Neurol Med Chir (Tokyo) 46, 309¿312, 2006

Spinal Arachnoid Causing Paraplegia Following Skull Base —Case Report—

Ryu KUROKAWA and Takeshi KAWASE*

Department of Neurological Surgery, Dokkyo University School of Medicine, Tochigi; *Department of Neurological Surgery, Keio University School of Medicine, Tokyo

Abstract

A 40-year-old woman presented with a right petroclival meningioma compressing the brainstem and manifesting as a 6-month history of and gait difficulty. The patient underwent subtotal removal of the tumor via an anterior transpetrosal approach. The postoperative course was complicated by rhinorrhea, bacterial , and acute hemorrhagic rectal ulcer. The patient was discharged home in good condition after prolonged medical treatment. Four months after the surgery, the patient noted recurrence of gait difficulty. Magnetic resonance (MR) imaging of the brain showed enlargement of the ventricles and no residual brainstem compression. A ventriculoperitoneal shunt was placed, but the symptoms were unchanged. The shunt was removed 2 months later because of infection. The patient's gait gradually deteriorated, although repeat brain MR imaging showed no significant increase in ventricular size. Ten months after the initial surgery she became paraplegic. MR imaging of the thoracic spine revealed a large arachnoid cyst extending from C-6 to T-6. The patient underwent T2–4 laminectomy, partial removal of the cyst wall, and duraplasty, but no clinical improve- ment was observed. Preexisting long-tract signs and coincidental confused the neurolog- ical findings and delayed detection of the spinal lesion in this case. Neurosurgeons should be alert to the possibilities of insidious spinal lesion if the patient has progressive neurological disorder which does not match the known cranial lesion.

Key words: postoperative complication, skull base, , bacterial meningitis, arachnoid cyst, rectal ulcer

Introduction thoracic level and can arise ventral, lateral, or dorsal to the . The prognosis is less favorable Spinal arachnoid can be classified into congen- after surgery. Spinal arachnoid cyst manifests as the ital and acquired types. The congenital type is signs and symptoms of spinal cord compression. thought to originate from defects in the septum However, these neurological signs may be obscured posticum, which divides the posterior spinal if the patient has coexistent cranial lesions. subarachnoid space longitudinally in the cervical We treated a patient who developed paraplegia and thoracic areas.18) Congenital spinal arachnoid caused by a cervicothoracic spinal arachnoid cyst cyst is usually located dorsal to the spinal cord and that developed after removal of a skull base menin- has a favorable prognosis after surgical excision. gioma. Detection of the spinal lesion was distracted Acquired spinal arachnoid cyst, also called by coexisting hydrocephalus and residual tumor. subarachnoid cyst,16) is a sequela of chronic inflam- mation in the subarachnoid space. The initiating Case Report cause may be trauma,5,7,14) myelography dye,10) subarachnoid hemorrhage,9,17) or infection.1,12) A 40-year-old woman presented with a 6-month Acquired spinal arachnoid cyst often occurs at the history of headache and gait difficulty. She had no significant past medical history. Neurological Received February 21, 2005; Accepted February 6, examination revealed bilateral papilledema, mildly 2006 decreased hearing on the right, hyperreflexia in all

309 310 R. Kurokawa et al. extremities, and upgoing toes. Muscle strength in A lumbar spinal drain was placed on postoperative the upper and lower extremities was within the nor- day 9. The opening pressure was 11 cmH2O. Liquor- mal range. Her gait was spastic. Magnetic resonance rhea disappeared immediately after the drain place- (MR) imaging of the brain revealed a right ment. The spinal drain was removed on postopera- petroclival meningioma associated with brainstem tive day 15, when the patient became feverish and compression and hydrocephalus (Fig. 1A). The comatose. The patient became alert after administra- tumor was subtotally removed via an anterior trans- tion of antipyretics, but she was deaf and confused. petrosal approach,6) leaving minimal remnant tumor The CSF cell count was 6,160/mm3.Themeningitis adherent to the brainstem and perforating arteries. was treated with intravenous cefotaxime and in- Histological examination confirmed the diagnosis of trathecal gentamicin given via serial lumbar pun- secretory type meningioma. ctures. On postoperative day 19, the patient sudden- Postoperatively, the patient had mild dysesthesia ly suffered massive rectal hemorrhage and went into in the region of the first and second divisions of the a state of hypovolemic shock. The was trigeminal nerve and mild abducens nerve paresis finally controlled with hemostatic clips under rec- on the right. Cefazolin was given prophylactically toscopy on postoperative day 26. At discharge on for 7 days postoperatively. Cerebrospinal fluid (CSF) postoperative day 47, she had bilateral hearing rhinorrhea was noted on postoperative day 3, which difficulties but the other cranial nerve deficits had continued through the 7-day course of bed rest. resolved. Her gait had improved. The patient noticed recurrence of gait difficulty 4 months after the surgery. MR imaging of the brain showed a small residual tumor and enlarged ventri- cles, but no compression of the brainstem (Fig. 1B). The patient underwent placement of a ven- triculoperitoneal shunt using a StrataTM Valve (Medtronic Neurosurgery, Goleta, Calif., U.S.A.) set at performance level 2. Despite mild decrease of the ventricle size, her symptoms were unchanged. The shunt valve was readjusted to performance level 0.5, but the symptoms remained stable. Two months later, pus was discharged from the cranial incision for shunt placement and therefore the shunt was removed. The patient was referred to another

Fig. 1 T1-weighted magnetic resonance images hospital for gamma-knife treatment of the residual with contrast medium of the brain revealing tumor. (A) a right petroclival meningioma, and (B) The patient's gait difficulty gradually worsened. satisfactory decompression of the brainstem Follow-up examination 10 months after the initial with enlarged ventricles 4 months after operation found that the patient was barely able to subtotal tumor removal. walk with the aid of hand supports. She had had no

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Fig. 2 T2-weighted magnetic reso- nance images of the cer- vicothoracic spine revealing (A) an arachnoid cyst extend- ing from C-6 to T-6 with severe spinal cord compression, (B) adequate decompression of the spinal cord 1 week after cyst removal, and (C) recurrence of the arachnoid cyst from C-5 to T-5 5 months after cyst removal.

Neurol Med Chir (Tokyo) 46, June, 2006 Paraplegia Following Skull Base Surgery 311

Discussion

In our case, MR imaging of the spine was only obtained after the patient became paraplegic. There- fore, we do not know whether the patient had the spinal arachnoid cyst before the cranial surgery or not. However, the arachnoid cyst in our case most likely formed secondary to , given the history of meningitis, irregular shape of the cyst, and severe adhesion observed at surgery. The incidence of spinal arachnoid cyst following meningitis is not known. The incidence of meningi- tis following skull base surgery is 1%11) and that Fig. 3 Still image from the intraoperative video following lumbar drainage placement is 4.2%.4) recording. The patient's head is toward the Prophylactic antibiotics after placement of lumbar left side of the picture. The spinal cord is drainage are apparently not effective for preventing compressed to the right. Dense adhesion infection.4) In our case, meningitis became apparent surrounds the nerve root. after placement of the lumbar drainage and discon- tinuation of prophylactic antibiotics. Whether the offending microorganism was introduced during episodes of urinary or fecal incontinence. The the initial surgery, at the subsequent CSF leakage, or patient was awake, alert, and oriented. She had mild through the lumbar drain is unclear. papilledema. Saccadic nystagmus toward the right Treatment of spinal arachnoid cyst involves resec- was observed on right-sided gaze. She was deaf on tion of the cyst wall, cyst shunting,3,7,9,15) or dissec- the left and hearing was decreased on the right. tion of adhesion.5,14) Ventriculoperitoneal shunting Muscle strength was normal in the upper extremi- maybeeffectiveinsomecases.1,9) The surgical out- ties. The lower extremities were spastic, but no come is unpredictable. Inflammation and adhesion voluntary motion was observed. Deep tendon reflex- of the pia may cause reduction of the spinal cord es were increased in all extremities. Babinski sign blood flow and result in irreversible neurological and ankle clonus were positive bilaterally. Sensory damage.3) is another condition level was at T-6 on the right and T-5 on the left. resulting from disturbances of CSF flow in the Follow-up neuroimaging studies of the brain re- spine. More information is available on syringomye- vealed minimal increase of the ventricle size. Spinal lia than arachnoid cyst. Surgical treatment for MR imaging revealed a large arachnoid cyst com- syringomyelia involves microlysis of adhesive pressing the spinal cord from C-6 to T-6 (Fig. 2A). and expansive duraplasty.8,13) The The patient underwent T2–4 laminectomy. The surgical outcome is generally good, but tends to be spinal cord was thin and compressed to the right worse in cases following meningitis.8) We elected to and dorsally. Adhesion of the arachnoid membrane perform dissection of the subarachnoid adhesion and the dentate ligament was dissected under the and expansive duraplasty, since this procedure operating microscope. After partial removal of the theoretically re-establishes free CSF flow in the cyst wall, the spinal cord re-expanded and regained subarachnoid space and corrects the pathogenesis. pulsation (Fig. 3). Expansive duraplasty was per- Our patient probably already had irreversible formed with GORE PRECLUDE (W.L. Gore & spinal cord injury by the time of decompression Associates, Inc., Flagstaff, Ariz., U.S.A.) membrane. because the symptoms did not improve after sur- The patient's symptom did not improve postoper- gery. In retrospect, recurrence of gait difficulty 4 atively. MR imaging on postoperative day 7 revealed months after the cranial surgery was caused by the satisfactory decompression of the spinal cord spinal arachnoid cyst, not hydrocephalus. The (Fig. 2B). Follow-up MR imaging of the spine 5 resultant paraplegia may have been avoided if we months later showed recurrence of the arachnoid had identified the spinal arachnoid cyst earlier. cyst (Fig. 2C). The patient's neurological status was However, detection of myelopathy was difficult unchanged and she refused further surgical treat- because the patient already had neurological deficits ment. caused by the brainstem lesion. Hydrocephalus and residual tumor distracted our attention away from the spinal lesion. The lesson is that hydrocephalus after meningitis implies an adhesive inflammatory

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Neurol Med Chir (Tokyo) 46, June, 2006