Cauda equina schwannoma presenting with intratumoral hemorrhage and intracranial subarachnoid hemorrhage

Abstract

<jats:p>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.</jats:p>

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

“…Bleeding can occur within the tumor (34%), 6,11,12,17,22,25,26,27,28,30) between the inner layer of the dura mater and the arachnoid mater of the meninges (subdural hematoma: 22%) 4,5,8,9,16,18,19) or into the subarachnoid space (subarachnoid hemorrhage: 16%) 7,10,20,21,24) ; multiple sites can also be involved (13%), such as intratumoral bleeding with subdural hematoma 2,23,29) or subarachnoid hemorrhage. 13) The clinical picture is clearly different from that of spinal non-hemorrhagic schwannomas, commonly causing slowly progressive symptoms or spinal pain. Most frequent neurological symptoms at clinical presentation are acute and sudden (91%), due to the rapid compression of neural structures by bleeding from lesion; depending on the site involved, flaccid paraplegia, pain, urinary incontinence or retention, and impaired sensitivity depict the clinical presentation.…”

Intralesional and subarachnoid bleeding of a spinal schwannoma presenting with acute cauda equina syndrome

“…Intratumoural haemorrhage in spinal cord schwannoma are rare and a consequent acute neurological deficit may be its first clinical finding 8 9. In case of intratumoural bleeding or SAH in patients with spinal schwannoma, literature reports two different theories: the vascular and the traumatic one 10–12. According to the vascular theory, ectasic and thin vessels of the tumour may undergo thrombosis with tumour necrosis and intratumoural haemorrhage 13.…”

“…According to the vascular theory, ectasic and thin vessels of the tumour may undergo thrombosis with tumour necrosis and intratumoural haemorrhage 13. The mechanical theory, instead, suggests that traction forces at the interface between the tumour and the surrounding neuronal tissue justified the bleeding of the superficial vascular structure of the tumour capsula; a spinal trauma may cause the acute vascular damage and the bleeding is predominantly localised in the subarachnoid space 12. In our case, the presence of mixed intensity within the tumour in the T2-weighted MRI (figure 2A,B) was highly suggestive of the presence of blood degradation products inside the tumour related to a recent bleeding episode.…”

A rare case of spinal schwannoma in a child presenting with subarachnoid hemorrhage: A case report with review of literature

“…A thorough search of literature led us to only 22 cases of spinal schwannomas with SAH till now. [ 6 29 30 ] In literature review that has the largest series on spinal schwannomas with SAH, Parmar et al . [ 6 ] identified 20 reports of spinal nerve sheath tumors that caused SAH, of which only 8 cases (28%) presented exclusively with intracranial symptoms as in our patient.…”