Spontaneous spinal epidural hematoma in a 7-year-old girl. Diagnostic value of magnetic resonance imaging

Spontaneous spinal epidural hematoma (SSEH) after cesarean section under epidural anesthesia: A case report

Spontaneous spinal epidural hematoma (SSEH) is an uncommon condition that can lead to severe neurological injuries, often accompanied by back pain. Pregnancy is identified as a risk factor for SSEH. Early diagnosis of SSEH presents challenges due to its atypical manifestations and the use of intraspinal anesthesia and analgesic techniques. In this case, we present the instance of a 29-year-old woman who initially received epidural labor analgesia during the first stage of labor but subsequently required a cesarean section under epidural anesthesia according to amniotic fluid turbidity. Unfortunately, the anomalous recovery of neurological function in her left lower extremity was not given sufficient attention at an early stage, and paralysis in the non-puncture segment occurred 45.5 hours after the initial puncture. Interestingly, she did not experience any back pain during these procedures. MRI examination and consultation with neurosurgeons confirmed the diagnosis of SSEH, prompting the patient to undergo emergency decompression surgery. She made an incomplete recovery 17 months after the operation. This case emphasizes the importance of considering the possibility of SSEH in pregnant women undergoing epidural analgesia, highlighting the need for spinal imaging and early neurosurgical interventions to facilitate treatment.

Role of Molecular Hydrogen in Ageing and Ageing-Related Diseases

Ageing is a physiological process of progressive decline in the organism function over time. It affects every organ in the body and is a significant risk for chronic diseases. Molecular hydrogen has therapeutic and preventive effects on various organs. It has antioxidative properties as it directly neutralizes hydroxyl radicals and reduces peroxynitrite level. It also activates Nrf2 and HO-1, which regulate many antioxidant enzymes and proteasomes. Through its antioxidative effect, hydrogen maintains genomic stability, mitigates cellular senescence, and takes part in histone modification, telomere maintenance, and proteostasis. In addition, hydrogen may prevent inflammation and regulate the nutrient-sensing mTOR system, autophagy, apoptosis, and mitochondria, which are all factors related to ageing. Hydrogen can also be used for prevention and treatment of various ageing-related diseases, such as neurodegenerative disorders, cardiovascular disease, pulmonary disease, diabetes, and cancer. This paper reviews the basic research and recent application of hydrogen in order to support hydrogen use in medicine for ageing prevention and ageing-related disease therapy.

Radiologic Features and Clinical Course of Chronic Spinal Epidural Hematoma: Report of 4 Cases and Literature Review

BACKGROUND

Spinal epidural hematoma (SEH) is a potentially devastating problem that requires rapid diagnosis and surgical intervention. A chronic course is rarely seen following SEH, and the clinical characteristics are quite different from acute cases. The epidemiology, clinical history, and radiologic findings of chronic SEH (CSEH) are not well understood, although the detection rate has increased with the widespread use of magnetic resonance imaging. The purpose of this article was to report 4 cases of surgically confirmed CSEH and clarify the radiologic features and clinical scenarios by reviewing all published cases of CSEH.

CASE DESCRIPTION

All 4 patients presented with gradually worsening radicular pain in the lower extremities. Patients' mean age was 69.5 years (range, 55-85 years). Magnetic resonance imaging revealed an epidural mass in the lower lumbar spine that was heterogeneously enhanced after gadolinium administration. The rim of the mass was low intensity on T2*-weighted images. Local erosions of the adjacent cortical bone were seen with computed tomography in all cases. All patients' postoperative courses were satisfactory with complete disappearance of radicular symptoms.

CONCLUSIONS

CSEH is a rare disease, and it is difficult to diagnose preoperatively on the basis of diagnostic imaging. The incidence of a low-intensity rim on T2*-weighted images and bone erosions on computed tomography may help differentiate rare CSEH from other lumbar degenerative diseases and epidural space-occupying masses.

Spontaneous ventral spinal epidural hematoma in a child: A case report and review of literature

Spontaneous spinal epidural hematoma is very uncommon cause of spinal cord compression. It is extremely rare in children and is mostly located in dorsal epidural space. Ventral spontaneous spinal epidural hematoma (SSEH) is even rarer, with only four previous reports in childrens. We are reporting fifth such case in a 14 year old male child. He presented with history of sudden onset weakness and sensory loss in both lower limbs with bladder bowel involvment since 15 days. There was no history of trauma or bleeding diasthesis. On clinical examination he had spastic paraplegia. Magnetic resonance imaging (MRI) of dorsal spine was suggestive of ventral spinal epidural hematoma extending from first to sixth dorsal vertebrae. Laminectomy of fourth and fifth dorsal vertebrae and complete evacuation of hematoma was done on the same day of admission. Postoperatively the neurological status was same.

Spontaneous thoracic epidural hematoma: a case report and literature review

Spinal epidural hematoma is a rare neurosurgical emergency in respect of motor and sensory loss. Identifiable reasons for spontaneous hemorrhage are vascular malformations and hemophilias. We presented a case of spontaneous epidural hematoma in an 18-year-old female patient who had motor and sensory deficits that had been present for 1 day. On MRI, there was spinal epidural hematoma posterior to the T2-T3 spinal cord. The hematoma was evacuated with T2 hemilaminectomy and T3 laminectomy. Patient recovered immediately after the surgery. Literature review depicted 112 pediatric cases (including the presented one) of spinal epidural hematoma. The female/male ratio is 1.1:2. Average age at presentation is 7.09 years. Clinical presentations include loss of strength, sensory disturbance, bowel and bladder disturbances, neck pain, back pain, leg pain, abdominal pain, meningismus, respiratory difficulty, irritability, gait instability, and torticollis. Most common spinal level was cervicothoracic spine. Time interval from symptom onset to clinical diagnosis varied from immediate to 18 months. Spinal epidural hematoma happened spontaneously in 71.8 % of the cases, and hemophilia was the leading disorder (58 %) in the cases with a definable disorder. Partial or complete recovery is possible after surgical interventions and factor supplementations.

Spontaneous epidural spinal haematoma in children caused by vascular malformations

PURPOSE

The occurrence of spinal epidural haematoma of 'spontaneous' origin in adults is a well-documented entity, though it is rare in children. In the literature to date, there are few cases of this kind of spontaneous haematoma proven to be due to an underlying vascular abnormality.

METHOD

Retrospective review of two cases of children under 15 years of age with spontaneous epidural spinal haematoma.

RESULTS

Underlying arteriovenous malformations were identified in both cases. Intra-operative photographs and histological sections of these anomalies are presented.

CONCLUSION

These are the first two such cases described with clinico-pathological correlation.

Spontaneous spinal epidural hematoma secondary to extradural arteriovenous malformation in a child: a case-based update

INTRODUCTION

The aim of this study was to report a rare pediatric case of spontaneous spinal epidural hematoma (SSEH) mimicking Guillain-Barré syndrome (GBS), secondary to an epidural arteriovenous malformation (AVM). Furthermore, a case-based update and insight into the entity is attempted.

METHODS

An 8-year-old male presented with progressing severe lower limb weakness and no traumatic history. Presentation was mimicking GBS with ascending symptoms. Magnetic resonance (MR) scan revealed a dorsal epidural mass, extending from C6-C7 to T2, compressing the spinal cord. Emergency laminoplasties and surgical evacuation of the hematoma were performed. An up-to-date review of reported SSEH cases in children was conducted, with emphasis on underlying vascular malformations (epidural AVMs in particular). Pathogenesis, predisposing factors, imaging, diagnosis, treatment and outcome are discussed.

RESULTS

The hematoma was successfully evacuated. A vascular membrane on the dura was peeled off and sent for histopathology. There was no evidence of intradural vascular penetration. The patient improved postoperatively and was able to walk with support 7 months later. Histology revealed closely packed thin-walled angiomatous structures with wide lumens (filled with red blood cells) with walls composed of collagen and smooth muscle fibers, findings consistent with AVM.

CONCLUSIONS

Non-traumatic SSEH is rare in the pediatric population. Although vascular malformations are suspected, they are extremely rarely identified histopathologically. This case represents one of the very few reports of pediatric SSEH caused by a histologically proven, purely epidural AVM. High index of clinical suspicion and low threshold for MR can lead to timely diagnosis and prompt treatment with good functional outcome.

Spontaneous spinal epidural haematoma due to arteriovenous malformation in a child

Spontaneous spinal epidural haematoma (SSEH) is a rare clinical entity, especially in infants, in whom only a few cases have been reported. In a paediatric emergency setting, SSEH should be considered as part of the differential diagnosis for acute extremity weakness and paraesthesia. Epidural vascular malformations are often suspected in these cases but have rarely been demonstrated. The authors report herein a case of SSEH in a 9-year-old boy arising from an epidural vascular malformation. He initially presented with sudden intense cervicodorsal pain followed by hypotonic lower extremities and progressive motor weakness, with no sensory change. The MRI showed an acute extradural haematoma extending from C7 to T4 with compression of the spinal cord. After submission to decompression surgery, he presented full recovery in 1 month. The histopathological analysis revealed a vascular malformation.

Cervical epidural hematoma in children: a rare clinical entity

✓ Pediatric spinal epidural hematoma is a very rare clinicopathological entity. In the vast majority of cases, spinal epidural hematomas have a nonspecific clinical presentation; this, along with their rapid progression, makes their early diagnosis and prompt surgical evacuation critical. Magnetic resonance imaging is the neuroimaging modality of choice, whereas hemilaminectomy or laminectomy is the indicated surgical intervention. The outcome is good when hematoma evacuation is performed before the onset of complete sensorimotor paralysis.

In this communication, the authors describe a 12-year-old girl with a traumatic acute cervical epidural hematoma. This lesion was successfully evacuated through a hemilaminectomy, and the patient had an excellent outcome. The pertinent literature is reviewed in terms of the incidence, origin, management, and prognosis of this rare and potentially disastrous clinical entity.

Recurrent idiopathic epidural hematoma: a case report

Spinal epidural hematoma is a relatively rare condition in children. We report the case of a 6-year-old girl who presented to a regional hospital with the complaints of severe thoracic back pain, neck stiffness, and gait disturbance of sudden onset. Clinical examination revealed no obvious cause for the symptoms. Spinal magnetic resonance imaging (MRI) revealed the presence of an epidural mass lesion extending from T1 to T3, compressing the spinal cord; the findings suggested a diagnosis of idiopathic spinal epidural hematoma. Twelve days after admission, the patient was transferred to our hospital for further observation. Blood tests, including a coagulation profile, were normal. At 22 days after the initial presentation, repeat MRI revealed resolution of the hematoma, with the mass showing an appreciable decrease in size. The patient became symptom-free and was walking normally at the time of discharge 28 days after her initial presentation. At 59 days after the initial presentation, she was readmitted with complaints of a sudden recurrence of back pain and weakness of both legs. Repeat MRI at this time revealed reappearance of the spinal epidural hematoma at the same level. Operative evacuation of the hematoma was performed 3 days after the diagnosis of the recurrence, with laminoplasty from T1 to T3. At a clinical review conducted 30 months after the operation, the patient remained symptom-free. Idiopathic resolution of a spinal epidural hematoma has previously been reported in 36 patients. However, we found no record in the literature of any case in which an epidural hematoma recurred following earlier MRI-confirmed idiopathic resolution.

Epidural haemorrhage of the cervical spinal cord: a post-mortem artefact?

Spinal epidural haemorrhage is a rare entity that occurs uncommonly in adults and rarely in children. It has a typical clinical presentation, although to date, the cause for the majority of cases remains unknown. We present a series of cases where epidural haemorrhage was identified at post-mortem, principly to the cervical cord, in cases outside the age range usually reported for clinical epidural haemorrhage, and with no underlying pathology to account for the finding. We present a hypothesis for a post-mortem cause for this finding and consider that, in the absence of any other identifiable causation, then this is a post-mortem occurrence similar to that of the Prinsloo-Gordon artefact of the soft tissues of the neck. This finding must be interpreted with care so as not to make the mistaken diagnosis of a nonaccidental head injury based on its finding, especially in the absence of intracranial, cranial nerve, optic nerve or eye pathologies.

A case of nontraumatic spinal epidural hematoma caused by extradural varix: consideration of etiology

BACKGROUND CONTEXT

Many cases of nontraumatic spinal epidural hematoma (SEH) have been reported, although the etiology of SEH remains unclear.

PURPOSE

Our purpose was to report a rare case of nontraumatic acute SEH caused by extradural varices and to discuss the etiology of this entity.

STUDY DESIGN/SETTING

Case report.

PATIENT SAMPLE

A 27-year-old man.

OUTCOME MEASURES

Resolution of the patient's paraplegia, and pathological examination of the epidural vein of the patient and three other patients with cervical spondylosis.

METHODS

Not applicable.

RESULTS

The patient recovered from paresis of both hands, although paraplegia remains complete. Pathological examination of the patient revealed abnormal veins that had thickened walls, varying caliber, and internal elastic lamina. In two of the three patients with cervical spondylosis, abnormally dilated veins resembling those in the SEH patient were observed.

CONCLUSIONS

We describe a rare case of SEH caused by extradural varices. It is speculated that spinal epidural veins can possibly develop an abnormal structure and fragility as seen in the present case and in spondylotic cases.

Spontaneous spinal epidural hematoma in children

Spontaneous spinal epidural hematoma is rare in children. It is usually confined to the dorsal epidural space. Ventral spontaneous spinal epidural hematoma (SSEH) is rarer, with only two previous reports. The authors present three children, two with dorsal and one with ventral spinal epidural hematoma, and review the literature. No etiology of the hematoma was found in the authors' patients and there was no history of trauma. A review of 24 patients of children younger than 18 years of age reported in the literature and the authors' three patients revealed that the cervicothoracic region was the most common site of SSEH, the mode of onset was frequently subacute, and there was no male preponderance as has been reported in adults. We found that the initial symptoms were often nonspecific, leading to a delay in diagnosis, especially in younger children. Follow-up data revealed that 15 of the 27 patients recovered completely, 11 had residual neurologic deficits, and one patient died. Irritability and neck pain with restricted movements of the cervical spine in an afebrile child may be early signs of SSEH and often precede onset of neurologic deficits by several hours to days. These signs should alert the clinician to consider spinal epidural hematoma and the need for urgent magnetic resonance imaging (MRI) of the spine for early diagnosis and treatment to minimize morbidity.

Spontaneous epidural hematoma as a cause of sciatic pain in a schoolboy

A previously healthy 13-year-old boy began to manifest radiating pain in his left leg after heavy physical exertion during judo training. He also had a sensation of numbness in his left buttock and leg. Initially, the patient was treated conservatively with a clinical diagnosis of disc herniation. However, following 3 months of conservative treatment, there was no relief of pain. Magnetic resonance imaging of the lumbar spine demonstrated an epidural mass causing compression of the dural sac at the L4-L5 disc level. During surgery, the L5 nerve root was found to be severely compressed in the spinal canal because of a chronic epidural hematoma. Following microsurgical removal of this hematoid mass, the patient had a good recovery. Spontaneous epidural hematomas in the lumbar region are rare, and only a few cases presenting with features simulating those caused by a disc herniation have been reported. Our patient represents the first such case described in a child.

Acute spontaneous spinal epidural hematoma: the influence of magnetic resonance imaging on diagnosis and treatment

BACKGROUND

Acute spontaneous spinal epidural hematoma (ASSEDH) is rare and its treatment standard were set prior to the era of magnetic resonance imaging (MRI). Recent data provided by this new technique necessitate a critical review of these standards.

METHODS

A case of ASSEDH diagnosed by MRI and confirmed at surgery is presented. In addition, all cases of ASSEDH reported in the pertinent literature since 1987 were reviewed and compared with those cases described earlier.

RESULTS

Since the introduction of MRI, the mean incidence of ASSEDH cases reported in the literature has increased from 2.2 to 6.4 new cases per year, with a remarkable rise in the percentage of those cases that did not require surgical treatment from 1.5% before the era of MRI to 29% thereafter.

CONCLUSION

ASSEDH runs a benign course more often than previously estimated and, therefore, the choice of the treatment should be decided for each case individually. Urgent surgical decompression remains the treatment method of choice for patients with ASSEDH presenting with disabling neurologic deficit.

Increasing irritability with sudden onset of flaccid weakness

Spontaneous spinal epidural hematoma (SSEH), is a rare and potentially fatal condition that responds favorably to early surgical intervention and should be considered in the differential diagnosis of spinal cord compression. There are few reported cases in children. We present a case of spontaneous spinal epidural hematoma in an 18-month-old child and review the literature.

Cervical spontaneous epidural hematoma as a complication of non-Hodgkin's lymphoma

Epidural hematoma is a rare cause of spinal cord compression, which usually provokes severe neurological deficits. It is presumed to originate from venous or, more probably, arterial bleeding. Thrombocytopenia and other disorders of coagulation may precipitate the onset of epidural hematoma and facilitate the evolution of the disease. We report the case of a patient suffering from a non-Hodgkin's lymphoma with severe thrombocytopenia during a MACOP-B schedule, who presented with a spontaneous cervical epidural hematoma. We discuss the etiopathological aspects, diagnosis, and treatment of this rare cause of acute cervical spinal cord compression.

Cervical epidural hematoma secondary to an extradural vascular malformation in an infant: case report

We present a report of a 22-month-old infant with a spontaneous spinal epidural hematoma arising from a purely epidural vascular malformation. Although often suspected as a cause of spontaneous epidural hemorrhage, vascular malformations have rarely been demonstrated. The important aspects of the presenting symptoms in this young age group are highlighted. We discuss the entity of spontaneous epidural hemorrhage and the characteristics that distinguish purely epidural from dural arteriovenous malformations.

Chronic spontaneous spinal epidural hematoma simulating a lumbar stenosis

A case of a patient with a clinical picture of lumbar spine stenosis actually caused by a chronic, spontaneous, spinal epidural hematoma is reported. There was no history of major or minor trauma to the lumbar spine. The correct preoperative diagnosis was made by magnetic resonance imaging. The possible etiology and clinical and radiological findings and treatment of this rare entity are discussed.

Spinal epidural hematoma. Report of a case and review of the literature

We report the case of a thoracic epidural hematoma at the T7-T9 level which occurred after placement of spinal epidural catheter for continuous anaesthesia in acute pancreatitis. The male patient felt a sudden back pain after six days of successful analgesia and became paraplegic 24 hours afterwards. An emergency laminectomy and removal of the hematoma were performed; however, the patient recovered only incompletely. We discuss the clinical signs and symptoms of spinal epidural hematoma as well as its diagnostics and therapy. The controversial views from the literature concernings its etiology are critically reviewed.

Spinal epidural haematoma: report of 11 cases and review of the literature

Spinal epidural haematomas (SEH) are rare; most are caused by trauma, anticoagulant therapy, vascular anomalies, hypertension, blood dyscrasias, epidural anaesthesia or, rarely, spinal surgery. We report 11 cases and review the literature (16 cases). The clinical picture is that of acute spinal cord compression. MRI characteristics are quite specific. On sagittal sections, the SEH appears as a biconvex mass, dorsal to the thecal sac, clearly outlined and with tapering superior and inferior margins. The dura mater is seen as curvilinear low signal separating the haematoma from the cord. Within 24 h of onset, the haematoma is isointense with the cord on T1-weighted images and heterogeneous on T2-weighted images. Later, it gives high signal on both T1- and T2-weighted images. Differential diagnosis must include subdural haematoma, epidural neoplasm and abscess. Complete neurological recovery rapidly follows laminectomy and removal of the clot. In three of our cases, the haematoma resolved spontaneously. MRI is the best examination for diagnostic and follow-up.

Cervical epidural haematoma following minor trauma

Cervical epidural haematoma following minor trauma is unusual in normal adults. It is important that the condition is diagnosed and treated promptly in order to improve the prognosis. Surgery to evacuate the haematoma is the treatment of choice.

Acute cauda equina syndrome from a ruptured aneurysm in the sacral canal. Case report

The case is presented of a young woman with acute cauda equina syndrome from a ruptured aneurysm in the sacral canal. The lesion was associated with pathological enlargement of the lateral sacral arteries bilaterally, which presumably occurred to provide cross-pelvic collateral flow in response to the diversion of the right internal iliac artery for renal transplantation. The patient presented with signs and symptoms of spontaneous spinal epidural hemorrhage. The radiographic features of this lesion are described. In addition to angiography and partial embolization of the vascular supply, contrast-enhanced high-resolution computerized tomography was essential in the diagnosis and treatment of this unique aneurysm.

Acute spontaneous spinal epidural haematoma with temporary resolution

A case of acute spontaneous spinal epidural haematoma is presented which underwent resolution of symptoms and signs before relapsing again hours later. Cases of spontaneous remission of this condition have been reported but not subsequent relapse. Conservative management of apparently resolving cases may therefore be inappropriate.