Chronic spinal subdural haematoma associated with intracranial subdural haematoma: CT and MRI

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.

Concomitant Intracranial and Lumbar Chronic Subdural Hematoma Treated by Fluoroscopic Guided Lumbar Puncture: A Case Report and Literature Review

A 40-year-old man presented with a severe headache, lower back pain, and lower abdominal pain 1 month after a head injury caused by falling. Computed tomography (CT) of the head demonstrated bilateral chronic subdural hematoma (CSDH) with a significant amount in the left frontoparietal region. At the same time, magnetic resonance imaging (MRI) of the lumbar spine also revealed CSDH from L2 to S1 level. A simple drainage for the intracranial CSDH on the left side was performed. Postoperatively, the headache was improved; however, the lower back and abdominal pain persisted. Aspiration of the liquefied spinal subdural hematoma was performed by a lumbar puncture under fluoroscopic guidance. The clinical symptoms were dramatically improved postoperatively. Concomitant intracranial and spinal CSDH is considerably rare so only 23 cases including the present case have been reported in the literature so far. The etiology and therapeutic strategy were discussed with a review of the literature. Therapeutic strategy is not established for these two concomitant lesions. Conservative follow-up was chosen for 14 cases, resulting in a favorable clinical outcome. Although surgical evacuation of lumbosacral CSDH was performed in seven cases, an alteration of cerebrospinal fluid (CSF) pressure following spinal surgery should be reminded because of the intracranial lesion. Since CSDH is well liquefied in both intracranial and spinal lesion, a less invasive approach is recommended not only for an intracranial lesion but also for spinal lesion. Fluoroscopic-guided lumbar puncture for lumbosacral CSDH following burr hole surgery for intracranial CSDH could be a recommended strategy.

Spontaneous spinal subdural hematoma of intracranial origin presenting as back pain

BACKGROUND

Spinal subdural hematoma (SDH) is an uncommon condition mainly associated with bleeding dyscrasias, use of anticoagulants, trauma, iatrogenic procedures, and vascular malformations. Prompt diagnosis and treatment are recommended to prevent progressive neurologic compromise. Spinal SDH concomitant with intracranial SDH is an even rarer entity, with few cases reported in the English literature. Here we present a case of spontaneous spinal SDH with intracranial SDH presenting as sacral back pain in a 70-year-old man. We also describe the potential mechanism, treatment, and prognosis of concomitant spinal and intracranial SDH.

CASE REPORT

We report an unusual case of spontaneous spinal SDH concomitant with intracranial SDH and discuss the epidemiology, clinical presentation, potential etiology, treatment, and prognosis of this disease. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Awareness of the association between spinal SDH and intracranial SDH can expedite appropriate imaging of both brain and spine, which can lead to a more complete diagnosis and require changes in patient management in the emergency setting.

Prospective assessment of concomitant lumbar and chronic subdural hematoma: is migration from the intracranial space involved in their manifestation?

Object

Spinal subdural hematomas (SDHs) are rare and some are concomitant with intracranial SDH. Their pathogenesis and etiology remain to be elucidated although their migration from the intracranial space has been suggested. The authors postulated that if migration plays a major role, patients with intracranial SDH may harbor asymptomatic lumbar SDH. The authors performed a prospective study on the incidence of spinal SDH in patients with intracranial SDH to determine whether migration is a key factor in their concomitance.

Methods

The authors evaluated lumbar MR images obtained in 168 patients (125 males, 43 females, mean age 75.6 years) with intracranial chronic SDH to identify cases of concomitant lumbar SDH. In all cases, the lumbar MRI studies were performed within the 1st week after surgical irrigation of the intracranial SDH.

Results

Of the 168 patients, 2 (1.2%) harbored a concomitant lumbar SDH; both had a history of trauma to both the head and the hip and/or lumbar area. One was an 83-year-old man with prostate cancer and myelodysplastic syndrome who suffered trauma to his head and lumbar area in a fall from his bed. The other was a 70-year-old man who had hit his head and lumbar area in a fall. Neither patient manifested neurological deficits and their hematomas disappeared under observation. None of the patients with concomitant lumbar SDH had sustained head trauma only, indicating that trauma to the hip or lumbar region is significantly related to the concomitance of SDH (p < 0.05).

Conclusions

As the incidence of concomitant lumbar and intracranial chronic SDH is rare and both patients in this study had sustained a direct impact to the head and hips, the authors suggest that the major mechanism underlying their concomitant SDH was double trauma. Another possible explanation is hemorrhagic diathesis and low CSF syndrome.

Spinal subdural hematoma following cranial subdural hematoma : a case report with a literature review

Coexistence of cranial and spinal subdural hematomas is rare and only a few cases have been reported in the literature. Herein, we report a case of cranial and spinal subdural hematomas after previous head trauma. As the pathogenesis of simultaneous intracranial and spinal subdural hematoma yet remains unclear, we developed an alternative theory to those proposed in the literature for their coexistence, the migration of blood through the subdural space.

Spontaneous concomitant intracranial and spinal subdural hematomas in association with anticoagulation therapy

Simultaneous intracranial and spinal subdural hematomas are extremely rare. In most cases, they are attributed to major or minor trauma and iatrogenic causes, such as those resulting from spinal puncture. To the best of the authors' knowledge, there has been only two reports of spontaneous concomitant intracranial and spinal subdural hematomas in a patient receiving anticoagulant therapy who had an absence of evident trauma history. We report on a case of spontaneous concomitant intracranial and spinal subdural hematomas that occurred in association with anticoagulant therapy and present a review of the relevant literature.

Spinal subdural hemorrhage in abusive head trauma: a retrospective study

PURPOSE

To compare the relative incidence, distribution, and radiologic characteristics of spinal subdural hemorrhage after abusive head trauma versus that after accidental trauma in children.

MATERIALS AND METHODS

This study received prior approval from the Human Subjects Protection Office. Informed consent was waived. This study was HIPAA compliant. Two hundred fifty-two children aged 0-2 years treated for abusive head trauma at our institute between 1997 and 2009 were identified through retrospective chart review. A second group of 70 children aged 0-2 years treated at our institute for well-documented accidental trauma between 2003 and 2010 were also identified through retrospective chart review. All clinical data and cross-sectional imaging results, including computed tomographic and magnetic resonance imaging of the brain, spine, chest, abdomen, and pelvis, were reviewed for both of these groups. A Fisher exact test was performed to assess the statistical significance of the proportion of the spinal canal subdural hemorrhage in abusive head trauma versus that in accidental trauma.

RESULTS

In the abusive head trauma cohort, 67 (26.5%) of 252 children had evaluable spinal imaging results. Of these, 38 (56%) of 67 children had undergone thoracolumbar imaging, and 24 (63%) of 38 had thoracolumbar subdural hemorrhage. Spinal imaging was performed in this cohort 0.3-141 hours after injury (mean, 23 hours ± 27 [standard deviation]), with 65 (97%) of 67 cases having undergone imaging within 52 hours of injury. In the second cohort with accidental injury, only one (1%) of 70 children had spinal subdural hemorrhage at presentation; this patient had displaced occipital fracture. The comparison of incidences of spinal subdural hemorrhage in abusive head trauma versus those in accidental trauma was statistically significant (P < .001).

CONCLUSION

Spinal canal subdural hemorrhage was present in more than 60% of children with abusive head trauma who underwent thoracolumbar imaging in this series but was rare in those with accidental trauma.

Traumatic subdural hematoma in the lumbar spine

Traumatic spinal subdural hematoma is rare and its mechanism remains unclear. This intervention describes a patient with mental retardation who was suffering from back pain and progressive weakness of the lower limbs following a traffic accident. Magnetic resonance imaging of the spine revealed a lumbar subdural lesion. Hematoma was identified in the spinal subdural space during an operation. The muscle power of both lower limbs recovered to normal after surgery. The isolated traumatic spinal subdural hematoma was not associated with intracranial subdural hemorrhage. A spinal subdural hematoma should be considered in the differential diagnosis of spinal cord compression, especially for patients who have sustained spinal trauma. Emergency surgical decompression is usually the optimal treatment for a spinal subdural hematoma with acute deterioration and severe neurological deficits.

A rare, high cervical traumatic spinal subdural hematoma

Spinal subdural hematomas (SSDH) are rare lesions occurring in association with a wide variety of conditions, including anticoagulation, coagulation disorders, spinal anesthesia, lumbar puncture, spinal tumors and vascular malformations. SSDH resulting from trauma are the exception. We present a 62-year-old woman with a rare post-traumatic focal SSDH at C1 with bulbomedullary compression, treated successfully with surgery. A review of the literature revealed 26 patients with traumatic SSDH. The aim of this report is to describe the clinical presentation, imaging characteristics and management of traumatic SSDH. The controversial pathogenesis is also discussed.

A Case Report of Cerebral Venous Thrombosis in Polycythemia Vera Presenting with Intracranial and Spinal Subdural Hematoma

Spinal subdural hematoma (SDH) is a rare condition and can be caused by several factors. Concomitant cranial and spinal SDH is even much less common. We present a 77-year-old male patient with lower back pain, paraparesis, and urinary retention following a sudden onset headache. Imaging revealed concomitant cranial and spinal SDH related to cerebral venous thrombosis (CVT) associated with hemorrhagic venous infarct. Laboratory examinations were consistent with polycythemia vera. There was no history of trauma and previous cranial surgery. Brain angiography did not reveal any evidence of arteriovenous fistula or vascular malformation. Since lower back pain occurred shortly after the headache and there was no other reasonable explanation for spinal hemorrhage, we suppose that the mechanism of spinal SDH is the migration of blood from the intracranial compartment. Therefore, this is the first report of concomitant spinal SDH and cerebral hemorrhage associated with CVT in a patient with myeloproliferative disease.

Cranial subdural haematoma with concomitant spinal epidural and spinal subarachnoid haematomas: a case report

A 76-year-old man presented with a 4-day history of bilateral leg pain. Magnetic resonance imaging (MRI) of the lumbosacral spine revealed a spinal subarachnoid and spinal epidural haematomas. MRI of the brain revealed a chronic intracranial subdural haematoma with a midline shift. On further questioning, the patient reported a history of a fall 6 weeks earlier and had no evidence of coagulopathy. He underwent a burr-hole decompression of the intracranial subdural haematoma. At the one-year follow-up, the patient was symptom free with no leg pain or headache. The concomitant occurrence of an intracranial subdural haematoma with spinal epidural and spinal subarachnoid haematomas is rare. MRI of the brain and the entire spine is essential in the presence of a spontaneous spinal haematoma.

Acute spontaneous spinal subdural haematoma presenting as paraplegia and complete recovery with non-operative treatment

Spontaneous spinal subdural haematoma (SSDH) with no underlying pathology is a very rare condition. Only 20 cases have been previously reported. It can be caused by abnormalities of coagulation, blood dyscrasia, or trauma, underlying neoplasm, and arteriovenous malformation. It occurs most commonly in the thoracic spine and presents with sudden back pain radiating to the arms, legs or trunk, and varying degrees of motor, sensory, and autonomic disturbances. Although the main approach to management is surgical decompression, conservative management is used as well. We report the case of a 57-year-old man who presented with sudden severe low back pain followed by rapid onset of complete paraplegia. Magnetic resonance imaging (MRI) revealed an anterior subdural haematoma from T9 to L1 with cord compression. Corticosteroid treatment was administered. The patient showed substantial clinical improvement after 7 days of bed rest and an intense rehabilitation programme. An MRI scan and a computed tomography angiogram did not reveal any underlying pathology to account for the subdural haematoma.

Rapid spontaneous remission of a spontaneous spinal chronic subdural hematoma in a child

A 13-year-old boy presented with a rare spontaneous spinal chronic subdural hematoma (SCSDH) with no associated trauma or medical problems manifesting as back and bilateral lower extremity pain persisting for 10 days. Neurological examination revealed mild weakness and paresthesia in both lower extremities. Magnetic resonance (MR) imaging performed 1 week after the appearance of symptoms revealed a chronic subdural hematoma at the thoracolumbosacral region. Follow-up MR imaging performed 1 week later showed significant resolution of the hematoma without the need for surgery. The patient was discharged with only conservative management. This case of spontaneous SCSDH with rapid spontaneous remission in a child not associated with coagulopathy indicates that aggressive surgical treatment should be delayed as long as possible in pediatric patients because the spinal structure is still developing.

MRI findings in spinal subdural and epidural hematomas

BACKGROUND

Spinal hematomas are rare entities that can be the cause of an acute spinal cord compression syndrome. Therefore, an early diagnosis is of great importance.

PATIENTS AND METHODS

From 2001 to 2005 seven patients with intense back pain and/or acute progressive neurological deficit were studied via 1.5 T MRI (in axial and sagittal T1- and T2-weighted sequences). Follow-up MRI was obtained in six patients.

RESULTS

Four patients showed the MRI features of a hyperacute spinal hematoma (two spinal subdural hematoma [SSH] and two spinal epidural hematoma [SEH]), isointense to the spinal cord on T1- and hyperintense on T2-weighted sequences. One patient had an early subacute SEH manifest as heterogeneous signal intensity with areas of high signal intensity on T1- and T2-weighted images. Another patient had a late subacute SSH with high signal intensity on T1- and T2-weighted sequences. The final patient had a SEH in the late chronic phase being hypointense on T1- and T2-weighted sequences.

DISCUSSION

MRI is valuable in diagnosing the presence, location and extent of spinal hematomas. Hyperacute spinal hematoma and the differentiation between SSH and SEH are particular diagnostic challenges. In addition, MRI is an important tool in the follow-up in patients with conservative treatment.

[Spontaneous spinal subdural hematoma: MRI findings in two cases]

Spontaneous spinal subdural hematoma is an uncommon finding. This report of two cases of spinal subdural hematoma (one hyperacute and one subacute) discusses the current theory of how it develops, the MRI findings, its differentiation from spinal epidural hematoma, and the value of MRI in monitoring patients undergoing conservative treatment. The most significant MRI findings in the hyperacute phase were isointense signal on T1-weighted sequences and hyperintense signal on T2-weighted sequences. Moreover, T2-weighted gradient-echo sequences showed a hypointense peripheral ring. In the subacute phase, a hyperintense signal was seen on T1-, T1-fat-suppression, and T2-weighted sequences.

Subacute spinal subdural hematoma associated with intracranial subdural hematoma

We describe a subacute spinal subdural hematoma in a patient with psot-traumatic subacute intracranial subdural hematoma. CT and MRI demonstrated hematoma within the interhemispheric subdural space and at the lumbar posterior subdural space which extended from the L1 to the S2 level. The lesion showed high signal intensity on both T1 and T2 weighted images. Surgical decompression of the spinal subdural hematoma was performed. The symptoms completely resolved after surgery. Spinal subdural hematoma may be concomitant with or may occur after intracranial subdural hematoma. If a patient with intracranial subdural hematoma complains of low back pain and weakness in both legs; lumbosacral MR examination should be performed to exclude spinal subdural hematoma.

Spinal chronic subdural hematoma in association with anticoagulant therapy: a case report and literature review

STUDY DESIGN

A case of spinal chronic subdural hematoma (SCSDH) in association with anticoagulant therapy was treated surgically.

OBJECTIVE

To clarify the etiopathogenesis, clinical presentation, and surgical outcomes of SCSDH.

SUMMARY OF BACKGROUND DATA

Intracranial chronic subdural hematoma is a well-recognized complication of anticoagulant therapy. However, SCSDH is very rare and its etiopathogenesis is uncertain.

METHODS

A 72-year-old man with SCSDH who had received anticoagulant therapy for atrial fibrillation complained of bilateral lower extremity pain, cramps, and gait disturbance. The patient underwent an operation for evacuation of the hematoma.

RESULTS

Lower-extremity pain, cramps, and gait disturbance improved, and the patient was discharged 10 days after surgery.

CONCLUSION

SCSDH should be included in the differential diagnosis of progressive spinal cord and nerve root compression in patients receiving anticoagulant therapy. Prompt diagnosis and early surgical decompression lead to a good outcome.

Simultaneous Cranial and Spinal Subdural Hematoma-Case Report-

A 59-year-old male presented with spinal subdural hematoma (SDH) with concomitant cranial chronic SDH manifesting as mild paraparesis and numbness in both lower extremities. Magnetic resonance (MR) imaging showed simultaneous occurrence of cranial and spinal SDHs. The patient was treated conservatively because of poor medical condition and mild neurological symptoms, and recovered well within 1 month. Serial follow-up MR imaging revealed spontaneous resolution of both lesions, with signal intensity changes suggesting the degenerative process of subacute hematoma. The spinal hematoma may have migrated from the cranial lesion. Spinal SDH is a potential sequela of chronic SDH in the cranium.

Spinal subdural hematoma following craniotomy: case report

BACKGROUND

Spinal subdural hematomas (SSH) are a rare cause of spinal cord compression. SSH following clipping of an aneurysm has only been reported once. We now report such a case and discuss the mechanism of SSH development after aneurysmal neck clipping.

CASE DESCRIPTION

A 32-year-old man complained of lumbago 7 days after craniotomy for the clipping of an aneurysm. Neurologic examination revealed no abnormality, but magnetic resonance imaging (MRI) demonstrated a lumbosacral spinal subdural hematoma. He received conservative management and his lumbago showed improvement. An MRI taken 19 days after surgery revealed a residual hematoma.

CONCLUSION

The downward movement of blood from the cranial subdural compartment under the influence of gravity is the most appropriate explanation for SSH following craniotomy.

Spinal subdural haematoma: a study of three cases

AIMS

To define the clinical, computed tomography (CT) and magnetic resonance imaging (MRI) features and the role of MRI in the follow-up of spinal subdural haematoma (SSH), and to compare these findings with those of spinal epidural haematomas (SEH).

METHODS

We report three cases of SSH (two women, one male, age: 50-74 years). Two patients were on anticoagulant therapy; in the other case the SSH was spontaneous. All the patients were examined 1-3 days after the onset of the symptoms. All of them had CT, two had MRI and one had angiography. Two patients underwent surgery.

RESULTS

The haematoma was located in the thoracolumbar region (two) and in the thoracic region (one), extending from five (two) to 11 vertebral body levels (one). The haematomas were posteriorly located with lateral extension. The transverse shape differed with the level: biconvex, biloculated or circumferential. The haematomas were hyperdense on CT. On MRI, SSH yielded high signal on both T1 and T2. The integrity of the posterior fat pads, which was well shown on CT and MRI, and the visualization of the dura mater demonstrated the intradural location of these collections, making them easily distinguishable from spinal epidural haematoma. MRI provides better evaluation of the longitudinal extent. Our results are compared with those reported in the literature.

CONCLUSION

MRI is superior to CT for diagnosis and follow-up of SSH. Our findings and those reported in the literature show that the MR features of SSH are quite specific and allow differentiation from SEH.