A rare chronic presentation of schwannoma with hemorrhage

Spinal schwannomas are slow-growing benign tumors arising from the nerves. In the spinal cord, they arise most commonly from cervical and lumbar levels. They are mostly intradural extramedullary (IDEM) accounting for 30% of intradural tumors showing a female preponderance. They are seen occurring between 25 and 50 years of age. Most of these cases show acute presentation as hemorrhage within the tumor with weakness. This is a rare presentation by itself reported by only 12 cases world over. It is even rarer to see them show chronic presentation. We are reporting one such case of a 61-year-old female who presented to us with chronic low backache for 3 years with radicular symptoms in the bilateral lower limbs following a fall on her back. Magnetic resonance imaging was done which showed a well-defined IDEM lesion from L3 to L5 vertebral level which was isointense on T1 and hyperintense on T2 with a peripheral rim and short inversion time inversion-recovery showed fluid-fluid level within. Gradient-recalled echo showed blooming with no suppression on fat-sat and no diffusion restriction. A computed tomography angiography was done which ruled out vascular malformation. Intraoperatively, a large feeding vessel with a tumor was visualized after laminectomy was done for the corresponding levels. Postoperatively, the patient showed a significant decrease in radicular symptoms and was discharged after 2 weeks with an uneventful postoperative period. HPE of the lesion showed sheets of fascicles of elongated spindle cells arranged in loose myxoid matrix with hyperchromatic nuclei and scanty hemorrhage and lymphocytic infiltrates suggestive of schwannoma with myxoid degeneration. Immunohistochemistry also confirmed a diagnosis of schwannoma. From this case, it is seen that the diagnosis of a spinal schwnnoma showing delayed presentation with atypical imaging findings is a challenge and must needs a high index of suspicion and appropriate surgical planning.

Key-words:

Chronic - haemorrhage - rare - schwannoma

Financial support and sponsorship

Nil.

Publication History

Article published online:
09 September 2022

• References

• 1 Nadeem M, Mansoor S, Assad S, Ilyas F, Qavi AH, Saadat S, et al. Spinal schwannoma with intradural intramedullary hemorrhage. Cureus 2017;9:e1082.
• 2 Drevelagas K, Bangeas P. Intradural extramedullary schwannoma of thr thoracic spine with intratumoral hemorrhage. OMICS J Radiol 2017;6:272.
• 3 Hdeib A, Goodwin CR, Sciubba D, Bydon A, Wolinsky JP, Witham T, et al. Hemorrhagic thoracic schwannoma presenting with intradural hematoma and acute paraplegia after spinal manipulation therapy. Int J Spine Surg 2016;10:42.
• 4 Ciappetta P, D'Urso PI, Colamaria A. Giant craniovertebral junction hemorrhagic schwannoma: Case report. Neurosurgery 2008;62:E1166.
• 5 Conti P, Pansini G, Mouchaty H, Capuano C, Conti R. Spinal neurinomas: Retrospective analysis and long-term outcome of 179 consecutively operated cases and review of the literature. Surg Neurol 2004;61:34-43.
• 6 Parmar H, Patkar D, Gadani S, Shah J. Cystic lumbar nerve sheath tumours: MRI features in five patients. Australas Radiol 2001;45:123-7.
• 7 Yeh HM, Leung JH, Huang KC, Tung CL, Huang CL, Huang KM. A long segmental hemorrhagic spinal schwannoma with atypical presentation. J Radiol Sci 2011;36:191-4.
• 8 Sahoo RK, Das PB, Sarangi GS, Mohanty S. Acute hemorrhage within intradural extramedullary schwannoma in cervical spine presenting with quadriparesis. J Craniovertebr Junction Spine 2015;6:83-5.
• 9 Zhang HZ, Li Y, Han Y, Wang X, She L, Yan Z, et al. Spontaneous acute hemorrhage of intraspinal canal cellular schwannoma with paraplegia: A case report. Br J Neurosurg 2015;29:425-7.
• 10 Vaibhav N, Mahalingam SS, Parthiban JK. Hemorrhage within the schwannoma of thoracic spinal cord presenting as acute rapidly progressive paraplegia: A rare case. J Spinal Surg 2016;3:160-2.
• 11 Jaiswal A, Shetty AP, Rajasekaran S. Giant cystic intradural schwannoma in the lumbosacral region: A case report. J Orthop Surg (Hong Kong) 2008;16:102-6.
• 12 Prasad GL, Kongwad LI, Valiathan MG. Spinal intradural schwannoma with acute intratumoural haemorrhage: Case report and review. J Clin Diagn Res 2016;10:PD01-3.
• 13 Vázquez-Barquero A, Pascual J, Quintana F, Figols J, Izquierdo JM. Cervical schwannoma presenting as a spinal subdural haematoma. Br J Neurosurg 1994;8:739-41.
• 14 Jenkins AL 3rd, Ahuja A, Oliff AH, Sobotka S. Spinal schwannoma presenting due to torsion and hemorrhage: Case report and review of literature. Spine J 2015;15:e1-4.
• 15 Tanaka H, Kondo E, Kawato H, Kikukawa T, Ishihara A, Toyoda N. Spinal intradural hemorrhage due to a neurinoma in an early puerperal woman. Clinical Neurology and Neurosurgery 2002;104:303-5.
• 16 Cohen ZR, Knoller N, Hadani M, Davidson B, Nass D, Ram Z. Traumatic intratumoral hemorrhage as the presenting symptom of a spinal neurinoma. Case report. Journal of Neurosurgery 2000;93(2 suppl):327-9.
• 17 Uemura K, Matsumura A, Kobayashi E, Tomono Y, Nose T. CT and MR presentation of acute hemorrhage in a spinal schwannoma. Surgical Neurology 1998;50:219-20.
• 18 Ichinose T, Takami T, Yamamoto N, Tsuyuguchi N, Ohata K. Intratumoral hemorrhage of spinal schwannoma of the cauda equina manifesting as acute paraparesis—case report. Neurologia medico-chirurgica (Tokyo) 2009;49:255-7.
• 19 Ng PY. Schwannoma of the cervical spine presenting with acute hemorrhage. Journal of clinical neuroscience 2001;8:277-8.
• 20 Smith RA. Spinal subdural hematoma, neurilemmoma, and actute transverse myelopathy. Surgical Neurology 1985;23:367-70.