Spontaneous spinal epidural hematomas: is the role of dural arteriovenous malformations underestimated?

Prognostic factors and surgical outcomes of spontaneous spinal epidural haematoma: a systematic review and meta-analysis

Spontaneous spinal epidural haematoma (SSEH) is a rare disease defined as blood accumulation within the vertebral epidural space without a cause identified, which can lead to severe neurological deficits. We aim to provide a comprehensive understanding of the prognostic factors affecting surgical outcomes in true SSEH and propose a critical time frame for operative management. A systematic literature search was performed and registered, using OVID Medline and EMBASE, in line with the PRISMA guidelines. Relevant demographic, clinical, surgical, and outcome data were extracted. The ASIA scale was uniformly used throughout our systematic review. Statistical analysis was performed via logistic regression. Of the 1179 articles examined, we included 181 studies involving 295 adult patients surgically treated for SSEH. SSEH were most commonly found in the cervicothoracic spine, with 2-4 spinal segments most commonly involved. Multivariable logistic regression model showed that the following factors were statistically significant in the post-operative outcome: operation type (P = 0.024), pre-operative neurologic status (P < 0.001), use of warfarin (P = 0.039), and operative interval (P = 0.006). Our retrospective analysis confirms the reversibility of severe neurological deficits after surgical intervention, with a prognosis of post-operative outcomes determined by the use of warfarin, pre-operative ASIA grade, and above all surgical evacuation within 12 h.

Thoracic spine extradural arteriovenous fistula

BACKGROUND

Spinal extradural arteriovenous fistula is a rare, disabling, but potentially treatable disease. Only 27 cases have been reported so far in the past 40 years.

CASE DESCRIPTION

An 18-year-old adolescent girl developed repeated back pain and mild paraplegia after a training course. Magnetic resonance imaging revealed a vessel-like lesion at the spinal extradural space, compressing the spinal medulla at the T5 level. Angiography disclosed a focal fistula fed by branches of the intercostal artery. The vascular mass was surgically removed and confirmed pathologically.

CONCLUSION

Spinal extradural arteriovenous fistulas have an arterial supply that originates outside the spinal dura, with venous draining into the spinal extradural venous plexus. They may lead to myelopathy, radiculopathy, or spontaneous extradural hematoma, due to dilated vein compression, blood stealing, or spinal venous hypertension. Extradural hematoma needs emergency laminectomy and clot evacuation. And extradural arteriovenous fistulas should be treated actively by embolization, surgical resection, or both. Appropriate treatment will stabilize the patient or result in neurological improvement.

Spontaneous vertex extradural hematoma: considerations about causes. Case report and review of the literature

A 36-year-old woman with an uneventful medical history was admitted to the emergency department following an initial generalized seizure. Neuroimaging workup disclosed a homogeneous mass at the vertex, which first was diagnosed as vertex meningioma. Anticonvulsant drug therapy was administered and the patient was discharged. Two months later the patient was examined in our neurosurgery department for additional therapeutic recommendations. A repeated neuroimaging examination showed considerable regression of the lesion. The findings on magnetic resonance imaging were consistent with those of a regressing extradural hematoma (EDH). A complete blood-coagulation study displayed no evidence of abnormality. Thorough questioning of the patient revealed no history of pericranial infection or head trauma occurring within the last 2 years. The final diagnosis was spontaneously occurring vertex EDH. In this report the authors describe the clinical and neuroimaging features of the case as well as the management strategy, and discuss etiological aspects within the context of a careful review of the literature.