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Neuroimaging findings and pathophysiology of dorsal spinal arachnoid webs: illustrative case
Neuroimaging findings and pathophysiology of dorsal spinal arachnoid webs: illustrative case
Nancy Pham MD1, Julius O. Ebinu MD, PhD2, Teja
Online Publication Date:
17 May 2021
· Department of Radiology, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California; and
· | 2 Departments of Neurosurgery and
· | 3 Radiology, University of California, Davis, School of Medicine, Sacramento, California
Spinal arachnoid webs are uncommon and difficult to diagnose, especially because causative intradural transverse bands of arachnoid tissue are radiographically occult. Left untreated, arachnoid webs may cause progressive, debilitating, and permanent neurological dysfunction. Conversely, more than 90% of patients may experience rapid neurological recovery after resection, even with a prolonged duration of presenting symptoms. Indirect imaging signs such as spinal cord indentation and compression with cerebrospinal fluid (CSF) flow alteration provide crucial diagnostic clues that are critical in guiding appropriate management of such patients.
Arachnoid webs and cysts may also derive from arachnoid recesses,36–38 in which the two arachnoid layers merge around the spinal nerve sheath origins (Fig. 5). Small lymphatic vessels, present around the arachnoid recesses, drain into satellite lymph nodes.39 The presence of activated macrophages and cellular debris within arachnoid recesses suggests a role in immune defense of the central nervous system through local CSF molecular composition and physiology.36,39 Because most lymph nodes are located in the cervicothoracic area, inflammatory phenomena within the arachnoid recesses may trigger arachnoid proliferation around the septum posticum.26
Arachnoid webs and cysts may also derive from arachnoid recesses,36–38 in which the two arachnoid layers merge around the spinal nerve sheath origins (Fig. 5). Small lymphatic vessels, present around the arachnoid recesses, drain into satellite lymph nodes.39 The presence of activated macrophages and cellular debris within arachnoid recesses suggests a role in immune defense of the central nervous system through local CSF molecular composition and physiology.36,39 Because most lymph nodes are located in the cervicothoracic area, inflammatory phenomena within the arachnoid recesses may trigger arachnoid proliferation around the septum posticum.26
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Spinal arachnoid web-a distinct entity of focal arachnopathy
Spinal arachnoid web-a distinct entity of focal arachnopathy
Spinal arachnoid web (SAW) is a rare condition characterized by focal thickening of the arachnoid membrane causing displacement and compression of the spinal cord with progressive symptoms and neurological deficits.
Retrospective review of prospectively collected data on all patients surgically treated for SAW from three participating neurosurgical centers between 2014 and 2020.
Retrospective review of prospectively collected data on all patients surgically treated for SAW from three participating neurosurgical centers between 2014 and 2020.
We want to emphasize SAW being a distinct entity of spinal arachnopathy with a favorable long-term outcome if diagnosed correctly and treated surgically. Intraoperative ultrasound aids visualizing the SAW before dural incision, as well as verifying restored CSF flow after resection.
We want to emphasize SAW being a distinct entity of spinal arachnopathy with a favorable long-term outcome if diagnosed correctly and treated surgically. Intraoperative ultrasound aids visualizing the SAW before dural incision, as well as verifying restored CSF flow after resection.
The present study comprises the largest series of surgically treated SAW, underscoring the unique clinical, radiographic, histopathological, and surgical findings. We want to emphasize SAW being a distinct entity of spinal arachnopathy with a favorable long-term outcome if diagnosed correctly and treated surgically. Affiliations
The present study comprises the largest series of surgically treated SAW, underscoring the unique clinical, radiographic, histopathological, and surgical findings. We want to emphasize SAW being a distinct entity of spinal arachnopathy with a favorable long-term outcome if diagnosed correctly and treated surgically. Affiliations
· 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland. Electronic address: stefanos.voglis@usz.ch.
· 2Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
· 3Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
· 4Institute of Neuropathology, University Hospital and University of Zurich, Zurich, Switzerland.
· 5Department of Neurosurgery and Faculty of Medicine, University Hospital Geneva, Geneva, Switzerland.
· 6Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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An Overview of Arachnoid Webs
An Overview of Arachnoid Webs
https://www.jneurology.com/articles/an-overview-of-arachnoid-webs-neuromed-1-1050.php
Rohit Aiyer1*, Lynne Voutsinas2, Yasir El-Sherif3 by R Aiyer · 2016
Department of Psychiatry, Hofstra Northwell Health - Staten Island University Hospital, USA
Department of Radiology, Hofstra Northwell Health – Staten Island University Hospital, USA
Department of Neurology, Hofstra Northwell Health – Staten Island University Hospital, USA
Arachnoid webs are abnormal formations of arachnoid membrane in the spinal subarachnoid space that prevents movement of cerebrospinal fluid (CSF) in the longitudinal direction1.These webs represent intradural extramedullary transverse bands of arachnoid tissue that extend to the dorsal surface of the spinal cord resulting in dorsal indentation2. These arachnoid webs may represent a variant of an arachnoid cyst3. However, they may also represent localized arachnoiditis (3).
· Syringomyelia and the arachnoid web Published: August 2003
· A. R. Brodbelt &
https://link.springer.com/article/10.1007/s00701-003-0071-9
Arachnoid webs are likely to represent a focal band of arachnoiditis and are difficult to visualise on standard preoperative MR imaging.
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Spinal arachnoid web—a distinct entity of focal arachnopathy with favorable long-term outcome after surgical resection
Spinal arachnoid web—a distinct entity of focal arachnopathy with favorable long-term outcome after surgical resection
Volume 22, Issue 1, January 2022, Pages 126-135
Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
b
Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
c
Institute of Neuropathology, University Hospital and University of Zurich, Zurich, Switzerland
d
Department of Neurosurgery and Faculty of Medicine, University Hospital Geneva, Geneva, Switzerland
Moreover, there is considerable ambiguity regarding the nomenclature of other spinal arachnopathies: Spinal arachnoiditis is used as a generic term for various inflammatory conditions of the arachnoid membrane, including those observed after previous spinal trauma or surgical intervention [17,23,24].
Moreover, there is considerable ambiguity regarding the nomenclature of other spinal arachnopathies: Spinal arachnoiditis is used as a generic term for various inflammatory conditions of the arachnoid membrane, including those observed after previous spinal trauma or surgical intervention [17,23,24].
The present study supports SAW as a distinct focal arachnopathy. It shows distinct diagnostic and clinical characteristics that facilitate distinction from unspecific arachnopathies after intradural bleedings or surgeries.
The present study supports SAW as a distinct focal arachnopathy. It shows distinct diagnostic and clinical characteristics that facilitate distinction from unspecific arachnopathies after intradural bleedings or surgeries.
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Most individuals with arachnoid cysts develop symptoms before the age of 20, and especially during the first year of life, but some people with arachnoid cysts never have symptoms.
Most individuals with arachnoid cysts develop symptoms before the age of 20, and especially during the first year of life, but some people with arachnoid cysts never have symptoms.
Typical symptoms of an arachnoid cyst around the brain include headache, nausea and vomiting, seizures, hearing and visual disturbances, vertigo, and difficulties with balance and walking. Arachnoid cysts around the spinal cord compress the spinal cord or nerve roots and cause symptoms such as progressive back and leg pain and tingling or numbness in the legs or arms.
Untreated, arachnoid cysts may cause permanent severe neurological damage when progressive expansion of the cyst(s) or bleeding into the cyst injures the brain or spinal cord. Symptoms usually resolve or improve with treatment.
Untreated, arachnoid cysts may cause permanent severe neurological damage when progressive expansion of the cyst(s) or bleeding into the cyst injures the brain or spinal cord. Symptoms usually resolve or improve with treatment.
Spinal arachnoid cysts may be associated with progressive weakness of the legs, tingling or numbness in the hands or feet, abnormal side-to-side curvature of the spine (scoliosis), back pain, and involuntary muscle spasms (spasticity) that result in slow, stiff movements of the legs. In rare cases, these cysts may cause paralysis of the legs (paraplegia). Urinary tract infections may also occur in individuals with spinal arachnoid cysts.
Other symptoms and physical findings have been reported to be associated with arachnoid cysts including migraine headaches, attention-deficit disorder and difficulties understanding or expressing language (aphasia). The exact cause and effect relationship between these findings and arachnoid cysts is not clear.
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Neurosurgical Management of a Thoracic Dorsal Arachnoid Web: Case Illustration
Neurosurgical Management of a Thoracic Dorsal Arachnoid Web: Case Illustration
Arvin R. Wali, Harjus S. Birk, Joel Martin, David R. Santiago-Dieppa, Joseph Ciacci
Author Information
Author Information
Arvin R. Wali Corresponding Author
Neurosurgery, University of California, San Diego, La Jolla, USA
Neurosurgery, University of California, San Diego, La Jolla, USA
Neurosurgery, University of California, San Diego, La Jolla, USA
Neurosurgery, University of California, San Diego, La Jolla, USA
Neurosurgery, University of California, San Diego, La Jolla, USA
Published: June 19, 2019 (see history)
DOI: 10.7759/cureus.4945
Cite this article as: Wali A R, Birk H S, Martin J, et al. (June 19, 2019) Neurosurgical Management of a Thoracic Dorsal Arachnoid Web: Case Illustration. Cureus 11(6): e4945. doi:10.7759/cureus.4945
“Spinal arachnoid webs may also copresent with syringomyelia [4]. Surgical treatment of spinal arachnoid webs includes careful microdissection to remove the arachnoid web and decompress the indented spinal cord. Within this case report, we describe the diagnosis and operative management of a dorsal arachnoid web in a 49-year-old male who presented with three years of progressive back pain, without radicular features or neurologic weakness.”
Conclusions
Conclusions
This case further supports the use of the “Scalpel Sign” on MRI to diagnose dorsal arachnoid web and demonstrates surgery as the safe and definitive treatment for painful symptoms caused by indentation of the thoracic spinal cord. Decompression of the cord may cause immediate improvement in SSEP, providing immediate relief for patients with dorsal arachnoid web-induced back pain.
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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6046336/
J Spine Surg. 2018 Jun; 4(2): 446–450.
PMCID: PMC6046336
PMID: 30069540
Spine Spine Surg. 2018 Jun; 4(2): 446–450.
arachnoid web—a review article
arachnoid web—a review article
Haitham Ben Ali, Preci Hamilton, Stefan Zygmunt, and Kamal Makram Yakoub
At the QDepartment of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK
EHB ,
we see approximately ten patients with SAW per annum and our experience with recent patients is that some can be managed conservatively with regular imaging and neurophysiology but some would benefit from surgery.
At the other end of the spectrum, we present a 44-year-old man who presented with interscapular pain with no neurological deficit but MRI showed focal anterior cord displacement at T3 level and syrinx evident at C6 (see Figure 2).
However, symptomatic patients should be offered surgery even without progressive neurological symptoms.
Endoscopic resection has been postulated for the management of spinal intradural arachnoid cysts (18). Minimally invasive intervention almost certainly will reduce the extent of adhesion and thereby lessen the chances of secondary scarring and blockage of CSF flow.
Management of spinal arachnoid webs ranges from conservative management to surgical excision where in the latter, the extent of excision remains the subject of debate.
These webs are sometimes considered as a variant of an arachnoid cyst or remnants of disrupted or collapsed arachnoid cysts or even the incomplete formation of an arachnoid cyst (1-3).
Patients with DAW present with neuropathic back pain or compressive myelopathic features or radiculopathy including episodic lower extremity weakness, and sensory symptoms and bowel and bladder incontinence. They may be found on clinical examination to have hyperreflexia, spastic paraparesis, clonus and gait instability (6,14).
mass effect on the dorsal spinal cord from the accumulated CSF is similar to a surgical scalpel with its blade pointing posteriorly (1,6,15)
MRI with constructive interference in steady state (CISS) has been used to identify webs where myelogram was only suggestive (17).
CINE—cardiac-gated phase-contrast cine-mode MRI in multiple axial planes was able to better identify, correctly localize
At this stage, the extent of web excision now comes into question as overzealous lytic procedure can result in secondary adhesion and relapse of CSF blockage (7)the SAW and demonstrate a one-way valve like the flow of CSF because of the web (5).
Conclusions
Conclusions
SAW is a rarely reported pathology with varying clinico-radiological presentation and whose etiology remains unknown. In our experience surgical resection/fenestration of the web is usually curative, treatment should however be individualized and take into consideration severity of symptoms, clinical and radiological findings. MRI with CISS imaging is in our view the best imaging modality.
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https://pubs.rsna.org/doi/full/10.1148/rg.2019190021
Diagnostic Approach to Intrinsic Abnormality of Spinal Cord Signal Intensity
Diagnostic Approach to Intrinsic Abnormality of Spinal Cord Signal Intensity
Michael J. Lee , Ryan Aronberg, Matthew S. Manganaro, Mohannad Ibrahim, Hemant A. Parmar
Published Online:Oct 7 2019https://doi.org/10.1148/rg.2019190021
Figure 19b. Arachnoid web in a 47-year-old man with a history of progressive paraparesis and lower extremity numbness. (a) Sagittal T2-weighted MR image demonstrates focal intramedullary abnormal SI with cord distortion at the T3-T4 level adjacent to slight cord expansion (arrow). (b) Sagittal CT myelogram demonstrates relative expansion of the cord at the T4 level (arrow) with focal cord thinning at the T3-T4 level (arrowhead), corresponding to the cord abnormality seen on the MR image. (c) Axial CT myelogram shows marked thinning with anterior displacement of the cord at the T3-T4 level (arrow). Intraoperatively, this was confirmed to be related to arachnoiditis with webs without evidence of cord herniation.
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Arachnoid cysts
Arachnoid cysts around the spinal cord compress the spinal cord or nerve roots and cause symptoms such as progressive back and leg pain and tingling or numbness in the legs or arms.
National Organization for Rare Disorders (NORD)
Federation of voluntary health organizations dedicated to helping people with rare "orphan" diseases and assisting the organizations that serve them. Committed to the identification, treatment, and cure of rare disorders through programs of education, advocacy, research, and service.
55 Kenosia Avenue
Danbury, CT 06810
orphan@rarediseases.org
http://www.rarediseases.org
Tel: Danbury
Fax: 203-798-2291
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https://my.clevelandclinic.org/health/articles/6023-arachnoid-cysts
Cleveland Clinic
Cleveland Clinic
symptoms:
Hydrocephalus (excess cerebrospinal fluid collects in the brain).
Vertigo and dizziness.
Other symptoms vary depending on the location of the cyst. They include:
Sometimes arachnoid cysts run in families, so providers think genetics may cause them to develop. People who have certain health conditions, such as arachnoiditis or Marfan syndrome, may be more likely to develop arachnoid cysts.
Spinal cord: Spinal arachnoid cysts can lead to numbness and tingling in the feet and hands, muscle spasms, movement problems and paralysis. Back pain and scoliosis are also common. Some people develop urinary tract infections from a spinal cyst.
Leaking fluid: If trauma or injury damages the cyst, a CSF leak can result. The fluid can leak into other parts of the brain, causing severe health problems.
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