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Título

Incomplete Cauda Equina Syndrome secondary to Tarlov cyst hemorrhage - Case report

RESUMO

Case Presentation: A 37-year-old male patient presented sudden onset of severe sacralgia (VAS 9), with paresthesia and allodynia in the right buttock, which radiated to the posterior aspect of the thigh, making it impossible for him to sit down. Five days later, he progressed to urinary and fecal retention and erectile dysfunction. There was no decrease in strength, coordination, or other changes in the neurological examination. MRI of the lumbosacral spine and pelvis showed multiple tubular images in sacral projections with hypersignal on T2 and hyposignal on T1, suggesting multiple Tarlov cysts (Perineural Cyst – PC), in addition to pelvic and perianal varicose veins, edema adjacent to the coccyx and fluid in the pelvis. An area of 50x25 mm was detected in pre-sacral projection at the S4 level, with hyposignal on T2, isosignal on T1 with peripheral areas of hypersignal, without restriction to diffusion, indicating hemorrhage in a PC with compression of the cauda equina. Before hemorrhage, the patient was being treated for hemorrhoidal disease with the drug combination diosmin and hesperidin for two months, possibly contributing to the bleeding of the PC. The patient underwent conservative treatment, with neuropathic pain and anxiety control with duloxetine, pregabalin, chlorpromazine and clonazepam. After 30 days there was an important spontaneous reduction of the cyst to 20x10 mm, with improvement in excretory functions, erectile dysfunction and pain. Discussion: Tarlov cyst consists of the formation of saccular dilatations filled with cerebrospinal fluid, located in the nerve sheaths of the posterior roots of the spinal nerves, mainly the sacral roots. It has a prevalence of 1-4%, with asymptomatic clinical course, being symptomatic in less than 1% of cases, due to pressure from the cyst on the nerve roots, caused by trauma, ischemia, inflammation, or hemorrhage, the latter being rare, with few cases reported in the literature. Symptoms can be back pain, sensory and motor radiculopathy, changes in excretory functions, dyspareunia and sexual dysfunction, indicating the need for clinical or surgical treatment. Final Considerations: This case highlights a rare complication of incomplete cauda equina syndrome secondary to Tarlov cyst hemorrhage, after treatment of hemorrhoidal disease, demonstrating the need to include PC in lumbosacral compressive etiologies, for rapid diagnosis, appropriate therapeutic intervention, and reversal of neurological symptoms.

Palavras Chave

Tarlov Cysts; Perineural Cysts; Hemorrhage; Cauda Equina Syndrome; Hemorrhoidal Disease