A case of hematomyelia presenting with neurogenic stunned myocardium

Various neurological disorders and emotional stress may cause left ventricular dysfunction, known as a neurogenic stunned myocardium. A previously healthy 71-year-old woman collapsed immediately after experiencing left arm numbness and pain. Thereafter, the patient complained of anterior chest pain and became comatose. An electrocardiogram showed ST-segment elevation of I, aVL, and V2-3 and depression of II, III, and aVF. Echocardiography revealed anteroseptal hypokinesis of the left ventricle. Emergency coronary angiography revealed no significant stenosis in the coronary arteries; however, left ventriculography revealed obvious anteroseptal hypokinesis. When the patient regained consciousness the following day, tetraplegia was observed. Spinal computed tomography and magnetic resonance imaging revealed an intramedullary spinal cord hemorrhage from the medulla to the conus. The cardiac function recovered, but the patient remained tetraplegic with poor spontaneous respiration. Although its incidence is extremely rare, hematomyelia should be recognized as a potential cause of neurogenic stunned myocardium.

Unique presentation and management of Gowers intrasyringal hemorrhage

Context: Intrasyringal hemorrhage was first described in literature in the renowned Lectures on Diseases of the Nervous System by Sir William Richard Gowers [Gowers W. A lecture on syringal haemorrhage into the spinal cord. Lancet [Internet]; 162(4180):993-997. [cited 2019 August 19]. Available from https://www.sciencedirect.com/science/article/pii/S0140673601362785]. The pathophysiology of this disease is a hemorrhage within a preexisting intramedullary fluid-filled cavity or hydrosyringomyelia in the spinal cord. Most common symptoms of this disease are numbness, weakness, paresthesia in the extremities and gait disturbances. Since first noted in 1903, there have been just fourteen confirmed cases of this disease reported in literature, making it extremely rare and difficult to study.Findings: Here we discuss a unique presentation of Gowers intrasyringal hemorrhage. The patient is a male in his late teens with no prior established neurological history. He presented at our institution four days post suspected injury with persistent mild left upper extremity numbness and weakness. The patient was admitted and underwent an MRI of the cervical spine without intravenous contrast. The imaging findings confirm subacute on chronic Gowers intrasyringal hemorrhage in the setting of a Chiari 1 malformation. This patient underwent neurosurgical intervention four months post initial presentation and had complete postoperative resolution of his interval non-progressive but persistent symptoms.Clinical relevance: This unique case suggests immediate surgical intervention may not always be necessary for treating Gowers intrasyringal hemorrhage.

Acute Myelopathy: Vascular and Infectious Diseases

Vascular and infectious causes are rare but important causes of spinal cord injury. High suspicion for these processes is necessary, as symptoms may progress over hours to days, resulting in delayed presentation and diagnosis and worse outcomes. History and clinical examination findings can assist with localization of the affected vascular territory and spinal level, which will assist with focusing spinal imaging. Open and/or endovascular surgical management depends on the associated vascular abnormality. Infectious myelopathy treatment consists of targeted antimicrobial therapy when possible, infectious source control, and again, close monitoring for systemic complications.

Primary spinal atypical teratoid/rhabdoid tumour presenting with hematomyelia and subarachnoid haemorrhage-a case report

Atypical teratoid/rhabdoid tumours (AT/RTs) are highly aggressive and uncommon malignant tumours of the central nervous system (CNS) affecting children younger than 3 years of age. Primary spinal cord involvement is an extremely rare presentation. AT/RTs show necrosis and haemorrhages on histopathology frequently. However, spinal atypical teratoid/rhabdoid tumour (AT/RT) with hematomyelia and spinal subarachnoid haemorrhage (SAH), as seen in our case, has never been reported in the literature in the paediatric age group. We report a case of primary spinal AT/RT in a 3-year-old male child presenting acutely with hematomyelia and spinal SAH and try to elucidate its pathophysiological basis.

Multiple Spinal Chronic Subdural Hematomas Associated with Thoracic Hematomyelia: A Case Report and Literature Review

BACKGROUND

Chronic subdural hematoma (CSDH) is uncommon in the spine. Most spinal CSDHs occur as solitary lesions in the lumbosacral region. We report a rare case of multiple spinal CSDHs associated with hematomyelia. The diagnostic and therapeutic management of these complex spinal CSDHs is reviewed as well as the pertinent literature.

CASE DESCRIPTION

A 79-year-old woman on warfarin therapy presented with lower back pain and progressive lower extremity weakness that had developed in the previous 2 weeks. She subsequently developed paraplegia and urinary incontinence. Thoracolumbar magnetic resonance imaging showed a CSDH from T12-L3 compressing the cauda equina. Single-shot whole-spine magnetic resonance imaging showed another CSDH and hematomyelia at T2-3. She underwent L2-3 hemilaminectomy, which revealed a liquefied subdural hematoma. Delayed T2 laminectomy exposed an organized subdural hematoma and xanthochromic hematomyelia. After each surgery, the patient showed significant motor recovery. Finally, the patient could walk, and the urinary catheter was removed.

CONCLUSIONS

Spinal CSDH may occur in multiple regions and may be associated with hematomyelia. Whole-spine magnetic resonance imaging is useful to examine the entire spine for CSDH accurately and thoroughly. Comprehensive surgical exploration of all symptomatic hematomas may restore neurologic functions even with delayed surgery.

Idiopathic Spontaneous Intramedullary Hemorrhage: A Report of a Rare Case of Repeated Intramedullary Hemorrhage with Unknown Etiology

A 48-year-old woman presented with acute voiding difficulty, numbness and weakness of both lower extremities. Magnetic resonance imaging (MRI) showed an intramedullary hemorrhagic mass that extended from T9 to T10. T8-T10 laminotomy and surgical removal of the hemorrhagic mass was performed. The pathological diagnosis was hematoma. Her neurological status remained the same after the operation. At 5 days post-operation, the patient suddenly became paraplegic, and MRI that was immediately performed revealed a recurrent intramedullary hemorrhage. Emergent surgical evacuation was performed. Again, histological examination showed only hematoma, without any evidence of abnormal vessels or a tumor. A postoperative MRI revealed no abnormal lesions other than those resulting from postoperative changes. At a 9-month follow up, the patient could walk a short distance with the aid of a walker. Because spontaneous intramedullary hemorrhage with unknown etiology is very rare, it is essential to perform a meticulous inspection of the hemorrhagic site to find the underlying cause. Repeated hemorrhage can occur; therefore, close observation of patients after surgery is important in cases without an apparent etiology. Urgent surgical evacuation is important to improve outcomes in these cases.