Solitary Ruptured Aneurysm of the Spinal Artery of Adamkiewicz with Subarachnoid Hemorrhage

Spinal subarachnoid hemorrhage (SAH) due to solitary spinal aneurysm is extremely rare. A 45-year-old female patient visited the emergency department with severe headache and back pain. Imaging studies showed cerebral SAH in parietal lobe and spinal SAH in thoracolumbar level. Spinal angiography revealed a small pearl and string-like aneurysm of the Adamkiewicz artery at the T12 level. One month after onset, her back pain aggravated, and follow-up imaging study showed arachnoiditis. Two months after onset, her symptoms improved, and follow-up imaging study showed resolution of SAH. The present case of spinal SAH due to rupture of dissecting aneurysm of the Adamkiewicz artery underwent subsequent spontaneous resolution, indicating that the wait-and-see strategy may provide adequate treatment option.     

Intracranial Extension of Spinal Subarachnoid Hematoma Causing Severe Cerebral Vasospasm

Spinal subarachnoid hemorrhages (SAH) can extend into the intracranial subarachnoid space, but, severe cerebral vasospasm is rare complication of the extension of intracranial SAH from a spinal subarachnoid hematoma. A 67-year-old woman started anticoagulant therapy for unstable angina. The next day, she developed severe back pain and paraplegia. MRI showed intradural and extramedullar low signal intensity at the T2-3, consistent with intradural hematoma. High signal intensity was also noted in the spinal cord from C5 to T4. We removed subarachnoid hematoma compressing the spinal cord. The following day, the patient complained of severe headache. Brain CT revealed SAH around both parietal lobes. Three days later, her consciousness decreased and left hemiplegia also developed. Brain MRI demonstrated multiple cerebral infarctions, mainly in the right posterior cerebral artery territory, left parietal lobe and right watershed area. Conventional cerebral angiography confirmed diffuse severe vasospasm of the cerebral arteries. After intensive care for a month, the patient was transferred to the rehabilitation department. After 6 months, neurologic deterioration improved partially. We speculate that surgeons should anticipate possible delayed neurological complications due to cerebral vasospasm if intracranial SAH is detected after spinal subarachnoid hematoma.     

A case of convexity subarachnoid haemorrhage from intracranial hypotension treated with epidural blood patch

The majority of subarachnoid haemorrhages (SAH) are of aneurysmal origin, and nontraumatic convexity SAH is rare. We describe one patient who had a convexity SAH caused by cortical veins thrombosis (CVT) secondary to intracranial hypotension (IH). We discuss possible pathophysiologic mechanisms and its treatment. A 52-year-old female presented with left hemiparesis and tonic–clonic seizures, following lumbar epidural injections of local anaesthetics and steroids because of chronic low back. Brain CT showed right fronto-parietal convexity SAH. Brain MRI revealed diffuse pachymeningeal enhancement and confirmed the SAH. Cerebral angiography showed no/low flow signal in few frontal and parietal cortical veins in the correspondence of the SAH. A restoration of flow signal in this area was revealed after 2?months. The patient was treated with lumbar epidural blood patch with recovery. Convexity SAH caused by CVT from IH may be treated only with lumbar epidural blood patch which eliminates by itself the determinants of CVT (vein dilatation and slow vein drainage).     

Surgical management of syringomyelia associated with spinal adhesive arachnoiditis.

The authors describe a new surgical technique to minimise the postoperative recurrence of adhesion after microlysis of adhesion to treat syringomyelia associated with spinal adhesive arachnoiditis. A 47 year old male presented with numbness of the lower extremities and urinary disturbance and was demonstrated to have a case of syringomyelia from C1 to T2 which was thought to be secondary to adhesive spinal arachnoiditis related to a history of tuberculous meningitis. Following meticulous microlysis of the adhesions, maximal expansion of a blocked subarachnoid space was performed by expansive duraplasty with a Gore-Tex surgical membrane, expansive laminoplasty and multiple tenting sutures of the Gore-Tex graft. Postoperatively, the syringomyelia had be en completely obliterated and improvement of the symptoms had been also achieved. The technique described may contribute to improvement of the surgical outcome following arachnoid dissection by maintaining continuity of the reconstructed subarachnoid space.     

Chronic spinal arachnoiditis following intracranial subarachnoid haemorrhage

A 54-year-old woman presented with progressive gait imbalance and increased urinary frequency, associated with spinal arachnoiditis. The symptoms started after the occurrence of communicating hydrocephalus as a sequel of subarachnoid haemorrhage (SAH), and were initially attributed to post-SAH vasospasm, decompensating hydrocephalus and/or periventricular leuko-encephalopathy. Further clinical deterioration led to the diagnosis of thoracic spinal arachnoiditis, as a second complication of SAH.     

Progress in syringomyelia

Syringomyelia management is showing some progressive improvements following surgical methods of investigation and treatment. Investigation of simultaneous pressure changes in the cerebrospinal fluid pathways has illustrated the importance of craniospinal pressure dissociation in impacting the cerebellar and medullary tissues in the foramen magnum in hindbrain related syringomyelia. Such pressure differences may be referred to as 'suck' and similar changes are to be found in non-hindbrain related forms of syringomyelia such as those associated with spinal arachnoiditis. When cavities have formed then impulsive movements may occur with them and enlargement of the cavities may be continued by sloshing of the fluid within them. Investigations have been improved following the widespread use of water soluble contrast media and CT scanning with reconstructions after myelography.

A definite relationship between birth injury and hindbrain related syringomyelia has been established especially with cases showing arachnoiditis. The nature of the relationship to hindbrain hernia and basilar invagination remains unclear. Magnetic resonance imaging holds great promise particularly in showing hindbrain deformation in new-born babies, showing whether or not a communication commonly exists between the fourth ventricle and the cavities within the spinal cord in early childhood and also in outlining the changes in the spinal cord in the presence of acute traumatic paraplegia. Treatment still relies upon valved ventricular to extrathecal shunts for hydrocephalus, cranio-vertebral decompression to prevent suck and drainage of the syrinx in appropriate cases. Syrinx to extrathecal shunting may be preferred to shunts to the subarachnoid space. The peritoneum and the pleura are favoured sites and a valve is not necessary. The advances for the future may depend on earlier diagnosis and greater understanding of the mechanisms of pathogenesis in which MRI seems likely to play an increasingly important part.     

Spontaneous chronic spinal subdural hematoma associated with spinal arachnoiditis and syringomyelia

Spontaneous chronic spinal subdural hematoma is rare. We describe a case of spontaneous chronic spinal subdural hematoma associated with arachnoiditis and syringomyelia in a 76-year old woman who presented with a 14-year history of progressive myelopathy. MRI scan revealed a thoraco-lumbar subdural cystic lesion and a thoracic syrinx. The patient underwent thoracic laminectomy and decompression of the lesion, which was a subdural hematoma. A myelotomy was performed to drain the syrinx. Pathological examination revealed features consistent with chronic subdural membrane. This report attempts to elucidate the pathogenesis of chronic spinal subdural hematoma. We discuss possible etiological factors in light of the current literature and pathogenesis of both spinal subdural hematoma and syrinx formation.     

Syringomyelia and hydromyelia: Current understanding and neurosurgical management

Syringomyelia is a rare disorder in which a fluid-filled cyst forms within the spinal cord, resulting in myelopathy. Meanwhile, the abnormal dilatation of the central canal is referred to as hydromyelia or slit-like syrinx. The most prevailing classification is based on anatomical features and pathogeny rather than pathophysiological mechanisms. It is usual to distinguish foraminal syringomyelia related mainly to abnormalities at the craniocervical junction, non-foraminal syringomyelia dealing with any cause of arachnoiditis (infection, inflammation, trauma…) and more rarely syringomyelia associated with intramedullary tumors. Although many pathophysiological theories have been argued over time, the prevailing one is that disturbances in cerebrospinal fluid (CSF) flow in the sub-arachnoid spaces disrupt flow velocity leading to the syrinx. Symptoms of paralysis, sensory loss and chronic pain commonly develop during the third/fourth decades of life. The natural history of syringomyelia is typically one of gradual, stepwise neurological deterioration extending over many years. Diagnosis is based on magnetic resonance imaging (MRI) including excellent morphological sequences (T1-, T2-, FLAIR-, T2*-, enhanced T1-) and dynamic MRI with careful study of CSF velocity (CISS, cine-MR sequences). Surgical management is at first dedicated to treat the cause of the syringomyelia, mainly to re-establish a physiological CSF pathway in the subarachnoid spaces. Mostly, the surgical goal is to enlarge the craniocervical junction with duraplasty. Other surgical strategies such as arachnoidolysis or shunt procedures are performed based on the pathogenic mechanisms or as second-line treatment. Medical treatments are also necessary as chronic pain is the main long-lasting symptom. As evolutive syringomyelia is a severe disease with a high impact on quality of life, it is recommended to treat without delay. There is no evidence for surgery for incidental asymptomatic syringomyelia or hydromyelia. Finally, syringomyelia associated with intramedullary tumors resolves spontaneously after tumor resection. Syringomyelia is a rare disease, which requires a dedicated multidisciplinary approach, emphasizing the need for a nationwide scientific organization so as to offer optimal care to the patient.     

Arachnoiditis ossificans and syringomyelia: a unique case report.

A 62-year-old male presented with progressive quadriparesis. Magnetic resonance imaging of the spine revealed a spinal cord syrinx but failed to detect extensive arachnoiditis ossificans noted on insertion of a syringopleural shunt. A postoperative computed tomography scan clearly demonstrated the abnormality and its extent. We present a rare case of syringomyelia resulting from spinal arachnoiditis ossificans and review the relevant literature.     

GDC血管内栓塞治疗动脉瘤性蛛网膜下腔出血后慢性脑积水的影响机制与预后研究

目的 探讨GDC血管内栓塞治疗动脉瘤性蛛网膜下腔出血后慢性脑积水发生的易患因素和临床预后.方法 纳入研究标准的132例动脉瘤性蛛网膜下腔出血患者均行GDC血管内栓塞治疗,术后对出血破入脑室伴脑室系统梗阻患者行脑室外引流术,对其他患者行腰椎穿刺脑脊液置换术,出血后1月CT评价慢性脑积水发生情况.对慢性轻度脑积水行短期临床观察,慢性重度脑积水行脑室腹腔分流术.根据改良Rankin量表评价患者6月后临床恢复情况.行统计学分析明确影响慢性脑积水发生的易患因素,比较动脉瘤性蛛网膜下腔出血治疗6月后有无慢性脑积水者在临床预后上的差异.结果 本组动脉瘤性蛛网膜下腔出血患者慢性脑积水的发生率为12.12%(16/132),其易患因素依次是年龄、术前Fisher分级、术前Hunt-Hess分级.GDC血管内栓塞治疗后6月随访,有无慢性脑积水者在临床预后方面差异无统计学意义(P>0.05).结论 动脉瘤性蛛网膜下腔出血后慢性脑积水的发生不是单因素作用的结果,重度慢性脑积水患者及时行脑室腹腔分流术可得到较好的预后结果.     

Theoretical analysis of the pathophysiology of syringomyelia associated with adhesive arachnoiditis

OBJECTIVE: To apply a theoretical model to analyse the derangement of cerebrospinal fluid (CSF) dynamics in syringomyelia associated with adhesive arachnoiditis. METHODS: An electrical circuit model of CSF dynamics in the spine was used. With this model, the derangement of CSF dynamics in adhesive arachnoiditis was simulated. The effects of various surgical procedures were then analysed, such as syringo-subarachnoid shunting, subarachnoid bypass, and foramen magnum decompression. RESULTS: When CSF flow in the subarachnoid space was obstructed at a certain point, the pressure inside the spinal cord increased in the segment immediately distal to the blockage. This location of increased pressure corresponded to the preferred site of syrinx formation in adhesive arachnoiditis. Syringo-subarachnoid shunting, subarachnoid bypass, and foramen magnum decompression were all effective at reducing this pressure gradient. CONCLUSIONS: Blockage of the spinal subarachnoid CSF pathway produces a relative increase in the pressure inside the spinal cord distal to the blockage point. Repetitive formation of this pressure gradient then induces CSF leakage into the spinal parenchyma, leading to the formation of syringomyelia. Using this model, alternative surgical procedures could be suggested that might be effective in treating this disease.     

脊髓蛛网膜炎合并脊髓空洞的显微手术治疗

目的探讨脊髓蛛网膜炎合并脊髓空洞的显微手术治疗方法。方法回顾性分析经显微外科手术治疗的15例脊髓蛛网膜炎合并脊髓空洞病人的临床资料。根据脊髓蛛网膜炎症黏连的特点分为3型：I型（弥漫黏连型）10例,Ⅱ型（局限黏连型）3例,Ⅲ型（囊肿型）2例。I型行脊髓空洞一胸腔分流术,Ⅱ型行脊髓黏连松解术,Ⅲ型行囊肿探查切除术。结果术后症状明显改善13例,同术前2例。MRJ复查显示：脊髓空洞缩小12例,消失1例,同术前2例。13例术后随访8个月～3年,症状改善9例,同术前3例,加重1例。结论显微手术是治疗脊髓蛛网膜炎合并脊髓空洞的有效方法,根据分型选择合适的显微手术治疗方案,治疗效果较好。     

Syringomyelia and arachnoiditis.

Five patients with chronic arachnoiditis and syringomyelia were studied. Three patients had early life meningitis and developed symptoms of syringomyelia eight, 21, and 23 years after the acute infection. One patient had a spinal dural thoracic AVM and developed a thoracic syrinx 11 years after spinal subarachnoid haemorrhage and five years after surgery on the AVM. A fifth patient had tuberculous meningitis with transient spinal cord dysfunction followed by development of a lumbar syrinx seven years later. Arachnoiditis can cause syrinx formation by obliterating the spinal vasculature causing ischaemia. Small cystic regions of myelomalacia coalesce to form cavities. In other patients, central cord ischaemia mimics syringomyelia but no cavitation is present. Scar formation with spinal block leads to altered dynamics of cerebrospinal fluid (CSF) flow and contributes to the formation of spinal cord cystic cavities.     

Early ischemic lesions following subarachnoid hemorrhage: common cold remedy as precipitating factor?

A 46-year-old woman presented with tetraplegia contrasting with a relatively preserved consciousness following aneurysmal subarachnoid hemorrhage (SAH). Multiple ischemic lesions were detected by magnetic resonance imaging (MRI), in the absence of vasospasm or signs of increased intracranial pressure. During the weeks before SAH, the patient had repeatedly used a nasal decongestant containing phenylephrine. After coiling of the aneurysm harboured by the right posterior cerebral artery, symptomatic vasospasm developed in the territory of the right middle cerebral artery and required aggressive therapy by intra-arterial infusion of milrinone followed by continuous intravenous administration. Follow-up MRI did not reveal new ischemic lesions. Echocardiography had demonstrated the presence of a patent foramen ovale. At 3 months follow-up, a major motor deficit persisted with akinetic mutism. The mechanisms of multiple early infarction following aneurysmal SAH are still debated, as vasospasm is usually not seen on the first imaging. Among precipitating factors of microvascular vasospasm, vasoactive substances like phenylephrine, may play a significant role.     

Surgical management of syringomyelia: a five year experience in the era of magnetic resonance imaging.

We summarize our experience with 59 consecutive surgically managed cases of syringomyelia (SM) over a 5 year period. All cases had magnetic resonance imaging (MRI) preoperatively and postoperatively. Twenty-eight patients presented with SM and the adult Chiari (Chiari I) malformation (SM-ACM), 6 patients had post traumatic syrinxes, 14 patients had syrinxes associated with an intramedullary neoplasm, 3 patients had syringomyelia associated with spinal arachnoiditis and 8 patients had idiopathic syringomyelia. Holocord syrinxes were more often associated with SM-ACM, while focal syrinxes were associated with posttraumatic, spinal arachnoiditis and neoplastic conditions. In all cases with neoplasms the MRI revealed parenchymal intramedullary signal abnormalities in addition to the syrinx cavity. Posterior fossa decompression with obex plugging (the Gardner operation) was the procedure of choice for SM-ACM and for idiopathic holocord syringomyelia. Exploration and drainage of the syrinx with or without shunting was carried out mainly for focal syrinxes associated with trauma and neoplasm. Patients with SM-ACM responded well to posterior fossa decompression with satisfactory results in 24/28 patients. Idiopathic SM is probably a forme fruste of SM-ACM and when treated with the Gardner procedure showed good results in all 8 patients. Posttraumatic and neoplastic SM had the least predictable results with surgery. The disappearance of the syrinx on postoperative MRI correlated well with a good surgical outcome.     

Progress in syringomyelia

Syringomyelia management is showing some progressive improvements following surgical methods of investigation and treatment. Investigation of simultaneous pressure changes in the cerebrospinal fluid pathways has illustrated the importance of craniospinal pressure dissociation in impacting the cerebellar and medullary tissues in the foramen magnum in hindbrain related syringomyelia. Such pressure differences may be referred to as 'suck' and similar changes are to be found in non-hindbrain related forms of syringomyelia such as those associated with spinal arachnoiditis. When cavities have formed then impulsive movements may occur with them and enlargement of the cavities may be continued by sloshing of the fluid within them. Investigations have been improved following the widespread use of water soluble contrast media and CT scanning with reconstructions after myelography. A definite relationship between birth injury and hindbrain related syringomyelia has been established especially with cases showing arachnoiditis. The nature of the relationship to hindbrain hernia and basilar invagination remains unclear. Magnetic resonance imaging holds great promise particularly in showing hindbrain deformation in new-born babies, showing whether or not a communication commonly exists between the fourth ventricle and the cavities within the spinal cord in early childhood and also in outlining the changes in the spinal cord in the presence of acute traumatic paraplegia. Treatment still relies upon valved ventricular to extrathecal shunts for hydrocephalus, cranio-vertebral decompression to prevent suck and drainage of the syrinx in appropriate cases. Syrinx to extrathecal shunting may be preferred to shunts to the subarachnoid space. The peritoneum and the pleura are favoured sites and a valve is not necessary. The advances for the future may depend on earlier diagnosis and greater understanding of the mechanisms of pathogenesis in which MRI seems likely to play an increasingly important part.     

Syringomyelia following <Emphasis Type="Italic">Listeria</Emphasis> meningoencephalitis: report of a case

A case of symptomatic syringomyelia which appeared six years after Listeria meningoencephalitis is described. Chronic spinal arachnoiditis, as shown by standard MRI and dynamic phase contrast (PC) cine-MRI, may occur after spinal infection and is likely the cause of syringomyelia. To our knowledge, there are no previous reports of delayed spinal complications following Listeria monocytogenes infection. The possibility of developing syringomyelia should be always considered in any patient with a history of central nervous system infection. Received: 12 September 2002 / Accepted in revised form: 30 January 2003 Correspondence to: R. Nardone     

Terson's syndrome in spontaneous spinal subarachnoid haemorrhage.

This paper is a case report of Terson's Syndrome (TS) in spontaneous spinal subarachnoid haemorrhage (SAH). A 66-year-old woman with acute onset of severe back pain was transferred to our institution for management of her sciatica. The presence of an intraretinal haemorrhage alerted us to consider intracranial SAH, but investigations showed no intracranial source. Eventually, the patient was diagnosed with a thoracic spinal SAH. The patient's symptoms gradually improved with conservative management but within 1 month she had a recurrence. A spinal and CT angiogram did not elicit the aetiology. The diagnosis of spontaneous spinal SAH can be difficult. The recognition of TS has important prognostic implications, often heralding subarachnoid rebleeding. Fundoscopic examination appears mandatory as a tool for diagnosis and regular non-invasive monitoring of patients with SAH.     

Experimental communicating syringomyelia in dogs after cisternal kaolin injection: Part 2. Pressure studies

Pressure measurements in cerebrospinal fluid have been made from the ventricles and the spinal subarachnoid space in dogs made hydrocephalic by intracisternal injections of kaolin. Raised intraventricular pressure has been confirmed in the ventricles. The spinal pressure is usually markedly different from that in the head, confirming that the arachnoiditis produced around the cistern isolates the spinal subarachnoid space from the CSF in the head. Pulsatile pressures have been investigated specifically and the interrelationship between the pulsation and baseline pressures in the development of communicating syringomyelia discussed. There are differences between these experimental animals and the human disease, particularly in the baseline pressures which are usually equal in the head and the spine of humans at rest even in cases with syringomyelia.     

Syringomyelia Associated with a Spinal Arachnoid Cyst

While syringomyelia is not a rare spinal disorder, syringomyelia associated with a spinal arachnoid cyst is very unusual. Here, we report a 62-year-old man who suffered from gait disturbance and numbness of bilateral lower extremities. Spinal magnetic resonance imaging (MRI) showed the presence of a spinal arachnoid cyst between the 7th cervical and 3rd thoracic vertebral segment and syringomyelia extending between the 6th cervical and 1st thoracic vertebral segment. The cyst had compressed the spinal cord anteriorly. Syringomyelia usually results from lesions that partially obstruct cerebrospinal fluid flow. Therefore, we concluded that the spinal arachnoid cyst was causing the syringomyelia. After simple excision of the arachnoid cyst, the symptoms were relieved. A follow-up MRI demonstrated that the syringomyelia had significantly decreased in size after removal of the arachnoid cyst. This report presents an unusual case of gait disturbance caused by syringomyelia associated with a spinal arachnoid cyst.