Acta Neurol Belg DOI 10.1007/s13760-013-0277-4
LETTER TO THE EDITOR
Hemorrhagic synovial cyst as an ‘evanescing’ spinal cervical mass: an issue for differential diagnosis Giulio Conforti • Giuseppe Maria Della Pepa • Fabio Papacci • Scerrati Alba • Nicola Montano
Received: 25 September 2013 / Accepted: 30 December 2013 Ó Belgian Neurological Society 2014
Keywords Synovial cyst Spinal schwannoma Spinal cord compression
We report on a case of hemorrhagic synovial cyst of the cervical spine, which represented an issue for differential diagnosis: initially interpreted as a cystic spinal schwannoma although ‘evanescing’ after 1 month from clinical onset. In this case, the main problem was the initial correct radiological diagnosis which could direct the management of this patient. Synovial cysts of the cervical spine are rare entities that in few cases have been described with intra-cystic acute bleeding with a sudden increase in the size of the lesion with compression on the spinal cord and nerve roots. Clinical and neuroradiological characteristics of hemorrhagic spinal synovial cysts had been herein described, with particular focus to neuroradiological differential diagnosis.
extending to left neuroforamen and determining compression of spinal cord (Fig. 1a–c). Patient did not refer any traumatic event; patient’s past clinical history was unremarkable, except for paroxysmal atrial fibrillation for which patient was on anticoagulation therapy. The pain was intense at time of examination, but the patient refused surgical treatment. So, corticosteroid and analgesic therapy was started. However, clinical symptoms progressively improved; patient experienced significant reduction of neck and left arm pain with improvement of left hand strength. Within 1 month, slightly complete resolution of symptoms was observed. Remarkably, new spine MRI exam displayed a nearly complete disappearing of the lesion with only a slight enhancing amount of pathological tissue still evident at level of left neuroforamen; the cystic component was not present anymore (Fig. 1d–f). The patient was dismissed home in good neurological condition.
Clinical background
Discussion
A 75-year-old man was examined for the acute onset of neck and left arm pain. Neurological examination showed weakness in the left hand. Spine MRI revealed a partially cystic lesion within the vertebral canal at C7–T1 level
This unusual case of spinal extradural lesion, with spinal cord compression, ‘evanescing’ after 1 month from clinical onset, was initially interpreted as a cystic spinal schwannoma, and the patient was originally addressed for surgical treatment. At time of first spine MRI, the radiological aspect of a cervical intra- and extra-spinal dumbbellshaped mass with a cystic component was consistent with such as hypothesis. However, the patient refused the initially proposed operation for the lesion removal. Fortunately, the progressively improving clinical set, with a
Introduction
G. Conforti (&) G. M. D. Pepa F. Papacci S. Alba N. Montano Institute of Neurosurgery, Catholic University, L-go A.Gemelli, 00168 Rome, Italy e-mail: [email protected]
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Acta Neurol Belg
Fig. 1 T2-weighted sagittal (a) and axial (b) spinal MRI showing an extradural dishomogeneous hyper-hypointense lesion at C7–T1 level (arrow) with compression and dislocation of spinal cord and enlargement of left neuroforamen. After gadolinium administration (c), the lesion shows a slightly homogeneous contrast-enhancement
with a cystic area (white asterisk) in the portion within vertebral canal. One month after cervical MRI demonstrates nearly complete disappearing of the lesion on T2-weighted sagittal (d) and axial (e) images. After gadolinium administration (f), a little enhancing amount of pathological tissue (arrow) is evident
nearly complete absence of pain, along with motor deficit recovery, and the radiological finding of a nearly complete mass disappearing, suggested an alternative diagnosis. The juxtafacet/intraforaminal position of the lesion could be consistent with a hemorrhagic synovial cyst of the cervical spine. Chronic inflammation of the synovial cyst has been reported to induce neovascularization of its walls determining a possible intra-cystic bleeding [1], producing a sudden increase in the size of the lesion with compression on the spinal cord and nerve roots [1]. This hypothesis might justify the acute symptoms presentation and the presence of a large cystic component within the lesion, as in our case. It is likely that intra-cystic bleeding led to rapid lesion size increase with severe compression of the nerve roots and the spinal cord [2]. In some reported cases, bleeding within the cyst led to a dramatic increase of its volume, accompanied by neurological deficits and painful symptoms, requiring emergency surgical decompression [3]. Furthermore, in our case, hemorrhagic presentation could also be favored by patient’s anticoagulation therapy [4]. Synovial cysts usually appear on MRI as isointense lesions on T1-weighted images enhancing after gadolinium administration. When hemorrhage is present, its appearance
on MRI can vary depending on the time elapsed since bleeding. In our case, most of the intra-cystic hemorrhage was subacute, appearing hyperintense on T1 and heterogeneously hypointense on T2 sequences because of the presence of haemoglobin products [3]. In this case, other possible radiological diagnosis was considered but was excluded: arachnoid cysts are usually intradural and have generally a CSF-like signal intensity; perineural (Tarlov) cysts are almost exclusively located at the lumbo-sacral level and other tumors such as meningioma are not consistent with such benign clinical course. Spinal hemorrhagic synovial cysts are uncommon causes of radicular pain. Usually associated with degenerative spinal disease, these juxtafacet cysts may rarely undergo intra-cystic hemorrhage. The pathogenesis of these cysts remains unclear, and risk factors that may contribute to hemorrhagic complications are largely unknown. In some cases, surgery is necessary to decompress nervous structures. In our patient, progressive blood degradation and reabsorption produced the gradual improvement of symptoms and the disappearing of the lesion on spine MRI.
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Conflict of interest
The authors declare no conflict of interest.
Acta Neurol Belg
References 1. Cicuendez M, Alen JF, Ramos A, Lobato RD, Lagares A (2010) Spontaneous hemorrhage into a lumbar synovial cyst. Eur Spine J 19(Suppl 2):S190–S192 2. Eck JC, Triantafyllou SJ (2005) Hemorrhagic lumbar synovial facet cyst secondary to anticoagulation therapy. Spine J 5:451–453
3. Pratesi A, Ginestroni A, Padovani R, Mascalchi M (2008) Neurological picture. An unusual cause of cord compression: synovial cyst of the thoracic spine. J Neurol Neurosurg Psychiatry 79:947 4. Wang YY, McKelvie P, Trost N, Murphy MA (2004) Trauma as a precipitant of haemorrhage in synovial cysts. J Clin Neurosci 11:436–439
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LETTER TO THE EDITOR
Hemorrhagic synovial cyst as an ‘evanescing’ spinal cervical mass: an issue for differential diagnosis Giulio Conforti • Giuseppe Maria Della Pepa • Fabio Papacci • Scerrati Alba • Nicola Montano
Received: 25 September 2013 / Accepted: 30 December 2013 Ó Belgian Neurological Society 2014
Keywords Synovial cyst Spinal schwannoma Spinal cord compression
We report on a case of hemorrhagic synovial cyst of the cervical spine, which represented an issue for differential diagnosis: initially interpreted as a cystic spinal schwannoma although ‘evanescing’ after 1 month from clinical onset. In this case, the main problem was the initial correct radiological diagnosis which could direct the management of this patient. Synovial cysts of the cervical spine are rare entities that in few cases have been described with intra-cystic acute bleeding with a sudden increase in the size of the lesion with compression on the spinal cord and nerve roots. Clinical and neuroradiological characteristics of hemorrhagic spinal synovial cysts had been herein described, with particular focus to neuroradiological differential diagnosis.
extending to left neuroforamen and determining compression of spinal cord (Fig. 1a–c). Patient did not refer any traumatic event; patient’s past clinical history was unremarkable, except for paroxysmal atrial fibrillation for which patient was on anticoagulation therapy. The pain was intense at time of examination, but the patient refused surgical treatment. So, corticosteroid and analgesic therapy was started. However, clinical symptoms progressively improved; patient experienced significant reduction of neck and left arm pain with improvement of left hand strength. Within 1 month, slightly complete resolution of symptoms was observed. Remarkably, new spine MRI exam displayed a nearly complete disappearing of the lesion with only a slight enhancing amount of pathological tissue still evident at level of left neuroforamen; the cystic component was not present anymore (Fig. 1d–f). The patient was dismissed home in good neurological condition.
Clinical background
Discussion
A 75-year-old man was examined for the acute onset of neck and left arm pain. Neurological examination showed weakness in the left hand. Spine MRI revealed a partially cystic lesion within the vertebral canal at C7–T1 level
This unusual case of spinal extradural lesion, with spinal cord compression, ‘evanescing’ after 1 month from clinical onset, was initially interpreted as a cystic spinal schwannoma, and the patient was originally addressed for surgical treatment. At time of first spine MRI, the radiological aspect of a cervical intra- and extra-spinal dumbbellshaped mass with a cystic component was consistent with such as hypothesis. However, the patient refused the initially proposed operation for the lesion removal. Fortunately, the progressively improving clinical set, with a
Introduction
G. Conforti (&) G. M. D. Pepa F. Papacci S. Alba N. Montano Institute of Neurosurgery, Catholic University, L-go A.Gemelli, 00168 Rome, Italy e-mail: [email protected]
123
Acta Neurol Belg
Fig. 1 T2-weighted sagittal (a) and axial (b) spinal MRI showing an extradural dishomogeneous hyper-hypointense lesion at C7–T1 level (arrow) with compression and dislocation of spinal cord and enlargement of left neuroforamen. After gadolinium administration (c), the lesion shows a slightly homogeneous contrast-enhancement
with a cystic area (white asterisk) in the portion within vertebral canal. One month after cervical MRI demonstrates nearly complete disappearing of the lesion on T2-weighted sagittal (d) and axial (e) images. After gadolinium administration (f), a little enhancing amount of pathological tissue (arrow) is evident
nearly complete absence of pain, along with motor deficit recovery, and the radiological finding of a nearly complete mass disappearing, suggested an alternative diagnosis. The juxtafacet/intraforaminal position of the lesion could be consistent with a hemorrhagic synovial cyst of the cervical spine. Chronic inflammation of the synovial cyst has been reported to induce neovascularization of its walls determining a possible intra-cystic bleeding [1], producing a sudden increase in the size of the lesion with compression on the spinal cord and nerve roots [1]. This hypothesis might justify the acute symptoms presentation and the presence of a large cystic component within the lesion, as in our case. It is likely that intra-cystic bleeding led to rapid lesion size increase with severe compression of the nerve roots and the spinal cord [2]. In some reported cases, bleeding within the cyst led to a dramatic increase of its volume, accompanied by neurological deficits and painful symptoms, requiring emergency surgical decompression [3]. Furthermore, in our case, hemorrhagic presentation could also be favored by patient’s anticoagulation therapy [4]. Synovial cysts usually appear on MRI as isointense lesions on T1-weighted images enhancing after gadolinium administration. When hemorrhage is present, its appearance
on MRI can vary depending on the time elapsed since bleeding. In our case, most of the intra-cystic hemorrhage was subacute, appearing hyperintense on T1 and heterogeneously hypointense on T2 sequences because of the presence of haemoglobin products [3]. In this case, other possible radiological diagnosis was considered but was excluded: arachnoid cysts are usually intradural and have generally a CSF-like signal intensity; perineural (Tarlov) cysts are almost exclusively located at the lumbo-sacral level and other tumors such as meningioma are not consistent with such benign clinical course. Spinal hemorrhagic synovial cysts are uncommon causes of radicular pain. Usually associated with degenerative spinal disease, these juxtafacet cysts may rarely undergo intra-cystic hemorrhage. The pathogenesis of these cysts remains unclear, and risk factors that may contribute to hemorrhagic complications are largely unknown. In some cases, surgery is necessary to decompress nervous structures. In our patient, progressive blood degradation and reabsorption produced the gradual improvement of symptoms and the disappearing of the lesion on spine MRI.
123
Conflict of interest
The authors declare no conflict of interest.
Acta Neurol Belg
References 1. Cicuendez M, Alen JF, Ramos A, Lobato RD, Lagares A (2010) Spontaneous hemorrhage into a lumbar synovial cyst. Eur Spine J 19(Suppl 2):S190–S192 2. Eck JC, Triantafyllou SJ (2005) Hemorrhagic lumbar synovial facet cyst secondary to anticoagulation therapy. Spine J 5:451–453
3. Pratesi A, Ginestroni A, Padovani R, Mascalchi M (2008) Neurological picture. An unusual cause of cord compression: synovial cyst of the thoracic spine. J Neurol Neurosurg Psychiatry 79:947 4. Wang YY, McKelvie P, Trost N, Murphy MA (2004) Trauma as a precipitant of haemorrhage in synovial cysts. J Clin Neurosci 11:436–439
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