Exploring Spinal Subarachnoid Hemorrhage: A Neurosurgical Case Series

Abstract

Spinal subarachnoid hemorrhage (SSAH) is a rare condition that can cause spinal cord or nerve root compression and permanent neurologic damage. The reported etiologies include trauma, vascular malformations or aneurysms, coagulopathies, neoplasms, autoimmune disease, and spontaneous hemorrhage. If there is evidence of neurologic deterioration, it is commonly managed as a surgical emergency, but cases of conservative management have also been reported. In this case series, we present three patients who suffered from SSAH. The first was a spontaneous cervical SSAH that occurred following cardiac catheterization, the second was a spontaneous thoracolumbar SSAH in a patient with a known history of coagulopathy, and the third was a thoracolumbar SSAH that was caused by a dural arteriovenous fistula (dAVF). All three patients exhibited neurologic deficits and thus underwent emergent decompression and hematoma evacuation. The patient with the dAVF also required open ligation of the fistula. Following surgical intervention, all three patients regained at least partial neurologic function, but one patient developed symptomatic arachnoid cysts that required further intervention. The presented case series highlights the importance and time-sensitivity of surgical decompression in patients experiencing neurologic deficits from SSAH. These cases underscore the urgency of timely neurosurgical intervention to mitigate neurologic impairment and add insights to the existing literature on this rare condition.

Keywords: dural arteriovenous fistula (davf); intraoperative neurologic monitoring; neurologic exam; spinal angiogram; spinal decompression; spinal subarachnoid cyst; spinal subarachnoid hemorrhage.

Figure 1. Sagittal MRI images from case one

(A) T2 sequence of the patient's cervical spine showing intradural hematoma (white arrow); (B) Post-contrast T1 sequence of the patient's cervical spine showing no abnormal enhancement; (C) T2 sequence of the patient's thoracic spine showing the intradural hematoma (white arrows); (D) Post-contrast T1 sequence of the patient's thoracic spine showing no abnormal enhancement.

Figure 2. Intraoperative image of case one

The dura has been opened at the midline and tacked up with sutures (small white arrows), and the subarachnoid hematoma is visible (large white arrow).

Figure 3. Sagittal MRI images from case two

(A) T2 sequence of the patient's thoracic spine showing intradural hematoma (white arrow); (B) Post-contrast T1 sequence of the patient's thoracic spine showing leptomeningeal enhancement presumably due to irritation of the thoracic cord and nerve roots from the hemorrhage; (C) T2 sequence of the patient's lumbar spine showing intradural hematoma (white arrow); (D) Post-contrast T1 sequence of the patient's lumbar spine showing leptomeningeal enhancement around the conus (white arrow).

Figure 4. Intraoperative images of case two hematoma evacuation

(A) The thecal sac appears to be bulging posteriorly (white arrow); (B) The dura has been opened at the midline and tacked up with sutures (small white arrows), and both the nerve roots (yellow stars), as well as the subarachnoid hematoma (large white arrow), are visible; (C) The hematoma has been evacuated.

Figure 5. Postoperative sagittal MRI images from case two

Sagittal MRI images of the patient's thoracic spine from case two at three months postoperatively showed arachnoid cysts. (A) T2 sequence showing the arachnoid cysts (white arrows); (B) Post-contrast T1 sequence showing no abnormal enhancement.

Figure 6. Intraoperative image of case two cyst fenestration

(A) The dura has been opened at the midline and tacked up with sutures. The spinal cord (small white arrow) is being displaced by the arachnoid cyst (large white arrow); (B) The cyst is being fenestrated with an arachnoid knife (yellow star); (C) Following cyst fenestration, the mass effect on the spinal has been relieved.

Figure 7. Sagittal MRI images from case three

(A) T2 sequence showing the intradural hematoma (white arrow); (B) T2 sequence showing hyperintensity at the conus, consistent with a possible infarct (white arrow); (C) T1 post-contrast sequence showing abnormal enhancement in the ventral spinal canal (white arrow).

Figure 8. Spinal angiogram from case three

Sequential images from the spinal angiogram of a right L1 radicular branch. The nidus of the dural AVF is fed from a linear ascending artery off the right L1 radicular branch and drains into veins on the posterior aspect of the spinal cord. (A) Anterior/posterior view; (B) Lateral view.