Spinal subdural haematoma: a study of three cases

Spinal subdural haemorrhage secondary to strenuous exercise and warfarin, complicated by acute ischaemic stroke

Spinal subdural haemorrhage or haematoma (SSDH) is a rare condition that is often overlooked and missed on initial presentation due to its non-specific features that may mimic other more common pathologies. It is associated with high morbidity and mortality rates, with few evidence-based management principles, particularly during the subacute stages of recovery. In this report, we detail a case of SSDH associated with exercise and anticoagulation therapy, which was complicated by acute ischaemic stroke. SSDH should be suspected in cases of acute back pain without a clear alternative cause, particularly in coagulopathic individuals. Following treatment, early recommencement of anticoagulation therapy may be justified in certain cases where indicated, after careful consideration of the affected individual's risk profile.

Spontaneous epidural and subdural hematomas of the spine: Review of anatomy and imaging findings

Spontaneous epidural (SEH) and subdural hematomas (SSH) of the spine are a rare cause of spinal injury and morbidity. They often present in the emergency setting, though magnetic resonance imaging is the gold-standard for diagnosis. Knowledge of anatomy, and in particular of the dural layers of the spine, is crucial to understand the location of SEH and SSH and their relationship with spinal structure. In this pictorial review, we aim to explain imaging features of the SEH and SSH, and to rule out their main differential diagnosis.

Risk factors for spinal subdural hematoma after minimally invasive transforaminal lumbar Interbody Fusion (MI-TLIF): a multivariate analysis

BACKGROUND

Spinal subdural hematoma (SSH) is a rare cause of compression of the neutral elements of the spinal cord. However, little is known about the presentation of acute SSH after lumbar spine surgery. The reason for this may be that symptomatic SSH occurs rarely and is not given enough attention by spine surgeons. Currently, the decision to perform MRI postoperatively is more dependent on surgeon preference; therefore, no high-quality studies have been published. Our team reports our experience in the diagnosis and management of SSH after lumbar decompression and fusion surgery.

METHODS

We retrospectively studied 215 patients who underwent routine MRI following minimal invasive transforaminal lumbar interbody fusion (MI-TLIF) between 2020-01-01 and 2022-06-30. The patients were divided into SSH group (17 cases) and non-SSH group (198 cases) according to the occurrence of SSH. Univariate analysis and multivariate logistic regression analysis were performed to identify relevant risk factors that increase the risk of SSH postoperatively.

RESULTS

None of the patients presented with serious neurologic symptoms, such as lower extremity paralysis or cauda equina syndrome that required emergency hematoma debridement. SSH was found in 17 (7.9%) patients and non-SSH in 198 (92.1%). Factors affecting SSH were presence of hypertension, presence of diabetes and postoperative anticoagulant therapy. The significantly independent risk factor of postoperative SSH were diabetes (P = 0.008, OR: 6.988) and postoperative anticoagulant therapy (P = 0.003, OR: 8.808).

CONCLUSIONS

SSH after MI-TLIF is not a rare condition, with generally no requirement of emergency evacuation. Comprehensive anti-symptomatic treatment could achieve satisfactory results. Diabetes mellitus and postoperative anticoagulant therapy are independent risk factors for SSH. Spine surgeons should hold applicability of the use of anticoagulants after lumbar surgery.

Pain in the back after a brain trauma-The revelation of a spinal subdural hematoma: A case report with a literature review

Traumatic spinal subdural hematoma is a rare condition mostly favored by an anticoagulation therapy, a traumatic lumbar puncture, a hematologic disease, or an epidural anesthesia. This pathological condition can be subtle or be at the origin of a compression of the spinal cord and the rootlets resulting in an irreversible damage if an emergent surgery is not performed. We report the case of a 45-year-old man who has been a victim of a brain trauma which resulted in a cerebral edema. A week later, the patient came to the emergency department for disabling abdominal pain, predominant in the back. An abdominal computed tomography was performed and showed an incidentally spontaneous hyperdensity in the spinal cord, which raised the suspicion of a spinal hematoma that has been confirmed through spine magnetic resonance imaging. In this case, we discuss the different subtypes of spinal hematoma. We recall the main differential diagnoses to help setting an accurate diagnosis and to not delay the adequate therapy that is most of the time emergent when indicated.

Multiple non-contiguous anticoagulation-related spontaneous acute spinal intradural extramedullary hemorrhages

Background:

Spinal intradural extramedullary hemorrhage is a rare and important pathology that may precipitate acute compressive myelopathy. It is most commonly associated with spinal trauma, neoplasia, vasculopathy, and iatrogenesis. In rare circumstances, it occurs spontaneously secondary to anticoagulant and antiplatelet medications without an underlying structural lesion. In these instances, it may be related to vasculopathy and/ or cardiovascular disease risk factors. We highlight the salient clinical and radiological features of this pathology, discuss putative mechanisms of its pathogenesis, and describe surgical considerations related to its management.

Case Description:

This report describes an elderly gentleman who presented with two discrete spinal hemorrhages associated with separate foci of bleeding, in the context of therapeutic anticoagulation, on a background of significant structural and functional cardiovascular disease with risk factors.

Conclusion:

Our report is novel in that there are no other cases, to the best of our knowledge, of multiple non-contiguous anticoagulation-related spontaneous acute spinal intradural extramedullary hemorrhages in the medical literature. This article is written with the purpose of assisting clinicians to recognize and expedite treatment of this rare pathology. Prompt diagnosis followed by urgent decompressive surgery provides the best functional outcomes.

Spinal Intradural Hematoma after Spinal Anesthesia in a Young Male Patient: Case Report and Review of the Literature

Spinal intradural hematoma (SIH) is a rare condition which can cause neurological sequelae such as permanent motor weakness and sensory loss in the lower extremities. Herein, we describe a case of SIH following spinal anesthesia. The patient was a 30-year-old man who underwent treatment for accessory navicular syndrome at our department. The patient was not receiving anticoagulation therapy, and spinal anesthesia was thus selected. No symptoms of hematoma were observed in the immediate postoperative period, but the patient complained of pain in both buttocks on postoperative day 5. However, neither motor weakness nor sensory loss were observed. Additionally, as the radiating pain extending to the lower extremities typical of neurological pain was not observed, musculoskeletal pain was suspected. Magnetic resonance imaging revealed intradural hematomas at L4-5 and S1. Conservative treatment and follow-up evaluations were performed to ensure that additional neurological sequelae did not occur. Six months after symptom onset, his pain Numeric Rating Scale score was 0, and no other neurological findings were observed. However, in patients who undergo spinal anesthesia, localized pain in the back without other neurological symptoms and lack of radiating pain may be associated with more than musculoskeletal pain. Such patients must be continuously monitored.

A Case of Idiopathic Thoracic Spinal Subdural Hematoma With Bilateral Lower Limb Paralysis

Subdural hemorrhage is rare and is mostly triggered non-traumatically due to intracranial surgery, lumbar puncture, anticoagulant therapy, blood diseases, vascular malformations, and tumors. We experienced a case of idiopathic subdural hematoma with acute bilateral lower limb paralysis on postoperative day 4 after laparoscopic hysteromyomectomy.

The patient was a 40-year-old woman with uterine myoma who took no medication nor had history of trauma or abnormalities such as vascular malformations. Four days after laparoscopic surgery, sudden chest and back pain and bilateral lower limb paralysis appeared. Muscle weakness was found predominantly on the left side. In manual muscle test (MMT), the quadriceps femoris was 5/5 on both sides, but the tibialis anterior, extensor pollicis longus and flexor pollicis longus were 5/5 only on the right, and 2/5 on the left side. Warm pain sensation was decreased below Th4 (Fourth thoracic vertebra), and the right side showed a greater decrease of deep sensation than the left. Excretion was difficult and dysuria was also apparent. There were no abnormalities in blood biochemical tests or in the blood coagulation system. Using the results of diagnostic imaging, as preoperative diagnosis of the patient, spinal subdural hematoma was suspected. Conservative treatment was initially conducted but the emergency surgery for hematoma removal was performed at 14 hours after the onset because of progression of paralysis. This resulted in improvement of neurological symptoms including lower limb paralysis, bladder-rectal disorder and hypoesthesia.

If subdural hematoma is suspected regardless of the cause, it is important to observe neurological findings over time and make a quick decision to treat with surgery.

UMR, Brinda K, Moscote-Salazar LR, Dhanireddy K. Posttraumatic Acute Spinal Epidural Hematoma of the Dorsolumbar Region

In spite of the relative common occurrence of spinal injuries, spinal epidural hematomas (SEHs) are rare lesions. Depending on the onset, site, size, and presence of neurological deficits, they can be treated conservatively or surgically. In the presented article, we report an uncommon case of posttraumatic dorsolumbar SEH and discuss the characteristic magnetic resonance imaging (MRI) imaging findings of epidural fat in the cases of traumatic spinal hematomas.

Iatrogenic Spinal Subdural Hematoma due to Apixaban: A Case Report and Review of the Literature

In the last decade, the clinical relevance for developing safer oral anticoagulants prompted the development of new classes of drugs that have shown a lower risk of life-threatening bleeding events as compared to standard warfarin. Nontraumatic spinal subdural hematoma is an uncommon urgent complication that can be associated with the use of these agents. An unusual case of spinal subdural hematoma related to apixaban treatment for nonrheumatic atrial fibrillation is reported here.

Acute, Nontraumatic Spontaneous Spinal Subdural Hematoma: A Case Report and Systematic Review of the Literature

Spontaneous spinal subdural hematoma (sSDH) is a rare condition outright. Moreover, cases that occur spontaneously in the absence of an identifiable etiology are considerably less common and remain poorly understood. Here, we present the case of a 43-year-old man with spontaneous sSDH presenting with acute onset low back pain and paraplegia. Urgent magnetic resonance imaging identified a dorsal SDH from T8 to T11 with compression of the spinal cord. Emergent T8–T10 laminectomies with intradural exploration and hematoma evacuation were performed. However, despite prompt identification and appropriate action, the patient's recovery was modest and significant disability remained at discharge. This unique and unusual case demonstrates that spontaneous sSDH requires prompt surgical treatment to minimize associated morbidity and supports the association between the presence of severe neurological deficits upon initial presentation with less favorable outcomes. We performed a comprehensive systematic review of spontaneous sSDH of unknown etiology, which demonstrates that emergent surgical intervention is indicated for patients presenting with severe neurological deficits and the presence of these deficits is predictive of poor neurological outcome. Furthermore, conservative management should be considered in patients presenting with mild neurological deficits as spontaneous resolution followed by favorable neurological outcomes is often observed in these patients.

Postpartum spinal subdural hematoma: irrelevant epidural blood patch: a case report

We report a healthy patient with postpartum headache and neck stiffness which were diagnosed as symptoms of pseudoaneurysm of vertebral artery. She had received a Cesarean section under the spinal anesthesia, and complaint of headache and neck stiffness. Epidural blood patches were done twice, but symptoms persisted. Eight days later, she experienced sensory disturbance and emergent laminectomy was done. When persistent postpartum headache occurs after epidural blood patch, more precise differential diagnosis should be made and considering other possible pathologies.

Spontaneous Spinal Subdural Hematoma causing Brown-Séquard Syndrome with Thrombocytopenic Myelodysplastic Syndrome

Spontaneous spinal subdural hematoma (SSDH) is a very rare condition. We report a case of SSDH presenting with Brown-Séquard syndrome, treated by surgical evacuation. A 77-year-old woman was hospitalized for back pain without trauma history. As she showed progressive sensory loss and right-side dominant paraparesis, we performed magnetic resonance imaging and confirmed the SSDH in the thoracic area. Therefore, she underwent emergent operation and the hematoma was evacuated successfully. After the operation, the patient showed improvement in neurologic function.

Migration of an Intracranial Subdural Hematoma to the Spinal Subdural Space: A Case Report

A 57-year-old man complained of severe lower back pain and radicular pain in both legs for 1 week after falling from a ladder. Magnetic resonance imaging (MRI) of the spine showed a subdural hematoma (SDH), which was surgically removed. The patient had no back pain or the radicular leg pain at 2 weeks post-surgery. However, he complained of diffuse headaches upon follow-up. Brain computed tomography (CT) and MRI revealed an intracranial SDH, which was immediately removed by surgery. During his 1-year follow-up, he reported that the pain had resolved without recurrence. Simultaneous spinal and intracranial SDH are rare and no standard treatment exists for this condition. This case suggests that it is possible that an intracranial SDH can migrate into the cerebrospinal fluid (CSF) space through an arachnoid tear. CSF circulation allows the intracranial SDH to enter subarachnoid spaces encasing the spinal cord. In order to prevent irreversible damage, surgical intervention should be considered for case of spinal SDH with progressive neurological deficits.

Spinal subdural hematoma with cauda equina syndrome: A complication of combined spinal epidural anesthesia

Combined spinal-epidural anesthesia (CSE) is considered safe in lower limb surgeries. We report a case of sudden neurological deterioration in a stable postoperative patient who was given CSE for total knee replacement and low molecular weight heparin in postoperative period. On the 4^th postoperative day, she developed sudden onset weakness in left lower limb along with bladder incontinence. Magnetic resonance imaging spine revealed a subdural hematoma at L2-L3 level. Immediate laminectomy along with cord decompression was done and patient recovered well except for a persistent foot drop on left side.

Acute spontaneous spinal subdural hematoma with vague symptoms

Spinal subdural hematoma is a rarely reported disease and spontaneous spinal subdural hematomas (SSDH) without underlying pathological changes are even rarer. The patients usually show typical symtoms such as back pain, quadriplegia, paraplegia or sensory change. But rarely, patients may show atypical symptoms such as hemiparesis and misdiagnosed to cerebrovascular accident. We recently experienced a case of SSDH, where the patient initially showed vague symptoms, such as the sudden onset of headache which we initially misdiagnosed as subarachnoid hemorrhage. In this case, the headache of patient improved but the neck pain persisted until hospital day 5. Therefre, we conducted the MRI of cervical spine and finally confirmed SSDH. The patient was managed conservatively and improved without recurrence. In this case report, we discuss the clinical features of SSDH with emphasis on the importance of an early diagnosis.

Spontaneous spinal subdural hematoma concurrent with cranial subdural hematoma

A 39-year old female presented with chronic spinal subdural hematoma manifesting as low back pain and radiating pain from both legs. Magnetic resonance imaging (MRI) showed spinal subdural hematoma (SDH) extending from L4 to S2 leading to severe central spinal canal stenosis. One day after admission, she complained of nausea and severe headache. Computed tomography of the brain revealed chronic SDH associated with midline shift. Intracranial chronic SDH was evacuated through two burr holes. Back pain and radiating leg pain derived from the spinal SDH diminished about 2 weeks after admission and spinal SDH was completely resolved on MRI obtained 3 months after onset. Physicians should be aware of such a condition and check the possibility of concurrent cranial SDH in patients with spinal SDH, especially with non-traumatic origin.

Spinal subdural hematoma mimicking epidural lipomatosis

We report a case of spinal subdural hematoma in the lumbar spine of a 75-year-old woman. Magnetic resonance imaging showed lesions of homogeneous high intensity in the spinal canal on both T₁- and T₂-weighted images, findings closely resembling those for epidural lipomatosis. Identification of 2-layered signal intensity surrounding the cauda equina on axial images is the key for accurate diagnosis.

Spontaneous Resolution of Non-traumatic Cervical Spinal Subdural Hematoma Presenting Acute Hemiparesis: A Case Report

Spontaneous cervical SDH with no underlying pathology is a very unusual condition. To the best of the authors' knowledge, only two cases have been previously reported. A 48-year-old female patient was admitted to our emergency room due to severe neck pain following standing up position with rapid onset of hemiparesis. MRI revealed a dorsolateral subdural hematoma from C3-C5 with cord compression. An emergency laminectomy was planned, but motor weakness gradually improved during surgical preparation. The patient showed substantial clinical improvement and complete recovery was confirmed after 7 days of conservative management without surgical treatment. To determine a differential diagnosis distinct from other conditions such as cervical epidural hematoma, a lumbar spinal puncture was performed. Follow-up MRI performed 10 days after admission revealed complete resolution of the hematoma. We report an extremely rare case of spontaneous cervical spinal subdural hematoma (SDH), present a review of relevant literature, and discuss the etiology, pathogenesis, and prognosis of this case.

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.

Lumbar intraspinal arachnoid cyst superimposed by hyperacute spinal subdural hematoma: an unusual case

BACKGROUND CONTEXT

Lumbar intradural arachnoid cyst (AC) concomitant with hyperacute spinal subdural hematoma (SSDH) has never been reported in the literature.

PURPOSE

To report a case of lumbar AC superimposed by hyperacute SSDH, which was difficult to diagnose preoperatively using magnetic resonance imaging. Herein, we describe diagrams showing the proposed mechanisms underlying the formation of a symptomatic AC.

STUDY DESIGN/SETTING

The study was designed to be a case report and literature review.

METHODS

A 65-year-old man presented with acute onset of low back pain, followed by 5-day history of numbness and weakness in both legs before admission. Magnetic resonance imaging of the lumbosacral spine revealed an intradural extramedullary biconvex lesion at the L3-L4 level; the lesion compressed the cauda equina posteriorly. The lesion mainly appeared as hyperintense on T2-weighted images and hypointense on T1-weighted images. On the basis of these findings, the lesion was preoperatively diagnosed as a symptomatic lumbar subdural AC that compressed the cauda equina.

RESULTS

The patient underwent laminectomy from L2 to L4. After a dura incision, a partially organized subdural hematoma was noted. Beneath the subdural hematoma was an AC compressing the underlying nerve roots. The patient's back pain and muscle strength markedly improved after the operation.

CONCLUSIONS

Preoperative diagnosis of concomitant hyperacute SSDH and AC is difficult. In cases of patients who present with intraspinal AC accompanied by an acute onset of clinical presentation, an associated etiology should be considered until proven otherwise.

Treatment of spontaneous cervical spinal subdural hematoma with methylprednisolone pulse therapy

We report herein a case of hyperacute onset of spontaneous cervical spinal subdural hematoma treated with methylprednisolone pulse therapy that showed good results. A 57-year-old man was admitted for posterior neck pain and paraparesis which occurred an hour ago. MRI revealed a ventral subdural hematoma distributed from the level of C1 down to T3, compressing the spinal cord. Conservative management with methylprednisolone pulse therapy was administered considering the patient's poor general condition. Although emergent surgical decompression is necessary in most cases of spinal subdural hematoma, conservative management with steroid therapy could be effective.

Acute cervical spinal subdural hematoma not related to head injury

We report an extremely rare case of traumatic cervical spinal subdural hematoma not related to intracranial injury. There has been no report on traumatic cervical spinal subdrual hematoma not related to intracranial injury. A 27-year-old female patient was admitted to our emergency room due to severe neck pain and right arm motor weakness after car collision. On admission, she presented with complete monoplegia and hypoesthesia of right arm. Magnetic resonance imaging (MRI) revealed subdural hematoma compressing spinal cord. Lumbar cerebrospinal fluid (CSF) analysis revealed 210,000 red blood cells/mm(3). She was managed conservatively by administrations of steroid pulse therapy and CSF drainage. Her muscle power of right arm improved to a Grade III 16 days after admission. Follow-up MRI taken 16th days after admission revealed almost complete resolution of the hematoma. Here, the authors report a traumatic cervical spinal SDH not associated with intracranial injury.

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.

Late spinal subdural haematoma after spinal anaesthesia for total hip replacement

We present a case of delayed presentation of a subdural haematoma causing cauda equina syndrome which occurred 96 hours after a spinal anaesthetic had been administered for an elective total hip replacement in an 86-year-old man. The patient had received low-molecular-weight heparin anticoagulation which had been delayed until 12 hours postoperatively. No other cause of the haemorrhage could be identified.

Spontaneous subdural hematoma of the thoracolumbar region with massive recurrent bleed

Spinal subdural hematoma is a rare disorder and can be caused by abnormalities of coagulation, blood dyscrasias, lumbar puncture, trauma, underlying neoplasm, and arteriovenous malformation. We discuss an unusual case of an elderly woman who presented with spontaneous spinal subdural hematoma and developed massive rebleeding on the third day following initial evacuation of hematoma. This case illustrates that a patient with routine normal coagulation profile and adequate hemostasis can still harbor platelet dysfunction (in present case due to polycythemia) and later on can manifest as rebleeding and neurological deterioration.

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.

Acute spontaneous spinal subdural hematoma presenting as paraplegia: a rare case

STUDY DESIGN

Case report.

OBJECTIVES

To report an unusual case of spontaneous spinal subdural hematoma and to review relevant literature and discuss the etiology, pathogenesis, clinical features, imaging, and prognosis.

SUMMARY OF BACKGROUND DATA

Spontaneous spinal subdural hematoma with no underline pathology is a very rare condition. Only 19 cases have been previously reported.

METHODS

The case of a 44-year-old man is presented. Pubmed (Medline) was used to search publications.

RESULTS

Our patient presented with sudden severe low back pain following a minimal effort, with rapid onset of complete paraplegia. MRI revealed an anterior subdural hematoma from T2-T6 with cord compression. An urgent laminectomy was performed. MRI scan, surgery, and CT angiogram did not reveal any underlying pathology to account for the subdural hematoma. The patient demonstrated substantial clinical improvement after 6 weeks of bed rest and intense rehabilitation program.

CONCLUSION

Spinal subdural hematoma (SSDH) is uncommon and can be caused by abnormalities of coagulation, blood dyscrasias, or trauma, underlying neoplasm, and arteriovenous malformation. SSDH is very rare in the absence of these underlying conditions. It occurs most commonly in the thoracic spine and presents with sudden back pain radiating to the arms, legs or trunk, varying degrees of motor, sensory, and autonomic disturbances. On MRI, SSDH is seen as a space-occupying lesion, usually ventrally, contained within the dura matter, and can demonstrate variable T1 and T2 signal depending on the age of the hematoma. The prognosis is variable. The majority of cases in the literature had surgical decompression, although cases that were managed conservatively have been reported to be successful as well. The indications of surgery need to be clarified.

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.

Observational study on intrathecal and peridural changes after routine spinal and epidural anesthesia in patients undergoing total joint arthroplasty

Epidural bleeding from spinal anesthetics or epidural catheter placement is concerning, especially when anticoagulants are used. Little is known of the natural changes that occur subdurally or epidurally after each of these procedures. To describe the natural history and occurrence of bleeding that may result from these anesthetics with anticoagulants, we studied 16 joint arthroplasty patients who underwent spinal magnetic resonance imaging postoperatively. Seven patients had an epidural catheter, 7 had a straight spinal injection, and 2 had a general anesthetic. All patients received 5 mg of warfarin postoperatively, with dosing to an international normalized ratio of 2.0. Magnetic resonance imaging readings were blinded. No magnetic resonance image demonstrated peridural inflammation or hemorrhage. No difference was observed between the anesthetics. Warfarin did not cause abnormal bleeding. Based on these observations, one should consider bleeding or peridural inflammation to be abnormal after spinal or epidural anesthesia.

[Acute non-traumatic extensive subdural spinal hematoma]

Acute spinal subdural hematoma is a somewhat rare pathology. Its severity comes from the constitution of an acute spinal cord compression. In many cases MRI is useful for the differential diagnosis with the epidural hematoma. A 79-year-old patient was referred for emergency neurosurgery for acute spinal cord compression. The vascular risk in this patient was significant: hypertension, oral anticoagulants. Clinically, acute non-traumatic subdural spinal hematoma was suspected. The spinal cord MRI was in favor of the diagnosis which was confirmed intraoperatively. The surgical procedure revealed an extensive hematoma which infiltrated the spinal cord. The diagnosis of nontraumatic subdural spinal hematoma may be difficult in some cases and correctly established only during the surgical procedure. In comparison with reports in the literature, we discuss the underlying mechanisms of this hematoma. Spinal subdural haematoma must be considered in patients taking anticoagulant therapy or with a coagulation disorder who present signs of acute spinal cord compression. MRI sagittal T1 and T2-weighted images are adequate and reliable for diagnosis of spinal subdural hematoma. Prompt surgical evacuation of this hematoma is crucial.

[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.

Atypical traumatic craniocervical junction focal spinal subdural hematoma

Spinal subdural hematoma (SSDH) is a rare entity and post-traumatic cervical SSDH is very rare. Review of the literature revealed 8 reported cases of traumatic SSDH and only 2 were cervical. The exact mechanism and pathogenesis of SSDHs are unclear. There are still controversies about the source of bleeding and mechanisms of formation of a hematoma. Here we report a case of a unique traumatic craniocervical junction focal subdural hematoma in an 8-year-old boy and discuss the possible mechanisms of SSDHs in trauma cases.