Superficial siderosis of the central nervous system

Last revised by Rohit Sharma on 24 Feb 2024

Superficial siderosis of the central nervous system refers to a condition resulting from deposition of hemosiderin along the leptomeninges and subpial surfaces, particularly infratentorially, with eventual neurological dysfunction, presumably due to a source of slow and chronic/recurrent subarachnoid bleeding.

Superficial siderosis of the central nervous system is a largely infratentorial pathology, and should not be confused with cortical superficial siderosis, which is a supratentorial pathology and has a different aetiopathogenesis with different clinicoradiological stigmata.

As there are many causes of recurrent or extensive subarachnoid hemorrhage, the demographics are ill-defined and represent those of the underlying cause 1,2. Cases have been reported in patients from a wide range of age groups, including from adolescence to older adults 13. Overall, there is a male predilection (M:F 3:1) 13.

The most common clinical features are 1-3:

Less common clinical features include 1-3:

If cerebrospinal fluid samples are taken via lumbar puncture, red blood cells and/or xanthochromia is commonly present 2.

Superficial siderosis of the central nervous system is thought to result from recurrent occult subarachnoid bleeds from spinal dural pathologies, although the source of bleeding is not usually identified on imaging 1,2. Although it is common to see a small amount of hemosiderin deposition at the margins of a previous hemorrhage or surgical resection margin, a single episode of subarachnoid hemorrhage (e.g. berry aneurysm rupture) is usually not sufficient to result in this condition 1,2.

Most patients will have a history of either spinal trauma (especially with ventral dural tears) or previous intradural neurosurgical intervention, and it is thought that these result in friable vessels prone to causing chronic or recurrent subarachnoid bleeding 2. Rarely, patients will have tumors or vascular malformations as the cause for superficial siderosis of the central nervous system 1,2.

The result of this subarachnoid bleeding, regardless of etiology, is accumulation of iron and its degradation products in the leptomeninges and subpial structures 1,2. Given these products are neurotoxic, there is subsequent neuronal loss and eventual atrophy of affected regions of the central nervous system 1. The prominent involvement of the vestibulocochlear nerve (CN VIII), which results in sensorineural hearing loss, is believed to be due to the combination of a long cisternal course (thus with ample exposure to the subarachnoid space) and the susceptibility of microglial cells (which have a role in myelination) to be damaged by iron compounds 6.

There are many etiologies 1-9:

CT brain is often normal, but in some cases, there may be a hyperdense ring appreciated around the brainstem 2.

Usually unrewarding and will usually not demonstrate a point of bleeding 2.

MRI brain is the modality of choice for assessment and diagnosis of superficial siderosis of the central nervous system 1,2. The findings are characteristic, with all pial and ependymal surfaces coated symmetrically with T2/T2* low signal hemosiderin, particularly those of the brainstem and cerebellum (the cerebellar vermis and folia are classic locations for identifying subtle deposits), but can be more extensive to involve the Sylvian fissure and even sulcal convexities 1,2. In long-standing cases, cerebellar atrophy will inevitably develop, particularly affecting the superior vermis 2.

  • T1: low signal

  • T2: low signal

  • GRE/SWI: low signal with blooming

As part of the workup for superficial siderosis, if no lesion is identified in the intracranial compartment, then imaging of the entire spinal canal should be performed (e.g. superficial siderosis due to myxopapillary ependymoma). In the spinal cord, like in the brain, the pial surfaces are again typically coated with T2/T2* low signal hemosiderin 1,2.

Workup and management is focused on identifying the causative lesion, although often even this is not possible. Regardless of cause, iron chelating agents may have benefit 10.

When no correctable cause is identified, signs and symptoms are slowly progressive.

Superficial siderosis of the central nervous system was first described by Ralph C Hamill (1877-1961), American neurologist and psychiatrist, in 1908 11.

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Cases and figures

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