A case of acute spontaneous epidural haematoma in a chronic renal failure patient undergoing haemodialysis: successful outcome with surgical management

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 cervical epidural hematoma in a patient with end-stage renal disease

Spontaneous spinal epidural hematoma (SEH) is extremely rare in patients with end-stage renal disease (ESRD). We report a case of a 71-year-old man with ESRD presented with progressive left limb weakness. Magnetic resonance imaging (MRI) revealed spinal cervical SEH involving C3-5 level. The patient received emergent decompression laminectomy with the evacuation of the epidural hematoma.

Acute spontaneous intracranial epidural haematoma and disseminated intravascular coagulation in a paediatric sickle cell patient

An African American teenage boy during an acute sickle cell crisis spontaneously developed acute bifrontal epidural haematomas (EDHs) in addition to disseminated intravascular coagulation (DIC). The successfully evacuated EDH reaccumulated postoperatively. After multiple transfusions, the patient underwent repeat surgery. Subsequent maximal medical therapy was unable to significantly improve the patient's neurological status, and due to family wishes, care was withdrawn. EDH are the most common emergent neurosurgical complication of sickle cell disease (SCD). Twenty-two such cases have been previously reported. We present one further complicated by DIC leading to reaccumulation of the patient's EDH. An understanding of the mechanisms of EDH formation in SCD and their associated radiological findings could help clinicians identify when a patient is at high risk of EDH formation and thus offer the potential for early intervention prior to the development of an emergency.

Repeated Spontaneous Intracranial Epidural Hemorrhage After Hysterical Crying

BACKGROUND

Spontaneous epidural hemorrhage (EDH) is a rare occurrence that may be caused by vascular anomalies, infections, coagulopathies, or tumors. Spontaneous EDH occurring in patients without specific underlying disease has been reported only as intraspinal lesion but has never been demonstrated in the intracranial area. This study presents a 19-year-old patient with repeated spontaneous intracranial EDH caused twice by hysterical crying.

CASE DESCRIPTION

The patient had spontaneous left frontal EDH after hysterical crying. Two years later, she had a similar episode after crying and a new spontaneous right frontal EDH was revealed. There was no obvious risk factor revealed by laboratory and radiologic survey. We postulated that hyperventilation during crying resulted in a sudden decrease in intracranial pressure. The intracranial hypotension induced detachment of the dura from the skull and spontaneous EDH occurred.

CONCLUSIONS

Crying or hyperventilation may trigger spontaneous EDH and should be suspected when there are signs of persisting headache and increased intracranial pressure. The prognosis is excellent if early diagnosis and surgical decompression are achieved.

Successful Recovery from Spontaneous Spinal Epidural Hematoma in a Patient Undergoing Hemodialysis

Patient: Male, 70

Final Diagnosis: Spontaneous spinal epidural hematoma

Symptoms: Abdominal pain • chest pain • complete paraplegia

Medication: —

Clinical Procedure: Conservative management

Specialty: Nephrology

Case Report: Thoracic Spinal Epidural Haematoma – an Unusual Cause of Chest Pain

Chest pain is a common presentation to the emergency department. Aetiologies to be considered are usually cardiac or pulmonary in origin. We reported a rare case of thoracic spinal epidural haematoma initially presenting to the emergency department with chest pain. The patient re-attended the emergency department four hours after discharge with symptoms of cord compression. Magnetic resonance imaging of the thoracic spine showed an epidural haematoma causing cord compression. Surgical decompression was performed with gradual resolution of symptoms. Simply ruling out acute coronary syndrome may not be sufficient in patients presenting with chest pain.

Spontaneous extradural hematoma: a rare entity

Spontaneous onset extradural hematoma (EDH) is a very rare entity and has been seen mostly to be associated with adjacent infective pathologies, dural vascular malformations, extradural metastasis, or coagulopathies. We report a series of two such cases and review the literature. One case presented with spontaneous EDH that was managed conservatively and was diagnosed to have chronic kidney disease later; the other had deranged coagulation profile and liver function secondary to drug induced hepatitis and was operated. Both patients were discharged in a stable condition and were improving on follow up.

Beware Neck Pain in a Haemodialysis Patient: Spontaneous Spinal Epidural Haematoma

Spontaneous spinal epidural haematoma is a rare and devastating disorder. To the best of our knowledge, only 4 haemodialysis patients with the diagnosis of spontaneous spinal epidural haematoma have been reported in the literature. Here, we reported a 70-year-old male haemodialysis patient who presented with a sudden onset of severe sharp neck pain. Spontaneous spinal epidural haematoma with cord compression from C2 to C6 was diagnosed by magnetic resonance imaging. After emergency surgery, the patient recovered completely from the profound neurological deficits. The relevant literatures were also reviewed.

Spontaneous Extradural Hemorrhage in a Patient with Chronic Kidney Disease: A Case Report and Review of Literature

BACKGROUND

Spontaneous extradural hemorrhage is a rare entity. It is usually reported in association with locoregional disease, which is often infective, inflammatory, and hematologic. Chronic kidney disease with hemodialysis is one of the most infrequent causes. The exact association or pathogenesis remains elusive, although possible mechanisms have been suggested. The presentation, associated comorbid conditions, and management vary among the reported cases.

CASE DESCRIPTION

A 39-year-old man with hypertension, well controlled with medications, and chronic kidney disease was on maintenance hemodialysis. He later underwent Tenckhoff catheter insertion for peritoneal dialysis; 2 weeks later, when peritoneal dialysis was started, he developed breathlessness. The Tenckhoff catheter was removed. However, the patient developed ascitic leak from the surgical site, which was repaired under general anesthesia. In the immediate postoperative period, he developed sudden, severe headache and was found to have bifrontal extradural hemorrhage. He underwent prompt drainage of the hematoma and was discharged on the fifth postoperative day in stable condition.

CONCLUSIONS

We report a rare case of spontaneous bilateral frontal extradural hemorrhage in the immediate postoperative period in a patient on hemodialysis. In addition, we review the existing literature on the topic.

Symptomatic spinal epidural hematoma after posterior cervical surgery: incidence and risk factors

BACKGROUND CONTEXT

The true incidence of symptomatic spinal epidural hematoma (SEH) after surgery of the posterior cervical spine and risk factors for its development remain unclear.

PURPOSE

The purpose of this study was to determine the 10-year incidence of symptomatic postoperative SEH and identify risk factors for its development.

STUDY DESIGN/SETTING

This study is a retrospective observational study at a Canadian tertiary care spine center.

PATIENT SAMPLE

The study sample includes adult patients undergoing posterior surgery of the cervical spine.

OUTCOME MEASURES

The outcome measures were the incidence of symptomatic postoperative SEH and risk factors for its development.

METHODS

Surgical procedure codes were used to identify study candidates. Using a standard data collection form, two independent reviewers manually searched paper and electronic medical records to extract patient-, treatment-, and complication-related data. Time to presentation, clinical findings, method of treatment, and intraoperative findings (when relevant) were recorded for patients with an SEH. The overall incidence of symptomatic SEH was calculated, and the categorical and continuous variables were summarized with percentages and means, respectively. Stepwise forward selection logistic regression analysis was performed to identify risk factors for the development of symptomatic SEH.

RESULTS

From January 2002 to December 2011, 529 patients (356 men and 173 women; mean age, 56.7 years) were identified for study inclusion. The mean Charlson Comorbidity Index (CCI) was 0.65 (range, 0-8). Myelopathy was the most common surgical indication (n=293; 55.4%), with the largest subset of patients undergoing decompression with or without instrumented fusion (n=266; 50.3%). Symptomatic postoperative SEH was diagnosed in eight patients for an overall incidence of 1.5%. Postoperative nonsteroidal anti-inflammatory drug (NSAID) use and an increased CCI were identified as significant predictors of the development of a symptomatic SEH in our study cohort (p=.024 and .003, respectively). When all other variables remained constant, a 1-point increase in CCI was associated with 1.6 times higher odds of hematoma development, whereas postoperative NSAID use increased the odds 6.6 times.

CONCLUSIONS

Symptomatic SEH may occur in up to 1.5% of patients undergoing posterior cervical spine surgery. Patients with a higher level of comorbid disease appear to be at increased risk of development of a symptomatic SEH, although avoidance of postoperative NSAIDs may decrease the risk of its development.

A spontaneous spinal epidural hematoma in a hemodialysis patient: a rare entity

Hemodialysis patients are at an increased risk of bleeding due to the platelet dysfunction caused by uremia and the use of anticoagulants during dialysis. Spontaneous spinal hematoma is a rare disorder as a complication in hemodialysis patients. Also it includes the hematoma secondary to coagulopathy, vascular malformation and hemorrhagic tumors. Here, we report the case of 77-year-old woman who presented with spinal cord compression due to spontaneous spinal epidural hematoma associated with hemodialysis. When an end-stage renal disease patient suffers from back pain and neurological deficits, the clinician should be alerted for the spontaneous spinal epidural hematoma as well as cerebrovascular events.

Non-traumatic spontaneous acute epidural haematoma -- report of two cases and review of the literature

Epidural haematomas are usually associated with preceding head trauma. The entity of non-traumatic spontaneous acute epidural haematoma is rare and most commonly occurs in the presence of infectious disease. It can also occur in the presence of coagulopathy, vascular malformations of the dura mater and haemorrhagic tumours. Sickle cell disease, systemic lupus erythematosus, open heart surgery and haemodialysis have also been implicated as causative factors. The authors report two cases of spontaneous epidural haematomas (one of unknown aetiology and one from a coagulation disorder) and discuss the aetiological agents involved in this rarely described condition.

Multilevel acute spinal epidural hematoma in a patient with chronic renal failure--case report

A 47-year-old female with diabetic nephropathy presented with acute onset of severe back pain and progressive weakness in both lower extremities. Neuroimaging revealed a spinal epidural hematoma extending from the T-3 vertebra to the sacrum. Removal of all or every other lamina on levels with epidural hematoma and emergent evacuation of the hematoma were planned. T-9 and T-10 laminectomies were performed, but excessive bleeding during the operation prompted us to abandon the procedure. Plasma and desmopressin administration controlled the bleeding from the drain 8 hours after the operation. Follow-up neuroimaging one month later revealed total resolution of the hematoma with improved neurological status. Acute spinal epidural hematomas extending over more than 15 segments are extremely rare and the surgical treatment is still challenging. Coexisting hemorrhagic diathesis creates more problems. Conservative treatment may be the best option.