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Neurology India, Vol. 58, No. 1, January-February, 2010, pp. 155-156 Letter To Editor Spinal schwannoma: An unusual cause of acute subarachnoid hemorrhage Liyong Sun, Zan Chen, Fengzen Jian, Feng Ling Department of Neurosurgery, Xuan Wu Hospital of Capital Medical University, Beijing-100053, China. Correspondence Address: Department of Neurosurgery, Xuan Wu Hospital of Capital Medical University, Beijing-100053, China, neuronsun@yahoo.com.cn Date of Acceptance: 09-Oct-2009
Code Number: ni10044 DOI: 10.4103/0028-3886.60430 Sir, A 32-year-old man presented with acute onset of severe headache and backache following sneezing. Neurological examination was normal except for nuchal rigidity. Computed tomography (CT)of head was normal and no evidence of subarachnoid hemorrhage (SAH). Multiple lumbar punctures showed bloody CSF with many RBCs. Both cerebral and spinal angiography were negative for aneurysm or arteriovenous malformation (AVM). Magnetic resonance imaging (MRI) of the spine revealed a 1.5 x 2 x 1 cm intradural extramedullary tumor at the level of T4-5 [Figure - 1]. The lesion was of heterogeneous signal intensity both on T1 and T2-weighted images with irregular enhancement. Flow void signals were presented intradurally on T2-weighted images in the peritumoral region suggesting dilated vessels. Surgical total resection of the tumor confirmed benign schwannoma on histopathological examination. Some subdural blood clots and dilated veins were also found intraoperatively [Figure - 2]. The patient was discharged with improved symptoms and without any neurologic deficits. Subarachnoid hemorrhage of spinal origin accounts for less than 1% of all SAH. [1] The common causes of spinal SAH include trauma, AVMs or aneurysms of spinal arteries. [2] Additionally, both primary and metastatic spinal tumors can present with SAH. The majority of these cases are attributed to ependymoma of the conus medullaris,which is the common spinal tumor associated with SAH. Nerve sheath tumors are rarely the cause for spinal SAH, more so with thoracic localization Two main theories have been proposed to explain this rare phenomenon in patients with spinal nerve sheath tumors. The mechanical theory [3] suggests that traumatic displacement may occur at the interface between the tumor and the normal nerve tissue, which causes a hemorrhage extending into the subarachnoid space. In the present case, the patient′s sneeze might have resulted in a tractional force resulting in a disruption of the vessels attached to the tumor. The location of the tumor may have a bearing. A relatively large space in the spinal canal, such as in the conus medullaris or cauda equine region may make this shearing force produce more displacement between the tumor and vascular attachments. The vascular theory proposes that sponateous thrombosis of the vessels in and around the tumor may result in vessel wall necrosis and hemorrhage, especial with large, rapidly growing, highly malignant, and highly vascular tumors. [4] We assume in the present case the spinal SAH is probably related to the rupture of this peritumoral dilated venous complex. In summary, we presented this case to emphasize that spinal schwsnnoma should be considered and whole spinal MRI scanning should be considered as a noninvasive adjunctive examination in cases of angiographic negative SAH, especially when patients have first onset of spinal symptoms. References
Copyright 2010 - Neurology India The following images related to this document are available:Photo images[ni10044f1.jpg] [ni10044f2.jpg] |
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