Spinal epidural hematoma progressing to Brown-Sequard syndrome: report of a case

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.

Spontaneous chronic epidural hematoma in the lumbar spine associated with Warfarin intake: a case report

INTRODUCTION

Spontaneous spinal epidural hematomas are rare. However, in patients on anticoagulant treatment the risk may increase. Symptomatically patients may present with radiculopathy and even progressive neurological deficits.

CASE DESCRIPTION

We present a case of a warfarin treated patient with left L5 radiculopathy. MRI was evaluated as showing a lumbar disc prolapse or synovial cyst at L4-L5 level. The patient was operated and an organized material was removed and analysed as a hematoma. No prolapsed disc or synovial cyst was found. The patient was neurologically restored following the operation.

DISCUSSION AND EVALUATION

This case illustrates how spontaneous epidural spinal hematomas can present with symptoms of radiculopathy and radiologically be misinterpreted as a protruding disc or cyst.

CONCLUSION

Warfarin treated patients may have an increased risk of spontaneous spinal epidural hematomas.

Small and medium size intracranial aneurysms - a 5 years retrospective analysis trial and multimodal treatment

Clinical context. Subarachnoid hemorrhage (SAH) due to rupture of an aneurysm is one of the most common neurosurgical emergencies who account for onethird of stroke .In the SAH cases , aneurysms accounted for 70%. Aneurysms had a bleeding rate of 12 per 100,000 population per year, and in particular between 50 to 60 years of age with a high morbidity and mortality, especially in the first episode of bleeding at about 43% of cases (1, 4, 14). Surgery is indicated to prevent rebleeding. 2.5% of patients in the general population may have unbroken aneurysms with a prevalence of 0.65%, with a preponderance of aneurysms in a 2: 1 in women. ACI aneurysms are more common in women and Acom aneurysms are more common in men and in 15-30% of patients with presence of multiple aneurysms. Surgical timing, the assessment in each individual case for rebleeding usage of endovascular techniques (3, 12), neurological status, the presence or absence of intraparenchymal hematoma or intraventricular hemorrhage with or without vasospasm, have an influence on the result. Over a period of 5 years from January 2010 to November 2014, 317 cases of patients with intracranial aneurysms in four clinics of neurosurgery in Bagdasar -Arseni hospital have been studied. The follow up period range between 6 month and 4 years and 3 month.

Spontaneous spinal epidural hematoma as a potentially important stroke mimic

Hemiparesis develops in response to a wide range of neurological disorders, such as stroke, neoplasms and several inflammatory processes. Occasionally, it may also occur due to a lesion located in the high cervical spinal cord. In this concise review, we describe the features of spontaneous spinal epidural hematoma, which should be included in the large list of stroke mimics. Various concerns regarding the diagnostic and therapeutic conundrums relating to the condition are also discussed.

Spontaneous cervical epidural hematoma causing brown-sequard syndrome

Spontaneous cervical epidural hematoma (SCEH) is a rare clinical entity and has a varied etiology. Urgent surgical decompression should be done to prevent serious permanent neurologic deficits. We describe a 59-year-old female who presented with Brown-Sequard syndrome due to spontaneous cervical epidural hematoma. Initially, she was misdiagnosed as cerebrovascular accident. Cervical magnetic resonance imaging revealed epidural hematoma to the right of the spinal cord extending from C3 to C6. She later underwent surgical evacuation and had complete restoration of neurologic function. The outcome in SCEH is essentially determined by the time taken from onset of the symptom to operation. Therefore, early and precise diagnosis such as careful history taking and MRI evaluation is mandatory.

Nontraumatic spinal epidural hematoma during pregnancy: diagnosis and management concerns

OBJECTIVE

Nontraumatic spinal epidural hematoma (SEH) during pregnancy is rare. Therefore, appropriate management of this occurrence is not well defined. The aim of this study was to extensively review the literature on this subject, to propose some novel treatment guidelines.

METHODS

Electronic databases, manual reviews and conference proceedings up to December 2011 were systematically reviewed. Articles were deemed eligible for inclusion in this study if they dealt with nontraumatic SEH during pregnancy. Search protocols and data were independently assessed by two authors.

RESULTS

In all, 23 case reports were found to be appropriate for review. The mean patient age was 28 years and gestational age was 33.2 weeks. Thirteen cases presented with acute interscapular pain. The clinical picture consisted of paraplegia, which occurred approximately 63 h after pain onset. Spinal cord decompression was performed within an average time of 20 h after neurological deficit onset. Fifteen patients had cesarean deliveries, even when the gestational age was less than 36 weeks.

CONCLUSION

This review failed to identify articles, other than case reports, which could assist in the formation of new guidelines to treat SEH in pregnancy. However, we believe that SEH may be managed neurosurgically, without requiring prior, premature, cesarean section.

Spontaneous epidural hematoma of thoracic spine presenting as Brown-Séquard syndrome: report of a case with review of the literature

BACKGROUND

Spontaneous spinal epidural hematoma (SSEH) is an uncommon clinical entity. It produces a severe neurological deficit and prompt decompression is usually the first choice of treatment. Brown-Séquard syndrome is commonly seen in the setting of spinal trauma or an extramedullary spinal neoplasm, but rarely caused by SSEH.

METHODS

Case report and literature review.

FINDINGS

A previously healthy man presented with Brown-Séquard syndrome below T5-T6 cord segment secondary to spontaneous epidural hematoma. He opted for conservative treatment, which was followed by rapid resolution.

CONCLUSIONS

Although Brown-Séquard syndrome as a presenting feature of SSEH is rare, it does exist in exceptional case, which should be taken into consideration for differential diagnosis. Prompt surgical decompression is an absolute surgical indication widely accepted for patient with progressive neurological deficit. However, SSEH presenting with incomplete neurological insult such as Brown-Séquard syndrome might have a benign course. Successful non-operative management of this problem does not make it a standard of care, and surgical decompression remains the standard treatment for SSEH.

Chronic spontaneous cervicothoracic epidural hematoma in an 8-month-old infant

Spontaneous spinal epidural hematoma is an uncommon cause of cord compression in children, especially in infants. An 8-month-old infant was admitted to our hospital for a 40-day history of paraparesis in the lower extremities. This rapidly progressed to paraparesis with an inability to move the lower extremities. MRI of the cervicothoracic spine revealed an epidural mass with compression of the spinal cord. The infant underwent C7-T3 total laminectomies. The pathology and postoperative MRI confirmed spinal epidural hematoma from a vascular malformation. We present the case to highlight the significance of recognizing this chronic spontaneous spinal epidural hematoma and discuss the diagnosis, treatment options and prognosis.

Spontaneous and idiopathic chronic spinal epidural hematoma: two case reports and review of the literature

Spinal epidural hematoma (SEH) represents the most frequent entity of acute or chronic spinal bleeding. Based upon pathogenesis, SEH can be classified as idiopathic, spontaneous, and secondary. The idiopathic forms are considered not to be attributed to any specific risk factors. Spontaneous SEH, accounting for 0.3–0.9% of all spinal epidural space occupying lesions, instead is associated with risk factors (such as substantial soft trauma or coagulation abnormalities). The chronic form, as our literature review revealed, is the rarest and its most frequent location is the lumbar spine. The pathophysiology of spontaneous and idiopathic SEH is still under debate: There are only a few reports in literature of chronically evolving SEH with progressively increasing pain and neurological impairment. Magnetic resonance imaging may be inconclusive for differential diagnosis. Here, we present two cases of lumbar chronic SEH with slow, progressive, and persistent lumbar radicular impairment. The first patient reported a minor trauma with slight back contusion and thus was classified as spontaneous SEH. In the second case not even a minor trauma was involved, so we considered it to be idiopathic SEH. In both cases preoperative blood and coagulation tests were normal and we did not find any other or co-factors in the patients’ clinical histories. MR imaging showed uncertain spinal canal obstructing lesions at L3 and L4 level in both cases. Surgical treatment allowed a correct diagnosis and resulted in full clinical and neuroradiological recovery after 1 year follow-up. Our aim is to discuss pathogenesis, clinical and radiological features, differential diagnosis and treatment options, on the background of relevant literature review.

Spontaneous thoracic spinal subdural hematoma associated with fibromuscular dysplasia

Spontaneous spinal subdural hematoma (SDH) is an uncommon cause of acute spinal cord compression. When it does occur, however, it may have disastrous results and a poor prognosis. The nontraumatic acute spinal SDH usually results from a defect in a hemostatic mechanism (such as coagulopathy or the use of anticoagulant therapy) or from iatrogenic causes (such as spinal puncture). Fibromuscular dysplasia (FMD) is a nonatherosclerotic systemic arteriopathy of unknown cause that typically affects the small and medium arteries in young to middle-aged women. The authors report on their experience with a patient with an acute spontaneous spinal SDH that occurred in conjunction with FMD.

Acute spontaneous cervical spinal epidural hematoma with hemiparesis as the initial presentation

Acute onset of hemiparesis is a common initial presentation of cerebral vascular accidents, but many differential diagnoses should be considered. Hemiparesis results from an upper motor neuron lesion above the midcervical spinal cord, and the absence of cranial nerve signs or facial palsy suggests a lesion in the high cervical spinal cord. Most spinal cord lesions, however, result in quadriparesis or paraparesis, but not hemiparesis. We present a rare case of acute spontaneous cervical spinal epidural hematoma, with initial presentation of right hemiparesis and mild neck pain.