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

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.

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.

A Rare Chronic Presentation of Schwannoma with Hemorrhage

Spinal schwannomas are slow-growing benign tumors arising from the nerves. In the spinal cord, they arise most commonly from cervical and lumbar levels. They are mostly intradural extramedullary (IDEM) accounting for 30% of intradural tumors showing a female preponderance. They are seen occurring between 25 and 50 years of age. Most of these cases show acute presentation as hemorrhage within the tumor with weakness. This is a rare presentation by itself reported by only 12 cases world over. It is even rarer to see them show chronic presentation. We are reporting one such case of a 61-year-old female who presented to us with chronic low backache for 3 years with radicular symptoms in the bilateral lower limbs following a fall on her back. Magnetic resonance imaging was done which showed a well-defined IDEM lesion from L3 to L5 vertebral level which was isointense on T1 and hyperintense on T2 with a peripheral rim and short inversion time inversion-recovery showed fluid-fluid level within. Gradient-recalled echo showed blooming with no suppression on fat-sat and no diffusion restriction. A computed tomography angiography was done which ruled out vascular malformation. Intraoperatively, a large feeding vessel with a tumor was visualized after laminectomy was done for the corresponding levels. Postoperatively, the patient showed a significant decrease in radicular symptoms and was discharged after 2 weeks with an uneventful postoperative period. HPE of the lesion showed sheets of fascicles of elongated spindle cells arranged in loose myxoid matrix with hyperchromatic nuclei and scanty hemorrhage and lymphocytic infiltrates suggestive of schwannoma with myxoid degeneration. Immunohistochemistry also confirmed a diagnosis of schwannoma. From this case, it is seen that the diagnosis of a spinal schwnnoma showing delayed presentation with atypical imaging findings is a challenge and must needs a high index of suspicion and appropriate surgical planning.

Haemosiderin cap sign in cervical intramedullary schwannoma mimicking ependymoma: how to differentiate?

A 37-year-old female presented with gradually progressive asymmetric ascending paraesthesia and weakness involving bilateral upper and lower limbs. The MRI spine images revealed expansile intramedullary, solid cystic, peripherally enhancing lesion with a haemosiderin cap along the lower margin. The lesion extended into the left C5 and C6 nerve root exit zones, along with thickening and enhancement of the nerve roots. She underwent excision of the lesion, which revealed intramedullary schwannoma on histopathological examination. Presence of the cap, an extension of the lesion into the nerve root exit zone, with associated thickening and enhancement of the dorsal nerve roots should alert the radiologist to consider the possibility of intramedullary schwannoma rather than ependymoma. Schwannoma showing compact Antoni A area with Schwannian whorls and nuclear palisades (A,B) and loose Antoni B area with haemosiderin pigment (C). The tumour exhibits diffuse positivity for S-100 protein (D) and negativity for GFAP (E). [Stain: A-C: Haematoxylin and Eosin; D,E: Immunoperoxidase. Magnification = Scale Bar, A-E: 100μm].

Hemorrhagic Spinal Schwannoma in Thoracolumbar Area with Total Paraplegia

Hemorrhagic schwannoma in the medulla spinalis is a rare occurrence. It is a variant of the slow-growing nerve sheath tumor that usually has subtle clinical symptoms. Injury to the spinal schwannoma that was previously suspected by spinal manipulations may accelerate the progression of symptoms and cause an acute presentation of paraplegia. We report a case of a patient that was suspected of an intradural tumor with paraparesis that initially refused treatment. Spinal manipulation procedures were performed outside of the hospital setting with subsequent advancement of paraparesis. A surgical intervention was performed, which found that the tumor mass has grown along with hemorrhage within the schwannoma. The bleeding within the mass may have caused the acute paraplegia that is rarely reported. The patient had a fair improvement on her lower motor extremity function from 1-2 to 3-4 out of 5 at six-month follow-up.