蜘蛛網膜下腔出血後續發脊髓空洞症：病例報告

背景：腦血管動脈瘤（cerebral artery aneurysm）破裂是導致蜘蛛網膜下腔出血（subarachnoid hemorrhage, SAH）常見的原因之一，這類腦出血病患可能有相當程度的神經學症狀及日常生活功能（activity of daily living）受損。脊髓空洞症（syringomyelia）是描述在脊髓內部產生空洞的一種疾病，成因可分為先天性及後天性，患者可有肢體疼痛及感覺異常等臨床症狀。根據現有之文獻資料，蜘蛛網膜下腔出血後續發脊髓空洞症之個案並不多見。本篇病例報告將描述這類患者的臨床表現及影像學特色，並回顧關於脊髓空洞症之診斷、治療方式及預後的文獻資料。病例報告：個案為一位35歲男性，初次入住本科病房前半年發生右側椎動脈瘤破裂導致蜘蛛網膜下腔出血併發水腦症並接受腦室腹腔引流管放置手術，因仍有左側肢體無力至本科接受住院復健，並同時有左側肩膀疼痛及麻痛分佈於左上肢等症狀，無明顯加重及緩解因子。理學檢查有左側第二頸椎至第一胸椎皮節之針刺感覺減弱，左上肢深肌腱反射減低。因懷疑感覺異常、無力及疼痛可能和肩頸部肌肉、神經及骨骼等構造異常有關，故安排進一步檢查。頸部X光影像檢查顯示輕度頸椎關節退化，無壓迫性骨折或椎體移位；左肩軟組織超音波顯示棘上肌夾擠伴有部分撕裂傷及慢性肌腱炎；上肢神經傳導檢查顯示可能存有左側頸椎神經根病變（cervical radiculopathy）。初步診斷為左側頸椎神經根病變伴有左肩棘上肌夾擠症及肌腱炎，並安排患者接受復健及藥物治療。其症狀雖稍緩解但仍反覆發生，追蹤腦部電腦斷層亦無發現新的腦內出血或水腦。因懷疑有脊髓內病灶故安排頸部核磁共振檢查，顯示頸椎第一頸椎至第七頸椎之脊髓空洞病灶，診斷為非創傷性脊髓空洞症。個案持續接受復健治療後，追蹤肢體疼痛及無力情形穩定無明顯惡化。結論：脊髓空洞症較常見於創傷性脊髓損傷的患者，於出血性腦中風族群特別是蜘蛛網膜下腔出血於文獻中僅有少數個案報告，可能病理機轉為蜘蛛網膜炎後造成腦脊髓液循環受阻。此個案報告顯示蜘蛛網膜下腔出血可併發脊髓空洞症，因此這類患者若有持續肢體疼痛及感覺異常之症狀，理學檢查顯示為眾多皮節異常而非單一神經病變時，我們建議需接受脊髓核磁共振檢查，以確認病因，作為後續治療計畫擬定之依據。

關鍵字

蜘蛛網膜下腔出血（subarachnoid hemorrhage）；脊髓空洞症（syringomyelia）；頸椎神經根病變（cervical radiculopathy）；腦血管動脈瘤（cerebral artery aneurysm）

並列摘要

Background: Cerebral artery aneurysm rupture is one of the common causes of subarachnoid hemorrhage. Patients with subarachnoid hemorrhage may have some degree of neurological defects and impairment on activity of daily living. Syringomyelia refer to the cavity formation in spinal cord. Possible etiologies may include congenital and acquired types. Patients with syringomyelia may suffer from limb pain and paresthesia. According to previous studies, secondary syringomyelia due to subarachnoid hemorrhage was not common. Hence, a case with syringomyelia secondary to subarachnoid hemorrhage was presented by introducing the clinical signs and image findings. Moreover, current literatures about syringomyelia secondary to subarachnoid hemorrhage were reviewed, and the diagnosis, treatments, and prognosis were discussed. Case: This is the case of a 35-year-old male, who suffered from subarachnoid hemorrhage due to right vertebral artery aneurysm rupture, complicated with hydrocephalus status post ventricle-peritoneal shunt placement six months ago before the first admission to rehabilitation ward for the recovery of left limbs weakness. During the first admission, he complained of left shoulder pain and numbness. The pain and numbness were distributed over the left upper arm. No obvious reliving or worsening factors about the symptoms were observed. Physical examination showed decreased in pinprick sensation over the left second cervical to the first thoracic dermatome. The left upper limb showed decreased deep tendon reflex. The source of the weakness and paresthesia of the left upper limb was suspected to be due to the diseases of the muscle, nerves and bones of the neck and shoulder. Hence, several examinations were performed. Cervical X-ray showed mild degenerative changes in the cervical spine with no evidence of cervical vertebral compression fracture or spondylolisthesis. Soft tissue ultrasound of the left shoulder showed left supraspinatus impingement with partial tear and tendinosis. The nerve conduction study of the bilateral upper limbs showed the possible left cervical radiculopathy. The initial impression was left cervical radiculopathy and left supraspinatus impingement with partial tear and tendinosis. A rehabilitation program was prescribed for him. However, the symptoms persisted and relapsed. Brain computed tomography was checked. Evidence of new intracranial hemorrhage or hydrocephalus were not observed. Cervical magnetic resonance imaging (MRI) was performed under the suspicion of spinal cord lesions, which showed syringomyelia form C1 to C7 levels. Further rehabilitation training and clinical follow-up were conducted. Clinical signs were stable and deterioration of symptoms was not observed after four months of rehabilitation. Conclusion: Syringomyelia is more common in traumatic spinal cord injury. Only few reports about the secondary syringomyelia due to subarachnoid hemorrhage have been reported. The pathophysiology may be due to the disturbance of normal cerebral fluid circulation after the subarachnoid hemorrhage. This case presented the possibility of secondary syringomyelia after subarachnoid hemorrhage. Hence, if a patient with subarachnoid hemorrhage has persistent limbs pain and paresthesia, with multiple dermatome involvement which can not be explained by mononeuropathy, the spinal MRI examination for the survey of syringomyelia should be considered.

並列關鍵字

subarachnoid hemorrhage ； syringomyelia ； cervical radiculopathy ； cerebral artery aneurysm

參考文獻

all A, O'Kane R. The Extracranial Consequences of Subarachnoid Hemorrhage. World Neurosurg 2018;109:381‒92.

uehlschlegel S. Subarachnoid Hemorrhage. Continuum (Minneap Minn) 2018;24:1623‒57.

orres-Parada M, Vivas J, Balboa-Barreiro V, et al. Post-stroke shoulder pain subtypes classifying criteria: towards a more specific assessment and improved physical therapeutic care. Braz J Phys Ther 2020;24:124‒34.

andertop WP. Syringomyelia. Neuropediatrics 2014;45:3‒9.

neling J, Boström S, Rossitti S. Subarachnoid hemorrhage-associated arachnoiditis and syringomyelia. Clin Neuroradiol 2012;22:169‒73.

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蜘蛛網膜下腔出血後續發脊髓空洞症：病例報告

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