Symptomatic Tarlov Cyst Following Spontaneous Subarachnoid Hemorrhage

Abstract

A 75-year-old woman was transferred to the emergency room, complaining of severe headache of sudden onset, low back pain, nausea, and dizziness. She was alert and oriented. She had signs of meningeal irritation, but the neurological examination was otherwise normal. Brain CT revealed SAH in the right Sylvian fissure and basal cistern. Three-dimensional brain CT angiography showed a right middle cerebral artery aneurysm. Emergent craniotomy via right-sided pterional approach without installation of lumbar cerebrospinal fluid (CSF) drain and neck clipping of the aneurysm was performed uneventfully under general anesthesia.Following operation, she complained of worsening pain in the lumbosacral, buttock, and the posterior aspect of the right thigh. The pain was intermittent at onset and exacerbated by sitting, walking, and coughing. Bed rest relieved the pain. She had no history of previous back problems, or recent trauma. On neurological examination, no abnormal findings were found. Lumbar spine MR images 2 weeks postoperatively showed a 15×15×16 mm Tarlov cyst at the S2 level affecting the right S2 root with high signal intensity in T2 and T1 images, suggestive of bleeding within the cyst and a so-called "dark disc" at multilevel lumbar spines (Fig. 1). She suffered from pain despite analgesics and physical therapy for 2 weeks after MR imaging.CT-guided aspiration of the cyst was performed and approximately 1 cc of old blood was aspirated (Fig. 2). Her pain was relieved immediately after aspiration and she had only mild dis- INTRODUCTIONTarlov or perineurial cysts were first described by Tarlov in 1938 as an incidental finding during autopsy studies of the filum terminale. The cysts arise at the junction of the dorsal root ganglion and the posterior nerve root and develop between the endoneurium and perineurium and are most often found in the sacral region 2,12) . The prevalence of perineurial cysts has been reported in 9% of autopsy specimens before the magnetic resonance (MR) era and estimated to be approximately 1.5-4.6% in large series using MR images 4,9,10) . Although cases of Tarlov cysts causing coccydynia, sacral pain, sacral radiculopathies, and sacral insufficiency fractures have been reported, most Tarlov cysts remain asymptomatic throughout the patient's life 1,4) . Most of the cysts are found incidentally during computed tomography (CT) or MR imaging for other reasons and 13-22% of the patients with the cysts had symptoms 4,9) . Why some of the Tarlov cysts progress to cause symptoms is unclear. These cysts may become symptomatic by local compression of adjacent bone or displacing nerve roots, if they become large 1,4) . Hemorrhage has been suggested as one of the possible causes of these cysts and trauma with resultant hemorrhage into the subarachnoid space has been suggested as an origin of these cysts 6,7,12) . However, symptomatic Tarlov cysts related to spontaneous SAH have not been reported. We report a J Korean Neurosurg Soc 50 : 123-125, 2011 http://dx.doi.org/10.3340/jkns.2011 Copyright ©...

Multiple Sacral Perineurial Cysts Presented Symptoms Triggered by Nonaneurysmal Perimesencephalic Subarachnoid Hemorrhage

“…The patient relieved from pain after CT-guided aspiration of the cyst, and 1 cc of old blood was aspirated from the cysts, which proved the accumulation of the SAH into the cysts. 10) In our case, the perineurial cysts presented symptoms 4 days after the onset of the SAH. Assuming that it takes a few days for the accumulation of the SAH into the sacral cysts to become symptomatic, this time lag appears to be reasonable.…”

“…To the best of our knowledge, there is only one previous report of symptomatic perineurial cysts related to the aneurysmal SAH, 10) and our case is the first report of those triggered by NAPH. In the previous report, the patient complained of worsening pain in the lumbosacral, buttock, and the posterior aspect of the right thigh, following neck clipping of ruptured aneurysm.…”

“…In the previous report, the patient complained of worsening pain in the lumbosacral, buttock, and the posterior aspect of the right thigh, following neck clipping of ruptured aneurysm. 10) The pain was intermittent at onset and exacerbated by, sitting, walking, and coughing. The patient relieved from pain after CT-guided aspiration of the cyst, and 1 cc of old blood was aspirated from the cysts, which proved the accumulation of the SAH into the cysts.…”

Incomplete cauda equina syndrome secondary to haemorrhage within a Tarlov cyst

“…Kong et al reported a case of a symptomatic perineural cyst secondary to spontaneous haemorrhage into the subarachnoid space 17. The authors suggested that the haemorrhage resulted in increased hydrostatic pressure of CSF, which leads to the infiltration of CSF and haemorrhage into a pre-existing perineural cyst.…”

Epidural blood patch treatment for headache caused by a ruptured Tarlov cyst

“…They are found most often in the sacral roots 1 and, rarely, cause symptoms related to nerve root compression. 2 The literature is limited when it comes to the management of these ruptured cysts.…”