SCIENTIFIC
Refractory Syringomyelia With Thoracic Arachnoid Scarring, Presenting Six Years After Subarachnoid Hemorrhage: A Case Report
AUTHORS: Denisse D. Arteaga, MD 1 Gennadiy A. Katsevman, MD 2 Cara L. Sedney, MD, MA 1
AFFILIATIONS:
1
Department of Neurosurgery, West Virginia University, Morgantown, West Virginia
2
Neuroscience and Spine Associates, Naples, Florida
ABSTRACT
INTRODUCTION
Subarachnoid hemorrhage( SAH) and subsequent scarring can rarely precipitate syringomyelia several years after the initial insult. We present a patient with a history of posterior circulation SAH six years prior who developed progressive lower limb weakness, numbness, low back pain, fecal retention, and sphincter dysfunction. Imaging revealed cervicothoracic syringomyelia associated with thoracic arachnoid scarring. Despite multiple surgical interventions, the patient experienced persistent and progressive syringomyelia. This case demonstrates that posterior circulation SAH may warrant prolonged surveillance for arachnoiditis, which may not be readily evident on imaging. Furthermore, surgical management should be tailored to the underlying pathology, often necessitating multiple interventions to effectively manage symptom progression.
CORRESPONDING AUTHOR:
Denisse D. Arteaga, MD dda0001 @ hsc. wvu. edu
DISCLOSURES: None
ETHICS STATEMENT:
Written informed consent was obtained from the patient and family for publication of this case report and any accompanying images.
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FIGURE 1
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FUNDING: None
CASE PRESENTATION
A 60-year-old male with a history of subarachnoid hemorrhage( SAH) from a ruptured right intracranial vertebral artery aneurysm presented nearly six years later with progressive fecal retention, sphincter dysfunction, lower extremity weakness, and gait instability. Magnetic resonance imaging( MRI) of the spine revealed a septated syrinx with cord edema extending from the cervicothoracic junction through the thoracic cord( Figure 1A).
The patient underwent T2 to T5 laminoplasty for intradural lysis of adhesions and tethered cord release. Intraoperatively, extensive arachnoid scarring and spinal cord distortion were noted. Despite intervention, the patient experienced worsening lower extremity weakness and sensory deficits,
( A) Sagittal T2-weighted MRI obtained six years after the initial subarachnoid hemorrhage demonstrated a septated syrinx with associated cord edema extending from the cervicothoracic junction( not well visualized) throughout the thoracic cord( yellow arrows).( B) Follow-up MRI performed five months later showed progressive cord edema, which began at the C3 level( solid white arrow), where it had previously begun at the cervicothoracic junction, extending into the thoracic region( dashed arrow), with a persistent septated syrinx.
including T6 hypoesthesia. Five months after the initial surgery, an MRI showed progressive cord edema, which began at the C3 level, where it had previously begun at the cervicothoracic junction, and extended into the thoracic region as well as persistent septated syrinx( Figure 1B). As a result, the patient underwent T9 syringoperitoneal shunt placement. However, his symptoms and syrinx size remained unchanged, prompting a shunt revision and insertion of an additional syringoperitoneal shunt at the T6 level.
At the age of 62, nearly two years after symptom onset, he developed upper extremity weakness, dysphagia, dysarthria, and visual disturbances. An MRI of the spine( Figure 2) demonstrated syrinx extension into the cervical spine up to the C1 level through thoracic cord to the conus medullaris. The patient underwent cerebrospinal fluid( CSF) diversion with an external ventricular drain with improvement in dysarthria and resolution of visual symptoms. A right parietal ventriculoperitoneal shunt was then placed for treatment of hydrocephalus likely secondary to arachnoiditis.
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