Spontaneous spinal epidural hematoma causing paraplegia: resolution and recovery without surgical decompression

Two pediatric observations of spinal extradural arteriovenous fistulas presenting with epidural hemorrhages and cord compression

We report two cases of acute spinal cord compression in children with low-flow spinal epidural arteriovenous fistulas (SEAVFs) and discuss the clinical presentation and management of these vascular anomalies. While most low-flow SEAVFs without radiculomedullary drainage are benign lesions typically diagnosed incidentally, we suggest that asymptomatic lesions may warrant aggressive management in specific circumstances, including lesions diagnosed at an early age or in patients under anticoagulation therapy. Our observations also emphasize that patients with a "spontaneous" epidural hemorrhage should undergo dedicated preoperative or postoperative vascular imaging to identify a possible underlying vascular anomaly.

An unusual case of ventral spontaneous spinal epidural hematoma: Case report with review of literature

Spontaneous spinal epidural hematoma is a rare predominantly idiopathic entity which can prompt acute neurologic symptoms and if not managed in time can lead to devastating outcomes. High index of suspicion is required for early diagnosis on MRI for a prompt management of patients showing sudden neurologic deficits. Our patient was 42-year-old female who presented with sudden onset of numbness followed by weakness in both lower limbs and urinary retention without any comorbidity or any medication. MRI whole spine done within 14 hours of symptom onset showed ventral epidural hematoma without any vascular malformation. Immediate decompressive laminectomy with evacuation of hematoma improved power in both lower limbs with regaining bowel and bladder function. The key here is timely surgical decompression of the hematoma for a favorable neurosurgical outcome. Although there is a recent development towards non–surgical treatment, it needs to be well established yet and require such approach on case-to-case basis.

Therapeutic strategy for acute spinal cord paralysis by epidural hematoma derived from the application of non-operative observation and the optimal timing to convert to surgical intervention

Some cases of acute spinal cord paralysis by epidural hematoma have made complete recovery through natural progression. This group cannot be ignored in choosing a therapy. We have considered the applications of non-operative observation and the optimal timing to convert to surgical intervention. Of the 454 cases reported, cases that were of trauma/post-operative, undergone epidural block, lumbosacral level, paralysis-free, were excluded. 10 clinical items were identified as factors related to the outcome of therapy, and a total of 142 cases (73 surgical and 69 non-surgical/observation cases) which included all items in its record, were extracted for this study. 104 cases that made complete recovery from spinal paralysis (CR) includes 65 cases without surgical intervention (NOP-CR). Using "paralysis recovery start time (PRST)", ROC analysis was conducted to show the diagnostic time needed to detect the cases of CR and NOP-CR. Clinical characteristics of CR and NOP-CR were identified using multiple logistics regression analysis. CR probability were higher at PRST < 15 h from the onset and NOP-CR was even higher at < 11 h. Three clinical items: incomplete motor paralysis, no use of anti-coagulant therapy, and PRST within 15 h were found to be the characteristics of CR and NOP-CR. The case with all 3 items; especially PRST within 11 h from onset, is applicable to non-operative observation. Immediate surgical intervention at 6-hours is recommended in cases that presented with unchanged complete motor paralysis. Observation treatment is discontinued and converted to surgery if motor usefulness is not regained at 15-hours.

Rapid Recovery of Spontaneous Spinal Epidural Hematoma without Surgical Treatment: Case Report and Literature Review

BACKGROUND

Spontaneous spinal epidural hematoma (SSEH) is a relatively uncommon yet potentially disabling neurologic emergency. The classical presentation includes a severe acute attack, sometimes radiating pain at the back, interscapular, or neck areas, followed by neurologic deficits. The main treatment is surgical, and self-healing cases are rare.

CASE DESCRIPTION

A 17-year-old female was admitted to the neurosurgery department with neck pain, myasthenia of the limbs, and difficulty moving. Mild neck pain had developed 1 week prior with no obvious predisposing causes. The patient had suddenly suffered severe neck pain during normal walking and developed rapid paralysis of her limbs. There was no recent history of trauma, infection, or drug administration. Magnetic resonance imaging performed 1 hour after the onset of limb paralysis demonstrated a large spinal epidural hematoma that extended from C4 to C6. However, 9 hours after the initial onset of severe neck pain, her symptoms completely ceased. Magnetic resonance imaging demonstrated that the SSEH had nearly dissipated.

CONCLUSIONS

Most cases of SSEH with spontaneous resolution are located on the upper thoracic and cervical spine. Surgery is the standard of care for these patients but can occasionally be deferred if the patient demonstrates significant rapid improvement.

Two cases of spontaneous cervical epidural hematoma without back or neck pain in elderly Japanese men

Cases

Spontaneous spinal epidural hematoma (SSEH) is an uncommon disease. Most SSEH cases involve back and/or neck pain. We report the cases of two men who experienced SSEH with dysstasia but without back or neck pain.

Outcomes

This study presents two cases involving elderly Japanese men who visited an emergency department because of sudden dysstasia without back or neck pain. The results of the neurological examinations revealed ataxic gait. Cervical spinal epidural hematomas were observed by computed tomography and magnetic resonance imaging. One patient underwent hematoma removal and decompression by corpectomy, whereas the other patient received conservative treatment and observation. The patients were discharged without sequelae.

Conclusion

Spinal epidural hematomas are difficult to diagnose, and a delayed diagnosis can adversely affect the patient's quality of life. These hematomas should be considered in the differential diagnosis of cerebrovascular diseases.

Spontaneous Spinal Epidural Hematoma: A Study of 55 Cases Focused on the Etiology and Treatment Strategy

BACKGROUND

Spontaneous spinal epidural hematoma (SSEH) is a rare neurologic emergency of the spinal cord. Its cause and treatment strategy remain controversial. This study aimed to evaluate a significant cause of SSEH and to discuss the treatment strategy according to the clinical outcomes of patients in 2 institutions.

METHODS

Fifty-five cases of SSEH treated at our institutions between February 2002 and February 2016 were retrospectively analyzed.

RESULTS

The mean age of the first SSEH onset was 31.8 years. The follow-up rate was 72.7%, with 28 patients (70%) showing satisfactory clinical outcomes. Forty patients received preoperative spinal digital subtraction angiography. Spinal epidural (extradural) arteriovenous fistula was detected in 6 patients (15%), 5 of whom showed 1 type of special slow-flow shunt. Nineteen patients (34.5%) suffered from multiple episodes until they underwent invasive treatments or last follow-up. Rebleeding was confirmed in 8 patients. None of the patients had a subsequent episode or rebleeding after invasive treatment. The risk factors for poor clinical outcome included advanced age at initial onset (P = 0.020), a short progression interval (P = 0.030), no symptom relief after admission (P = 0.011), hypesthesia (P = 0.017), complete spinal cord injury (P = 0.001), and hematoma below the T4 level (P = 0.014).

CONCLUSIONS

Spinal epidural (extradural) arteriovenous fistula is a significant cause of SSEH. Standard spinal digital subtraction angiography is necessary for patients with SSEH. Conservative treatment could not prevent occurrence of multiple episodes or rebleeding in patients. Microsurgery should be recommended as the preferred treatment strategy for SSEH. Endovascular embolization is also recommended if applicable.

Idiopathic Thoracic Spontaneous Spinal Epidural Hematoma

A 33-year-old male patient experienced temporary sensory loss and weakness in the right lower extremity one month prior to admission. The patient was admitted to a private clinic with a three-day history of acute onset of sensory loss and weakness in both lower extremities and was treated and followed up with a prediagnosis of transverse myelitis and the Guillain-Barre syndrome (GBS). The patient was subsequently transferred to our clinic and the neurologic examination revealed paraplegia in both lower extremities, positive bilateral Babinski signs, and hypesthesia below the T10 dermatome with saddle anesthesia. The patient had urinary incontinence and thoracic magnetic resonance imaging (MRI) showed an image of a mass compressing the medulla.

Solitary spinal epidural cavernous haemangiomas as a rare cause of myelopathy

Cavernous haemangiomas rarely occur in the spinal epidural space. We report the case of a 27-year-old man who presented with myelopathy secondary to spinal cord compression from a purely epidural lesion. The imaging characteristics of cavernous haemangiomas are unique, reflecting a highly vascular lesion. Key differentiating features from intracranial or intramedullary lesions include the lack of a surrounding hemosiderin ring and popcorn appearance. An urgent referral to a neurosurgeon is recommended given the possibility of acute neurological deterioration from intralesional haemorrhage, and good recovery from early surgical resection. Preoperative planning with thorough patient counselling and availability of matched blood is important, and an en bloc resection approach should be taken to minimise blood loss. In this case, the patient experienced complete recovery after surgical resection. No recurrence after complete resection has been reported in the literature. This suggests a good long-term outcome for the patient and that no early adjuvant therapy is necessary.

Cervical epidural haematoma causing Brown-Sequard syndrome: a case report

Brown-Sequard syndrome secondary to compression of the spinal cord by an epidural haematoma following minor trauma is rare. A 65-year-old woman presented with neck pain and sudden onset hemiplegia with contralateral anaesthesia. Magnetic resonance imaging showed a haematoma in the epidural space in the C3 to C5 levels. She underwent open-door laminoplasty for evacuation of the haematoma. At the 2-year follow-up, she had regained normal sensations and a neurological grade of 5/5.

[Spontaneous resolution of a paraparesis due to a dorsolumbar epidural haematoma associated with subarachnoid anaesthesia and postoperative analgesia using an epidural catheter]

Spinal epidural haematoma after neuroaxial anaesthesia is a rare but serious complication. Most cases are attributed to anticoagulant therapy or bleeding tendency. It presents as an acute spinal cord compression and usually requires emergency surgical decompression. The interval between the onset of clinical signs and surgical evacuation is very important, influencing the neurological prognosis. We report a case of a spinal epidural haematoma after epidural analgesia in a patient who was treated with low molecular weight heparin for thrombo-prophylaxis in the perioperative period. In some cases, such as the one reported here, good neurological recovery can be achieved with conservative management.

Chronic Spinal Epidural Hematoma Related to Kummell's Disease

Chronic spinal epidural hematoma related to Kummell's disease is extremely rare. An 82-year-old woman who had been managed conservatively for seven weeks with the diagnosis of a multi-level osteoporotic compression fracture was transferred to our institute. Lumbar spine magnetic resonance images revealed vertebral body collapse with the formation of a cavitary lesion at L1, and a chronic spinal epidural hematoma extending from L1 to L3. Because of intractable back pain, a percutaneous vertebroplasty was performed. The pain improved dramatically and follow-up magnetic resonance imaging obtained three days after the procedure showed a nearly complete resolution of the hematoma. Here, we present the rare case of a chronic spinal epidural hematoma associated with Kummell's disease and discuss the possible mechanism.

An unusually rapid spontaneous recovery in a patient with spinal epidural hematoma

BACKGROUND

Spontaneous epidural hematoma is a rare condition, which usually requires urgent surgical treatment.

OBJECTIVES

To report two cases of spontaneous epidural hematoma, one of which was treated conservatively, and the other surgically, and discuss the possibility of unusual spontaneous recovery and treatment decision-making.

CASE REPORT

We encountered 2 patients with spontaneous spinal epidural hematoma, both of whom were taking an anti-platelet agent, producing severe paraplegia. One patient with a hematoma at C2-T3 experienced a rapid neurological recovery while a magnetic resonance imaging scan was being performed. A complete resolution of the hematoma and complete neurological recovery ensued without surgical intervention. A second patient with a hematoma at T10-12 showed no neurological recovery up to the time emergency surgery started and was treated surgically by T10-12 laminectomy and excision of the hematoma. Neurological function returned to normal in both patients.

CONCLUSION

The occurrence of spontaneous recovery in some patients makes the decision for surgery difficult. Emergency physicians need to be aware of the possibility of spontaneous rapid neurological recovery in patients with spinal epidural hematoma. To avoid unnecessary surgery in patients who will spontaneously have neurological recovery, neurological evaluations need to be repeatedly performed up to the time the emergency surgery begins. However, unfortunately, there is no diagnostic tool at present to identify the patients who recover spontaneously, and the interval between onset and surgery is correlated with clinical results, therefore, conservative treatment should be prescribed only for those patients who exhibit improving neurological signs early in the clinical course.

Vertebral artery dissection as an extremely rare cause of spinal epidural hematoma: case report and review of the literature

OBJECTIVE

To present a patient with a cervico-thoracic ventrally located epidural hematoma caused by dissection and subsequent bleeding of the cervical portion of the vertebral artery.

SUMMARY AND BACKGROUND DATA

Non traumatic epidural hematoma is a rare entity. The etiology usually is not clarified: a venous origin is usually suspected although an arterial source is also possible.

CLINICAL REPORT

A 32-year-old woman presented with a ventrally located cervico-thoracic epidural hematoma caused by non traumatic dissection and dissecting aneurysm rupture of the cervical portion of the vertebral artery. The dissection was demonstrated by magnetic resonance imaging and digital subtraction angiography. The patient had no neurological symptoms and was treated by conservative methods. Follow up imaging showed healing of the vertebral artery and resorption of the epidural hematoma.

CONCLUSION

Dissection of the cervical portion of the vertebral artery with subsequent perivascular bleeding is not well recognized as a possible cause of a spinal epidural hematoma. Even though this entity and the underlying cause may be rare, we suggest a vigilant search for vertebral artery injury in cases of ventrally located cervical and upper thoracic epidural hematoma.

Spontaneous cervical epidural hematoma masquerading as an abscess on magnetic resonance imaging scan

OBJECTIVE

The aims of the study are to describe a case of spontaneous spinal epidural hematoma (SSEH) without any predisposing factors and magnetic resonance imaging (MRI) features of epidural abscess and to highlight the importance of high clinical suspicion.

CLINICAL FEATURES

A 75-year-old male presented to the emergency department after a severe neck pain. He progressively showed sensory and upper motor signs on the left side of the body. The MRI scans were suggestive of cervical epidural abscess with peripheral enhancement of the lesion.

INTERVENTIONS AND OUTCOMES

He underwent a multiple level (C3-T1) laminectomy when he was found to have an SSEH. There has been no history of trauma or other predisposing factor, and presence of arteriovenous malformation was ruled out by MR angiography.

CONCLUSIONS

The MRI features of SSEH may be misleading and mimic other spinal lesions such as abscess. Presence of tapering superior and inferior margins, spotty Gadolinium enhancement in the mass, along with abrupt clinical onset of pain and neurologic deficit, should raise the suspicion toward epidural hematoma. Enhancement in the hyperacute stage of the hematoma itself might indicate continued bleeding and, in the case of deteriorating neurologic status, will necessitate decompression.

Spontaneous spinal epidural hematoma as the initial presentation of leukemia

We present a case of a 55-year-old male with progressive neurological deficits that appeared dramatically. MRI detected a spinal epidural hematoma at the cervicothoracic junction and blood tests showed leukocytosis, mild anemia, and thrombocytosis. Spontaneous spinal epidural hematoma (SSEH) as the initial presentation of leukemia was diagnosed. Urgent posterior decompression was performed after 28 h from acute onset of backache, and the patient experienced remarkable improvement in neurological findings.

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.

Spontaneous spinal epidural hematoma: analysis of 23 cases

BACKGROUND

Spontaneous spinal epidural hematoma is a rare but disabling disease. To explore its characters and find out what factors influence the prognosis, we gave a retrospective analysis of 23 patients in our department in the past 8 years.

METHODS

Spontaneous spinal epidural hematoma was diagnosed by taking MRIs of patients without surgical management or by histopathological examination. We registered patient's case history, laboratory examination, radiological image, treatment, pathological result, and prognosis after 3 months and gave them nonparameter analysis.

RESULTS

Primary neurological status and progressive intervals have correlation with prognosis (P< .01), and the latter less than 12 hours predict worse prognosis (P= .032). Spinal edema in MRI predicts pessimistic prognosis (P= .013). Long hematoma predicts worse prognosis (P= .02). Preoperative interval, emphasized by other authors, has no statistical correlation with prognosis in this study (P= .832). Finally, patients with a single hematoma or hematoma mingled with other spinal disturbance have the same prognosis (P= .065).

CONCLUSIONS

The primary neurological status, progressive interval, spinal edema, and size of hematoma will influence the prognosis of the patient with SSEH. The major treatment is surgical intervention, and it should be operated as soon as possible to avoid the aggravation of neurological status. Conservative treatment is not considered unless patient's neurological deficiency has relieved in the early period.

Acute presentation of spinal epidural cavernous angiomas: case report

OBJECTIVE

Spinal extramedullary hematomas stemming from cavernous angiomas in the epidural compartment are rare. It is more common for spinal epidural cavernous angiomas to present with slow and progressive myelopathy or radiculopathy. They seldom present with clinical evidence of acute spinal cord or nerve root compression.

CLINICAL PRESENTATION

Three consecutive cases of acute spinal cavernous angiomas with overt neurological deficits were presented. These presentations included acute onset of neck pain and tetraparesis, bilateral lower extremity pain and paraparesis, and acute sciatic pain with plantar flexor weakness. The lesions were located in the cervical, thoracic, and sacral spine, respectively. The cases included either abrupt lesion enlargement secondary to a pure intralesional hemorrhage or a cavernous hemorrhage that invaded the epidural space.

INTERVENTION

All patients were treated with either laminotomy or complete resection of the hematoma and cavernoma within 12 hours after admission.

CONCLUSION

Spontaneous spinal epidural hematomas presented with significant pain and acute spinal cord and nerve root compression may represent the manifestation of a cavernous angioma. Appropriate interpretation of preoperative imaging studies may prevent delay in proper management, especially for patients in whom nerve root deficit is the only clinical expression.

Recurrent spontaneous spinal epidural hematoma in a child: first case report

Spontaneous spinal epidural hematomas are a rare cause of spinal cord compression. These are typically isolated events. Recurrent spontaneous spinal epidural hematomas have been reported only in two instances in adults. There have been no reports of recurrent spontaneous spinal epidural hematomas involving a child. This report details the case of a 10-year-old female with a recurrent spontaneous spinal epidural hematomas who presented with two episodes of transient lower extremity paralysis, 2 months apart, followed by a third episode a year later which resulted in permanent paralysis.

Spinal Epidural Hematoma After Thrombolysis for Deep Vein Thrombosis with Subsequent Pulmonary Thromboembolism: A Case Report

A 38-year-old male was initially admitted for left leg swelling. He was diagnosed as having deep vein thrombosis (DVT) in the left leg and a pulmonary thromboembolism by contrast-enhanced chest computed tomography (CT) with delayed lower extremity CT. The DVT was treated by thrombolysis and a venous stent. Four hours later, he complained of severe back pain and a sensation of separation of his body and lower extremities; he experienced paraplegia early in the morning of the following day. Magnetic resonance imaging showed a spinal epidural hematoma between T11 and L2, which decompressed following surgery. We, therefore, report a case of a spinal epidural hematoma after thrombolysis in a case of DVT with a pulmonary thromboembolism.

Spontaneous spinal epidural haematoma: report of two cases and review of the literature

The clinical presentation, investigation, management and outcome of two patients with spontaneous spinal epidural haematoma (SSEH) are presented. CT myelogram revealed an extradural compressive lesion in one patient and MRI confirmed extradural haemorrhage in the second. Both the cases were treated surgically. One patient made a complete recovery and the other made no neurological recovery. The clinical presentation, diagnosis, treatment and factors determining the outcome of SSEH are discussed and the literature reviewed.

Revisión de 22 casos de hematomas epidurales espinales. Factores pronósticos y manejo terapéutico

INTRODUCTION

Spontaneous and non-spontaneous spinal epidural hematoma (SEH) is a rare condition in neurosurgical practice. It presents as an acute spinal cord compression and usually requires emergent surgical decompression. Recently non-surgical treatment (corticoid therapy) has been proposed in selected cases of SEH with good neurological recovery.

OBJECTIVES

To identify the prognostic factors of this condition. A treatment management based upon our results is proposed.

MATERIAL AND METHODS

Between 1985 and 2001, 22 patients suffering SEH were treated at our Department. Age, sex, initial neurological condition (evaluated using the Frankel grading scale), surgical timing, radiological data such as location, extension and degree of radiological cord compression, anticoagulation or antiplatelet therapy, epidural anesthesia and previous spinal surgery were analyzed in order to find prognostic factors. Finally, conservative or surgical treatment as well as final neurological condition were also considered for the analysis.

RESULTS

The average age was 69 years with a male preponderance (72.7%). Surgical decompression was done in 17 cases, most of them (11 cases) presenting with high neurological deficit (Frankel A-B). Conservative treatment was used on 5 patients. Operated patients showed a larger degree of neurological recovery. The incidence of post-operative complications was of 13%.

CONCLUSIONS

This study shows the efficiency of SEH surgical evacuation performed within the first 24 hours, particularly when the patient presents a severe neurological deficit (Frankel A-B). Patients presenting minimal neurological involvement (Frankel D-E) can be managed successfully with conservative treatment.

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.

Resolution of spontaneous spinal epidural hematoma without surgery: report of two cases

STUDY DESIGN

Case report.

OBJECTIVE

To report two cases of spontaneous spinal epidural hematoma that completely resolved, clinically and radiographically, without surgical treatment.

SUMMARY OF BACKGROUND DATA

The treatment of spinal epidural hematoma is usually surgical. Spontaneous spinal epidural hematoma is an uncommon phenomenon and may be of uncertain cause.

METHODS

One patient with acute onset of complete quadriplegia and another with complete paraplegia caused by spontaneous spinal epidural hematoma were treated without surgery.

RESULTS

Both patients recovered nearly completely with respect to their neurologic function at 3-month follow-up. No source of hematoma was ever identified.

CONCLUSIONS

Spontaneous spinal epidural hematoma should be considered in the differential diagnosis of sudden onset of spinal cord compression in association with back pain. Patients initially presenting with severe neurologic dysfunction are potential candidates for conservative management if they demonstrate rapid and progressive improvement in neurologic function. Patients treated in this manner can have nearly complete restoration of function.

Magnetic resonance imaging-monitored conservative management of traumatic spinal epidural hematomas. Report of four cases

Spinal epidural hematomas (SEHs) are uncommon complications of traumatic injury to the spine. Emergency surgical evacuation is the standard treatment. Although it is recognized in the literature, the possibility of nonsurgical treatment of traumatic SEH is far from being codified. The authors report excellent outcomes in four conservatively managed patients who had sustained a severe spine injury with fracture of the lumbar vertebral body and in whom traumatic SEHs were diagnosed by magnetic resonance imaging. Although in the authors' experience a good spontaneous outcome in this subgroup of minimally symptomatic patients harboring moderate-sized SEHs has been achieved, further studies are necessary to understand the real spectrum of nonsurgical treatment of such lesions.

Traumatic epidural hematoma of the cervical spine: magnetic resonance imaging diagnosis and spontaneous resolution: case report

OBJECTIVE AND IMPORTANCE

Demonstration of interest of medical treatment of cervical epidural hematomas.

CLINICAL PRESENTATION

A young patient developed cervical pain after experiencing cervical trauma. Computed tomography and magnetic resonance imaging demonstrated an epidural cervical hematoma. A spontaneous resolution of the clinical symptoms and the radiological abnormalities was observed.

CONCLUSION

Although surgical decompression is generally regarded as mandatory in selected patients with incomplete and nonprogressing deficits, conservative management may be possible.

Spontaneous spinal epidural hematoma associated with thrombolysis and anticoagulation therapy: report of three cases

Three patients with a spontaneous spinal epidural hematoma are presented, one of which is exceptional because it could be attributed to thrombolysis with alteplase. The other two were correlated with oral anticoagulant therapy. Our second case suggests that Morbus Kahler may be an underlying pathology in spinal extradural hematoma. In the third patient neither an obvious 'locus minoris resistentiae' nor a pathological coagulation test could be held responsible for the spontaneous bleeding. All three patients underwent laminectomy and evacuation of the hematoma. Although two of our cases are examples of complete recuperation after late operative intervention, early surgery is preferable. Permanent clinical attention together with a low threshold to perform magnetic resonance imaging (MRI) leads to a quicker diagnosis of spinal epidural hematoma. We show that administration of gadolinium may facilitate correct preoperative localization of the hematoma because there may be contrast enhancement of the hematoma. Finally, the postoperative policy concerning thromboembolic prophylaxis is discussed.

Spontaneous spinal epidural hematoma with spinal cord compression complicating plasma cell myeloma. A case report

STUDY DESIGN

A case is reported in which a patient had acute paraplegia with sensory loss caused by a spontaneous epidural hematoma that was ascribed to bleeding of pre-existing myeloma lesions of the thoracic vertebrae.

OBJECTIVES

To highlight the causes of secondary epidural hematomas with special attention to pre-existing vertebral or epidural lesions.

SUMMARY OF BACKGROUND DATA

There are no apparent previous reports of epidural spinal hematomas ascribed to underlying malignant diseases. Benign dysplasia, such as hemangioma or Paget's disease, has been implicated in a few cases.

METHODS

A case of spontaneous dorsal epidural hematoma is reported in a patient followed up for plasma cell myeloma with osteolytic lesions in the lower thoracic spine. There was no history of major trauma or coagulation disorders. Complete loss of motor and sensory function in both lower limbs was noted, with sphincter dysfunction. Magnetic resonance imaging of the thoracic spine showed a large posterolateral epidural hematoma responsible for spinal cord compression.

RESULTS

The patient failed to improve despite surgical decompression within 6 hours of symptom onset. He died 13 days later of refractory bacterial pneumonia. A large epidural hematoma adjacent to myelomatous lesions of the thoracic vertebrae was found at autopsy.

CONCLUSIONS

This is the first reported case of spontaneous epidural hematoma ascribed to underlying malignant disease, with confirmation of the diagnosis by postmortem examination. Possible mechanisms include tumor-related epidural inflammation and fragility of epidural venous plexuses.

Spinal epidural vascular malformation presenting in association with a spontaneously resolved acute epidural hematoma. Case report

A 16-year-old boy developed acute neck pain and severe quadriparesis after mild rotatory movement of his neck. Magnetic resonance imaging revealed a cervical epidural hematoma that resolved spontaneously within a few days. Vertebral angiography demonstrated a small vascular malformation in the upper cervical epidural space. The vascular mass on the dural surface was totally resected and confirmed to be an arteriovenous malformation. This case represents the importance of including routine angiography in designing therapeutic strategy for cases of spinal epidural hematoma with spontaneous resolution.

Conservative treatment of acute spontaneous spinal epidural hematoma

BACKGROUND

In cases of acute spontaneous epidural hematoma producing neurological deficits, emergency surgical evacuation is the standard treatment.

METHODS

Such a case is presented in which complete resolution of neurological deficits occurred without surgical intervention.

RESULTS

This is the fifth reported case of complete recovery in a patient managed conservatively. In most reports, significant and sustained neurological recovery had occurred with 12 hours of impairment of walking.

CONCLUSION

In cases of acute spontaneous spiral epidural hematoma in which neurological deterioration is followed by early and sustained recovery, non-operative therapy may be considered.

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

A 51-yr-old woman was transferred to the emergency department with nonspecific interscapular pain and a progressive right-sided hemiparesis. Physical examination and laboratory examination revealed moderate right-sided hemiparesis, with no other focal neurologic deficits. A computed axial tomography scan of the brain was negative. Emergency arteriography revealed bilateral highgrade fibromuscular dysplasia involving the origins of the left and right common carotid arteries. The patient was admitted with the presumptive diagnosis of embolic cerebrovascular accident. Subsequently, the patient developed a left-sided sensory deficit, and magnetic resonance imaging of the cervical spine revealed a C5-T2 epidural hemorrhage. The patient underwent emergent surgical evacuation of the clot and recovered without incident. Spinal epidural hematomas are rare and typically present as cord compressions with or without pain rather than as unilateral hemiplegia.

Spontaneous cervicothoracic epidural hematoma following prolonged valsalva secondary to trumpet playing

Spontaneous spinal epidural hematoma is an uncommon clinical entity. Patients with this disease may present with devastating neurological deficits that can mimic other diseases. Emergency physicians should be familiar with this condition to assure appropriate therapy in a timely manner. A typical case of spontaneous spinal epidural hematoma is presented with review of appropriate differential diagnosis and management.

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.

Subacute cervical epidural hematomas

The authors report two cases of cervical epidural hematomas with atypical subacute clinical presentation; both were operated on with excellent results. The literature is reviewed and the etiologic factors, clinical presentation, diagnosis, and therapy are discussed. It is concluded that the clinical presentation and evolution of cervical epidural hematomas are more variable than previously described, including slow evolving forms and even cases with spontaneous resolution. Magnetic resonance imaging is the diagnostic procedure of choice. Early surgical decompression and evacuation of the lesion is the indicated therapy in most cases.

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.