inferior cerebellar arteries aneurysms

BACKGROUND

Adhesive arachnoiditis is a rare yet serious complication that may occur following subarachnoid hemorrhage (SAH). In this circumstance, it is mainly due to ruptured vertebral artery (VA) or posterior inferior artery (PICA) aneurysms. It disrupts cerebrospinal fluid (CSF) flow leading to complications such as spinal arachnoiditis, syringomyelia, trapped 4th ventricle, or a combination of these conditions. Evidence for effective treatment strategies is currently limited. We aimed to review the epidemiology, clinical characteristics, treatment, complications, outcomes, and prognosis of cranio-vertebral junction and spinal adhesive arachnoiditis resulting from ruptured VA and PICA aneurysms.

METHODS

This study involved a comprehensive literature review and complemented by our own case. We focused on adult cases of arachnoiditis, syringomyelia, and trapped 4th ventricle with SAH caused by ruptured VA or PICA aneurysms, excluding cases unrelated to these aneurysms and those with insufficient data.

RESULTS

The study included 22 patients, with a mean age of 52.4 years. Symptoms commonly manifest within the first year after SAH and timely diagnosis requires a high index of suspicion. Treatment approaches included lysis of adhesions and various shunt procedures. Most patients showed improvement post-treatment, though symptom recurrence is significant.

CONCLUSION

Adhesive arachnoiditis is a critical complication following SAH, most commonly from ruptured VA and PICA aneurysms. Early detection and individualized treatment based on the type of arachnoiditis and CSF flow impact are crucial for effective management. This study underscores the need for tailored treatment strategies and further research in this field.

New histopathological evidence for the relationship between hydromyelia and hydrocephalus following subarachnoid hemorrhage: An experimental study

Objectives

Subarachnoid hemorrhage (SAH) is a serious pathology with a high death and morbidity rate. There can be a relationship between hydromyelia and hydrocephalus following SAH; however, this subject has not been well investigated.

Materials and Methods

Twenty-four rabbits (3 ± 0.4 years old; 4.4 ± 0.5 kg) were used in this study. Five of them were used as the control, and five of them as the SHAM group. The remaining animals (n = 14) had been used as the study group. The central canal volume values at the C1-C2 levels, ependymal cells, numbers of central canal surfaces, and Evans index values of the lateral ventricles were assessed and compared.

Results

Choroid plexus edema and increased water vesicles were observed in animals with central canal dilatation. The Evans index of the brain ventricles was 0.33 ± 0.05, the mean volume of the central canal was 1.431 ± 0.043 mm3, and ependymal cells density was 5.420 ± 879/mm2 in the control group animals (n = 5); 0.35 ± 0.17, 1.190 ± 0.114 mm3, and 4.135 ± 612/mm2 in the SHAM group animals (n = 5); and 0.44 ± 0.68, 1.814 ± 0.139 mm3, and 2.512 ± 11/mm2 in the study group (n = 14). The relationship between the Evans index values, the central canal volumes, and degenerated ependymal cell densities was statistically significant (P < 0.05).

Conclusions

This study showed that hydromyelia occurs following SAH-induced experimental hydrocephalus. Desquamation of ependymal cells and increased cerebrospinal fluid secretion may be responsible factors in the development of hydromyelia.

Spinal arachnoiditis leading to recurrent reversible myelopathy: A case report

Context: A patient followed in the outpatient spinal cord injury support clinic at a VA Medical Center with a prior remote history of a gunshot wound to the back and multiple prior myelograms presented with a recurrent waxing and waning weakness of the left lower extremity and intermittent incontinence of bowel and bladder.Findings: During the evaluation, the patient experienced an immediate albeit temporary improvement in symptoms after a diagnostic lumbar puncture performed for CT myelogram. The symptoms of myelopathy reoccurred several weeks, but then the patient had a similar experience with rapid improvement in symptoms after an accidental fall down a flight of steps. Subsequently, the foot weakness and incontinence returned one week later. The patient ultimately developed permanent improvement in signs and symptoms after surgical intervention which included intradural lysis of adhesions, incision of the arachnoid membrane and resection of a cystic lesion.Clinical relevance: Patients who experience unexpected, albeit transient improvement in myelopathic symptoms who are known or suspected to have arachnoiditis should be evaluated for surgically remediable lesions. Remediation of these lesions can potentially improve long term outcome.

Immunotherapies in chronic adhesive arachnoiditis - A case series and literature review

Chronic spinal adhesive arachnoiditis (CSAA) is a rare condition with limited therapeutic options. Surgical treatment proves effective in approximately 60% of cases. Conservative treatment options have not been extensively investigated. Here, we report the course of the disease, analyze the effect of immune treatments in patients with CSAA who were treated in the University Hospital Essen between 2015 and 2020, and conduct a literature review. Three out of four patients showed no improvement after treatment with corticosteroids, methotrexate, or plasmapheresis. All non-responders suffered from CSAA for several years, while one patient who had a disease duration of less than one month fully recovered. It is necessary to verify whether treatment at an early stage of the disease is better than treatment after chronic adhesion manifestation, as it interrupts the development of adhesions and all subsequent complications.

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Surgical treatment of CSAA patients proves effective in approx. 60% of cases.

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High-dose steroid treatment may be effective in early stages of CSAA.

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Only conservative therapy cannot be recommended in long-standing CSAA.

Sudden death and cervical spine: A new contribution to pathogenesis for sudden death in critical care unit from subarachnoid hemorrhage; first report - An experimental study

Context:

Sudden death from subarachnoid hemorrhage (SAH) is not uncommon.

Aims:

The goal of this study is to elucidate the effect of the cervical spinal roots and the related dorsal root ganglions (DRGs) on cardiorespiratory arrest following SAH.

Settings and Design:

This was an experimental study conducted on rabbits.

Materials and Methods:

This study was conducted on 22 rabbits which were randomly divided into three groups: control (n = 5), physiologic serum saline (SS; n = 6), SAH groups (n = 11). Experimental SAH was performed. Seven of 11 rabbits with SAH died within the first 2 weeks. After 20 days, other animals were sacrificed. The anterior spinal arteries, arteriae nervorum of cervical nerve roots (C6–C8), DRGs, and lungs were histopathologically examined and estimated stereologically.

Statistical Analysis Used:

Statistical analysis was performed using the PASW Statistics 18.0 for Windows (SPSS Inc., Chicago, Illinois, USA). Intergroup differences were assessed using a one-way ANOVA. The statistical significance was set at P < 0.05.

Results:

In the SAH group, histopathologically, severe anterior spinal artery (ASA) and arteriae nervorum vasospasm, axonal and neuronal degeneration, and neuronal apoptosis were observed. Vasospasm of ASA did not occur in the SS and control groups. There was a statistically significant increase in the degenerated neuron density in the SAH group as compared to the control and SS groups (P < 0.05). Cardiorespiratory disturbances, arrest, and lung edema more commonly developed in animals in the SAH group.

Conclusion:

We noticed interestingly that C6–C8 DRG degenerations were secondary to the vasospasm of ASA, following SAH. Cardiorespiratory disturbances or arrest can be explained with these mechanisms.

Longitudinal measurements of syrinx size in a rat model of posttraumatic syringomyelia

OBJECTIVE Syringomyelia pathophysiology is commonly studied using rodent models. However, in vivo studies of posttraumatic syringomyelia have been limited by the size of animals and lack of reliable noninvasive evaluation techniques. Imaging the rat spinal cord is particularly challenging because the spinal cord diameter is approximately 1-3 mm, and pathological lesions within the spinal cord parenchyma are even smaller. The standard technique has been histological evaluation, but this has its limitations. The aim of the present study was to determine whether syrinx size could be reliably measured using a preclinical high-field MRI animal system in a rat model of posttraumatic syringomyelia. METHODS The authors used an existing rat model of posttraumatic syringomyelia, which was created using a controlled pneumatic compression device to produce the initial spinal cord injury, followed by a subarachnoid injection of kaolin to produce arachnoiditis. T2-weighted MRI was performed on each animal using a 9.4-T scanner at 7, 10, and 13 weeks after injury. Animals were killed and syrinx sizes were calculated from in vivo MRI and histological studies. RESULTS MRI measurements of syrinx volume and length were closely correlated to histological measurements across all time points (Pearson product moment correlation coefficient r = ± 0.93 and 0.79, respectively). CONCLUSIONS This study demonstrates that high-field T2-weighted MRI can be used to measure syrinx size, and data correlate well with syrinx size measured using histological methods. Preclinical MRI may be a valuable noninvasive technique for tracking syrinx formation and enlargement in animal models of syringomyelia.