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Kim Y, Koutsouras GW, Bourdages G, Beutler T. Insidious onset of spontaneous spinal epidural hematoma in immune thrombocytopenic purpura: a case-based review. Childs Nerv Syst 2023; 39:1903-1909. [PMID: 37126139 DOI: 10.1007/s00381-023-05963-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/16/2023] [Indexed: 05/02/2023]
Abstract
INTRODUCTION Spontaneous spinal epidural hematoma (SSEH) can result from various etiologies with a variable degree of neurological deficits. Here, we describe a rare case of SEH secondary to immune thrombocytopenic purpura (ITP) in a child and review the literature of SSEH caused by ITP. CASE REPORT A 9-year-old female who presented with rapid neurological decline, including bowel and bladder incontinence and paraparesis. A SSEH was observed extending from C2 to T6, causing a mass effect on the spinal cord. Her platelet count was only 7000/µL. Multidisciplinary care was established with neurosurgery, pediatric hematology, and pediatric surgery. The patient was managed emergently with splenectomy and surgical evacuation, with multilevel laminectomy and laminoplasty for evacuation of the hematoma. After a short course of rehabilitation, the patient regained all neurological function. CONCLUSION We report the first case of cervicothoracic SSEH secondary to ITP in a child managed with emergent splenectomy and surgical evacuation with multilevel lamoplasty. We also described the methods of timely diagnosis, urgent management, and overall prognosis of patients with this condition.
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Affiliation(s)
- YeonSoo Kim
- Department of Neurosurgery, SUNY Upstate University Hospital, Syracuse, NY, USA
| | - George W Koutsouras
- Department of Neurosurgery, SUNY Upstate University Hospital, Syracuse, NY, USA.
| | - George Bourdages
- Department of Neurosurgery, SUNY Upstate University Hospital, Syracuse, NY, USA
| | - Timothy Beutler
- Department of Neurosurgery, SUNY Upstate University Hospital, Syracuse, NY, USA
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Zhao W, Shu LF, Cai S, Zhang F. Acute Cervical and Thoracic Ventral Side Spontaneous Spinal Epidural Hematoma Causing High Paraplegia: A Case Report. Anesth Pain Med 2017; 7:e14041. [PMID: 29696120 PMCID: PMC5903384 DOI: 10.5812/aapm.14041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/24/2017] [Accepted: 10/10/2017] [Indexed: 01/30/2023] Open
Abstract
Introduction Spontaneous spinal epidural hematoma (SSEH) is a rare condition that can potentially cause paraplegia. SSEH has an increasing incidence rate and its cause remains unclear. Magnetic resonance imaging (MRI) results shows that SSEH presents a spinal epidural space-occupying lesion; therefore, emergency surgical treatment is required in some cases. MRI results of most SSEH cases showed that hematoma occurs in the dorsal or lateral side. By contrast, hematoma in the ventral side is very rarely shown. Case Presentation A 42-year-old healthy woman developed a sudden onset of severe neck pain with mild limb weakness, gradual breathing difficulty, and high paraplegia. MRI results revealed that an SSEH was compressing her spinal cord in the ventral epidural space from C2 to T3. Upon admission, she received emergency decompressive laminectomy in a posterior approach from C3 to T1, and the epidural hematoma was evacuated through full incision of the dorsal side dural, release of cerebrospinal fluid, and intermittent incision of the ventral side dural. The symptoms of limb paralysis and breathing distress gradually improved after recover rehabilitation, and the patient was discharged with life self-care after 2 months. Conclusions Performing early decompressive laminectomy and evacuation of hematoma on severe SSEH patients improves neurological outcomes. For patients with ventral side SSEH, the cerebrospinal fluid should be released after the incision on the dorsal side dural, and the ventral side dural should be gradually as well as intermittently clipped to evacuate the hematoma. The patient would also receive a good prognosis after the total release of the spinal cord compression.
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Affiliation(s)
- Wei Zhao
- Department of Neurospinal and Neurotrauma, Craniocerebal Injury Cure Center of PLA, the No.101 Hospital of PLA, Wuxi, Jiangsu 214044, China
| | - Long-Fei Shu
- Department of Neurospinal and Neurotrauma, Craniocerebal Injury Cure Center of PLA, the No.101 Hospital of PLA, Wuxi, Jiangsu 214044, China
| | - Sang Cai
- Department of Neurospinal and Neurotrauma, Craniocerebal Injury Cure Center of PLA, the No.101 Hospital of PLA, Wuxi, Jiangsu 214044, China
- Corresponding author: Sang Cai, Department of Neurospinal and Neurotrauma, Craniocerebal Injury Cure Center of PLA, the No.101 Hospital of PLA, Wuxi, Jiangsu 214044, China. Tel: +82-18921150098, E-mail:
| | - Feng Zhang
- Department of Neurospinal and Neurotrauma, Craniocerebal Injury Cure Center of PLA, the No.101 Hospital of PLA, Wuxi, Jiangsu 214044, China
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Siasios ID, Vakharia K, Gibbons KJ, Dimopoulos VG. Large, spontaneous spinal subdural-epidural hematoma after epidural anesthesia for caesarean section: Conservative management with excellent outcome. Surg Neurol Int 2016; 7:S664-S667. [PMID: 27843682 PMCID: PMC5054634 DOI: 10.4103/2152-7806.191073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 04/28/2016] [Indexed: 12/22/2022] Open
Abstract
Background: Iatrogenic or spontaneous spinal hematomas are rarely seen and present with multiple symptoms that can be difficult to localize. Most spontaneous spinal hematomas are multifactorial, and the pathophysiology is varied. Here, we present a case of a scattered, multicomponent, combined subdural and epidural spinal hematoma that was managed conservatively. Case Description: A 38-year-old woman came to the emergency department (ED) complaining of severe neck and back pain. She had undergone a caesarean section under epidural anesthesia 4 days prior to her arrival in the ED. She was placed on heparin and then warfarin to treat a pulmonary embolism that was diagnosed immediately postpartum. Her neurological examination at presentation demonstrated solely the existence of clonus in the lower extremities and localized cervical and low thoracic pain. In the ED, the patient's international normalized ratio was only mildly elevated. Spinal magnetic resonance imaging revealed a large thoracolumbar subdural hematoma with some epidural components in the upper thoracic spine levels. Spinal cord edema was also noted at the T6-T7 vertebral level. The patient was admitted to the neurosurgical intensive care unit for close surveillance and reversal of her coagulopathy. She was treated conservatively with pain medication, fresh frozen plasma, and vitamin K. She was discharged off of warfarin without any neurological deficit. Conclusions: Conservative management of spinal hematomas secondary to induced coagulopathies can be effective. This case suggests that, in the face of neuroimaging findings of significant edema and epidural blood, the clinical examination should dictate the management, especially in such complicated patients.
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Affiliation(s)
- Ioannis D Siasios
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA; Department of Neurosurgery, Kaleida Health, Buffalo, New York, USA
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA; Department of Neurosurgery, Kaleida Health, Buffalo, New York, USA
| | - Kevin J Gibbons
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA; Department of Neurosurgery, Kaleida Health, Buffalo, New York, USA
| | - Vassilios G Dimopoulos
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA; Department of Neurosurgery, Kaleida Health, Buffalo, New York, USA
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Babayev R, Ekşi MŞ. Spontaneous thoracic epidural hematoma: a case report and literature review. Childs Nerv Syst 2016; 32:181-7. [PMID: 26033378 DOI: 10.1007/s00381-015-2768-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Accepted: 05/22/2015] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Rasim Babayev
- Department of Neurosurgery, National Center of Oncology, Baku, Azerbaijan
| | - Murat Şakir Ekşi
- Department of Orthopedic Surgery-Spine Center, University of California at San Francisco, 500 Parnassus Avenue MU320 West, San Francisco, CA, 94143-0728, USA.
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Muñoz González A, Cuello J, Rodríguez Cruz P, Iglesias Mohedano A, Domínguez Rubio R, Romero Delgado F, García Pastor A, Guzmán de Villoria Lebiedziejswki J, Fernández García P, Romero Martínez J, Ezpeleta Echevarri D, Díaz Otero F, Vázquez Alen P, Villanueva Osorio J, Gil Núñez A. Spontaneous spinal epidural haematoma: A retrospective study of a series of 13 cases. NEUROLOGÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.nrleng.2014.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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Muñoz González A, Cuello JP, Rodríguez Cruz PM, Iglesias Mohedano AM, Domínguez Rubio R, Romero Delgado F, García Pastor A, Guzmán de Villoria Lebiedziejswki J, Fernández García P, Romero Martínez J, Ezpeleta Echevarri D, Díaz Otero F, Vázquez Alen P, Villanueva Osorio JA, Gil Núñez A. Spontaneous spinal epidural haematoma: a retrospective study of a series of 13 cases. Neurologia 2014; 30:393-400. [PMID: 24839904 DOI: 10.1016/j.nrl.2014.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Revised: 02/26/2014] [Accepted: 03/10/2014] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Spontaneous spinal epidural haematoma (SSEH) has an estimated incidence of one per million inhabitants. It is classified as spontaneous when no identifiable cause can be linked to its onset. OBJECTIVE To describe a sample of patients with SSEH and analyse variables related to its functional prognosis. PATIENTS AND METHODS Retrospective study carried out in patients diagnosed with SSEH between 2001 and 2013 in our hospital. RESULTS We included 13 subjects (7 men) with a mean age of 71 years. Of the total, 62% had hypertension and 54% were treated with oral anticoagulants; of the latter, 57% had an International Normalised Ratio above 3. The most frequent manifestation was spinal column pain (85%). Nearly all subjects presented an associated neurological deficit, whether sensory-motor (70%), pure motor (15%), or pure sensory (7%). Five patients underwent surgical treatment and 8 had conservative treatment. After one year, 3 of the patients treated surgically and 4 of those on conservative treatment had a score of 2 or lower on the modified Rankin Scale. Poorer prognosis was observed in patients with anticoagulant therapy, large haematomas, location in the lumbar region, and more pronounced motor disability at onset. CONCLUSIONS Old age, hypertension, and anticoagulant therapy are the main risk factors for SSEH. The typical presentation consists of back pain with subsequent motor deficit. In patients with established motor symptoms, surgical treatment within the first 24hours seems to be the best option.
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Affiliation(s)
- A Muñoz González
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - J P Cuello
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - P M Rodríguez Cruz
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - A M Iglesias Mohedano
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - R Domínguez Rubio
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - F Romero Delgado
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - A García Pastor
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | | | - P Fernández García
- Servicio de Radiología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - J Romero Martínez
- Servicio de Radiología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | | | - F Díaz Otero
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - P Vázquez Alen
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - J A Villanueva Osorio
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - A Gil Núñez
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
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