Spontaneous Spinal Subdural Hematoma with Simultaneous Cranial Subarachnoid Hemorrhage

Subarachnoid hemorrhage misdiagnosed as acute coronary syndrome leading to catastrophic neurologic injury: A case report

BACKGROUND

Elevated levels of cardiac troponin and abnormal electrocardiogram changes are the primary basis for clinical diagnosis of acute coronary syndrome (ACS). Troponin levels in ACS patients can often be more than 50 times the upper reference limit. Some patients with subarachnoid hemorrhage (SAH) also show electrocardiogram abnormalities, myocardial damage, and elevated cardiac biomarkers. Unlike ACS patients, patients with SAH only have a slight increase in troponin, and the use of anticoagulants or antiplatelet drugs is prohibited. Because of the opposite treatment modalities, it is essential for clinicians to distinguish between SAH and ACS.

CASE SUMMARY

A 56-year-old female patient was admitted to the emergency department at night with a sudden onset of severe back pain. The final diagnosis was intraspinal hematoma in the thoracic spine. We performed an emergency thoracic spinal canal hematoma evacuation procedure with the assistance of a microscope. Intraoperatively, diffuse hematoma formation was found in the T7-T10 spinal canal, and no obvious spinal vascular malformation changes were observed. Postoperative head and spinal magnetic resonance imaging (MRI) showed a small amount of SAH in the skull, no obvious abnormalities in the cervical and thoracic spinal canals, and no abnormal signals in the lumbar spinal canal. Thoracoabdominal aorta computed tomography angiography showed no vascular malformation. Postoperative motor system examination showed Medical Research Council Scale grade 1/5 strength in both lower extremities, and the patient experienced decreased sensation below the T12 rib margin and reported a Visual Analog Scale score of 3.

CONCLUSION

Extremely elevated troponin levels (more than 50 times the normal range) are not unique to coronary artery disease. SAH can also result in extremely high troponin levels, and antiplatelet drugs are contraindicated in such cases. Emergency MRI can help in the early differential diagnosis, as a misdiagnosis of ACS can lead to catastrophic neurological damage in patients with spontaneous spinal SAH.

Cranial subdural migrating to lumbar subdural space in a toddler

Migrated spinal subdural haematoma (sSDH) is a significantly uncommon finding. This case involves a paediatric patient representing after cranial trauma with new abnormal gait and leg pain who was found to have a migrated sSDH. Literature review for reported cases of pathogenesis theories, causes and management was performed and summarised in this report. The authors concluded that new abnormal gait and leg pain in a paediatric patient with previous cranial trauma is an indication for spinal MRI if migrated subdural haematoma is suspected. Non-surgical management is generally tolerated, and steroids can be trialled for radiculopathy if clinically indicated.

Subarachnoid hemorrhage due to intradural cerebral aneurysm and simultaneous spinal subdural hematoma: illustrative case

BACKGROUND

Spontaneous spinal subdural hematomas (SSDHs) are unusual. Among their probable etiologies, an association with ruptured brain aneurysms has been described in an extraordinary way. The underlying pathophysiological mechanism is not conclusively described in the literature.

OBSERVATIONS

The authors reported an exceptional case of a 59-year-old woman admitted for a condition that included sudden headache, stiff neck, and vomiting associated with pain in the left flank area that radiated to the leg. Computed tomography (CT) of the brain evidenced acute subarachnoid hemorrhage distributed in the bilateral posterior parieto-occipital fossa and occipital horns of the ventricles. CT angiography detected a dissecting aneurysm in the left vertebral artery (V4) that was treated urgently via the endovascular route. In the next hours, the patient’s symptoms worsened, with paraplegia of the lower extremities. Magnetic resonance imaging showed SSDH at T4–6 and extensive associated myelopathy.

LESSONS

The origin of the spinal hematoma may be the rupture of the aneurysm of the V4 segment in the dura mater of the foramen magnum and subsequent rostrocaudal migration of the hemorrhage to the spinal subdural space, enhanced by an intracranial pressure increase. This hypothesis is discussed, as is a brief literature review.

Massive Acute Spinal Subdural Hematoma Causing Sudden Onset Paraplegia in a Patient on Anticoagulation

Spinal subdural hematoma (SSDH) is a rare but known entity that can cause severe and irreversible motor, sensory, and autonomic dysfunction if not decompressed in a timely manner. We present here a 74-year-old female on anticoagulation who developed sudden onset back pain with rapidly progressive paraplegia. On neurologic exam, she was completely flaccid in the bilateral lower extremities with absent sensation from the umbilicus down. Imaging demonstrated a massive extra-axial spinal hematoma from T12 to S1 that initially was believed to be epidural in origin. She was taken emergently to the operating room for a T11-L5 decompressive laminectomy, and dural opening demonstrated a thick subdural clot encasing the conus and cauda equina confirming the subdural pathology. Despite decompression and partial evacuation of the subdural hematoma, she did not recover neurologic function.

Spontaneous Spinal Subdural Hematoma Mimicking Myocardial Infarction

Spontaneous spinal subdural hematomas (SSDHs) are rarely encountered in clinical practice. In this paper, we report a case of a 70-year-old female who presented to the Emergency Department with symptoms of mid-epigastric pain radiating to her mid-scapular region. Her workup demonstrated mildly elevated cardiac troponin I levels and electrocardiogram (ECG) leads V3-V5 ST-depressions. She was subsequently treated through the non-ST elevation myocardial infarction (NSTEMI) protocol and given an antiplatelet agent. The next morning, she developed bilateral lower extremity paresthesias, progressive left lower extremity weakness, and urinary retention. Magnetic resonance imaging (MRI) of the spine demonstrated a hematoma in the thoracic region resulting in spinal cord compression. The patient underwent surgical decompression. After the decompression of the thoracic spinal cord, the patient’s neurological symptoms gradually improved and she regained lower extremity function. This report brings to light a very unusual presentation of an uncommon clinical entity. To the best knowledge of the authors, spontaneous SSDH presenting as myocardial injury and subsequently exacerbated by anticoagulation therapy has not been reported in the literature to date.

Aneurysmal Subarachnoid Hemorrhage with Spinal Subdural Hematoma: A Case Report and Systematic Review of the Literature

OBJECTIVE

Spinal subdural hematoma (S-SDH) rarely occurs after aneurysmal subarachnoid hemorrhage (SAH). Little information is known regarding the management and prognosis of patients with both S-SDH and SAH. Here, we present an illustrative case and provide a systematic review of S-SDH in the setting of SAH.

METHODS

A systematic literature review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines revealed 11 previous cases of concurrent intracranial SAH and spinal SDH, which are presented with our new reported case.

RESULTS

Intracranial sources of spontaneous SAH included 8 aneurysms, 1 pseudoaneurysm, and 3 angiogram-negative cases. Hunt Hess grades ranged from 1 to 4, mean time between SAH and S-SDH was 5.8 days, and S-SDH presented most frequently in the lumbar spine. Eight patients showed significant to complete clinical recovery, 2 had continued plegia of the lower extremities, and 2 expired. Modified Rankin scores (mRS) ranged from 0 to 6, with mRS >2 for 4 of 12 patients. Patients with a poor clinical outcome (mRS >2) had an initially negative cerebral angiogram, earlier presentation with less time between SAH and S-SDH (0.8 vs. 7.6 days), use of antithrombotic medication, no diversion of cerebrospinal fluid, and cervical or thoracic S-SDH.

CONCLUSION

S-SDH is uncommon in the setting of aneurysmal SAH; better outcomes are associated with lumbar location, delayed presentation, cerebrospinal fluid diversion, and lack of antithrombotic use. Conservative treatment may be sufficient in patients with delayed S-SDH and lack of significant neurologic deficits. More reported cases will allow greater understanding of this clinical entity.

A Case of Spontaneous Spinal Subdural Hematoma Complicated by Cranial Subarachnoid Hemorrhage and Spinal Adhesive Arachnoiditis

A 76-year-old woman with a spinal subdural hematoma (SDH) was presented with severe back pain without headache. Magnetic resonance imaging (MRI) performed 4 days after onset showed SDH extending from Th2 to L3. She was diagnosed with spontaneous SDH without neurological manifestation, and conservative treatment was selected. Transient disturbance of orientation appeared 7 days after onset. Small subarachnoid hemorrhage (SAH) was detected on head CT, and strict antihypertensive therapy was started. Symptoms changed for the better. Back pain disappeared 4 weeks after onset. On follow-up MRI at 6 months after onset, the SDH had been resolved spontaneously. Although adhesive arachnoiditis was observed at Th4-6, the recurrence of clinical symptoms was not observed at one year and a half after onset. Spinal subdural space is almost avascular; a hematoma in a subdural space is considered to come from a subarachnoid space when it is a lot. A hemorrhage in subarachnoid space was flushed by cerebral spinal fluid; hematoma or arachnoiditis was not formed in general. In our case, hemorrhage was a lot and expansion of SDH was large enough to cause cranial SAH and arachnoiditis. But longitudinally expanded SDH did not show neurological manifestation and resolved spontaneously in our case.

Lumbar chronic subdural hematoma mimicking an intradural extramedullary tumor: A case report

Background:

Chronic spinal subdural hematomas are extremely rare with only 28 cases reported in the literature. Nevertheless, they should be considered among the differential diagnoses for spinal intradural/extramedullary lesions.

Case Report:

A 65-year-old male presented with progressive back pain and right S1 radiculopathy. Magnetic resonance imaging scan revealed a right-sided posterolateral intradural/extramedullary lesion at the L5–S1 level. It was hyperintense on T1 and hypointense on T2-weighted images; on the short TI inversion recovery sequence it was hyperintense. The lesion was excised through a right L5 hemilaminectomy, and the patient was neurologically intact postoperatively. Histopathology revealed a chronic subdural hematoma.

Conclusion:

Chronic spinal subdural hematoma can mimic intradural extramedullary spinal tumors even in the absence of trauma and/or coagulopathies.

Spinal Subarachnoid Hemorrhage Migrated from Traumatic Intracranial Subarachnoid Hemorrhage

Very rarely, spinal subarachnoid hemorrhage (SSAH) can occur without any direct spinal injury in patients with traumatic intracranial SAH. A-59-year-old male with traumatic intracranial subarachnoid hemorrhage (SAH) presented with pain and numbness in his buttock and thigh two days after trauma. Pain and numbness rapidly worsened and perianal numbness and voiding difficulty began on the next day. Magnetic resonance imaging showed intraspinal hemorrhage in the lumbosacral region. The cauda equina was displaced and compressed. Emergent laminectomy and drainage of hemorrhage were performed and SSAH was found intraoperatively. The symptoms were relieved immediately after the surgery. Patients with traumatic intracranial hemorrhage who present with delayed pain or neurological deficits should be evaluated for intraspinal hemorrhage promptly, even when the patients had no history of direct spinal injury and had no apparent symptoms related to the spinal injury in the initial period of trauma.