Spontaneous spinal epidural hematoma in an 11-month-old girl

Spontaneous Cervicothoracic Extradural Hematoma with Rare Presentation in Pediatric Patient with Stroke-Like Features in Association with COVID-19, Presenting as Management Dillemma

Presentation of cervico-thoracic extradural hematoma in pediatric age is rare with stroke-like features. Its association with COVID-19 in the active stage of the disease had not been reported and its management presents a management dilemma as COVID-19 with stroke-like features.

A 14-year-old boy was referred to our institute with complaints of sudden-onset upper and middle back pain, associated with loss of sensation below the middle of the back, sudden progressive weakness of both lower limbs (power 0/5) and upper limbs (power grade-2/5), and incontinence of urine, following bouts of vomiting 12 days back. There was no history of trauma, bleeding diathesis, etc. Blood investigation was suggestive of leukocytosis, and RT-PCR test for COVID-19 was positive with raised D-dimer, serum ferritin, and C-reactive protein. MRI spine was suggestive of cervicothoracic extradural hematoma extending from C5-D3 level and compressing the spinal cord. The patient refused surgical decompression and was managed conservatively, following which he improved with power grade in limbs to 4/5.

Surgical decompression is the treatment of choice but the patient can sometimes improve on medical management. Association of COVID-19 with spontaneous cervicothoracic extradural hematoma had not been reported earlier in the active stage, but its role in inducing vasculopathy and increased chances of bleeding at the uncommon site had been reported in the literature, and it may precipitate such cervical epidural hematoma.

Spontaneous spinal epidural hematoma in an infant presenting with Horner syndrome

BACKGROUND

Spontaneous spinal epidural hematoma (SSEH) is a rare neurologic entity, especially in infants, that develops in the absence of underlying coagulopathy, bleeding diathesis, infection, vascular malformation, trauma, iatrogenic, or other identifiable cause. In contrast to adults, diagnosis is frequently delayed or missed in infants due to non-specific symptoms and limited clinical examination.

CASE ILLUSTRATION

An 11-month-old female demonstrated symptoms of irritability, intermittent diarrhea, lethargy, decreased oral intake, and difficulties crawling before presenting to the emergency room. At time of presentation, she was noted to have minimal spontaneous movement of the lower extremities and anisocoria with ptosis of the right eye. Given her clinical presentation, a magnetic resonance image (MRI) of the spine was obtained which revealed an epidural hematoma with compression extending from C7-T3. She underwent C7-T3 laminoplasty and hematoma evacuation. Following surgical intervention, she demonstrated significant improvements in her lower extremity strength and resolution of Horner syndrome.

CONCLUSION

SSEH in infants is a rare neurologic condition, with diagnosis often delayed due to nonspecific symptomatology. Prompt diagnosis and intervention are essential in the treatment of SSEH to prevent permanent neurologic dysfunction. Physicians should have a high index of suspicion for SSEH in these instances, and investigation with spinal MRI imaging is recommended.

Spinal epidural hematoma without significant trauma in children: two case reports and review of the literature

BACKGROUND

Spinal epidural hematoma without significant trauma is a rare condition with potentially severe outcome. This case report and systematic review of the literature illustrates the clinical presentation, risk factors, evaluation, treatment and outcomes of spinal epidural hematoma without significant trauma in children.

CASE PRESENTATION

We report one case of a 7-year-old girl who developed a neck pain after minor cervical sprain. MRI showed a right posterior epidural hematoma extending from C2/3 to T1. The hematoma was surgically evacuated, and the histopathology showed an arteriovenous malformation. Postoperative MRI showed complete evacuation of the hematoma and no residual vascular malformation. We report a second ASE with idiopathic spinal epidural hematoma of a 4½-year-old boy presenting with neck pain. MRI showed a right-sided latero-posterior subacute spinal epidural hematoma at C3-C5. Owing to the absence of any neurological deficit, the patient was treated conservatively. MRI at 3 months showed complete resolution of the hematoma.

CONCLUSIONS

Spinal epidural hematoma without significant trauma in children is a rare condition. It may present with unspecific symptoms. Screening for bleeding diathesis is warranted and neuroradiologic follow-up is essential to rule out vascular malformation. Whereas most children have a favorable outcome, some do not recover, and neurological follow-up is required.

Sudden Onset of Severe Cervical Pain in an Adolescent Girl: Case Report and Review of Literature

A previously healthy 13-year-old girl presented with a 9-day history of acute onset severe neck pain associated with limited range of movement. Medical evaluation at day 2 was suggestive of muscle contracture, and she was discharged home with diazepam, antiinflammatory agents, and rest; however, she returned because of progressive clinical worsening with left arm distal paresthesia and paralysis since day 3. There was no history of trauma or other systemic complaints, and her familial medical history was unremarkable.Physical examination revealed left cervical and paravertebral tenderness on palpation with severe limitation of cervical and trunk movements; neurologic examination revealed left forearm and hand weakness and paralysis (grade II/V) with thenarhypothenar atrophy. Laboratory studies including coagulation profile were normal. Magnetic resonance imaging revealed an epidural hematoma from C4-T1 without underlying cause apparent on magnetic resonance angiography. On day 12, she underwent C3-7 laminotomy with laminoplasty and complete drainage of the hematoma. After 5 months of follow-up, she displays no neurological deficits. The spontaneous spinal epidural hematoma is a rare neurosurgical emergency in children. It usually presents acutely with neurologic deficits, but the initial presentation may be atypical or insidious, delaying diagnosis and intervention. Definitive diagnosis is made by magnetic resonance imaging and implies a high index of suspicion. Surgical drainage of the hematoma is the mainstay of treatment with favorable prognosis even in cases with a delayed diagnosis.

Delayed-onset paralysis induced by spontaneous spinal epidural hematoma communicated with hematoma in the paraspinal muscle in a 6-month-old girl: a case report

Spontaneous spinal epidural hematoma (SSEH) very rarely develops in infants younger than 1 year old. To our knowledge, no previous case of delayed-onset paralysis induced by SSEH communicated with hematoma in the paraspinal muscle has been reported in the literature. The authors present the case of a 6-month-old girl with a tumor mass on her back who developed a paresis of her bilateral lower limbs. On spinal magnetic resonance imaging, the epidural mass appeared to be a dumbbell type and communicated with the mass in the paraspinal muscle through T12/L1 intervertebral foramen at the right side. After excision of the mass in the paraspinal muscle, hemi-laminectomy of T10-L3 was performed. No solid lesion was also present in the spinal canal and it was found to be an epidural hematoma. No malignancy was observed on pathological examination, and vascular and nerve system tumors were negative. When a tumor mass suddenly develops on the back of an infant and motor impairment of the lower limbs develops as the mass gradually enlarges, differential diagnosis should be performed taking SSEH into consideration.

Spontaneous Spinal Epidural Hematoma in an Infant with Developmental Disabilities

Introduction

Spontaneous spinal epidural hematomas (SSEHs) are rare in childhood, especially in infants.

Case Report

We present the case of a 17-month-old-boy with trisomy 21 and a large SSEH. He was hospitalized for acute onset paraplegia after 6 days of irritability. Nine days after symptom onset, magnetic resonance imaging (MRI) of the spine revealed an extensive epidural hematoma between C7 and T5 causing severe spinal cord compression. After a coagulation disorder was ruled out (12 days after onset), he underwent emergency hemilaminectomy with evacuation of the hematoma. His neurologic impairment gradually improved, and 4 months after surgery he was back to his neurologic baseline. At 18 months after surgery, he was walking independently, although he had some developmental disabilities due to trisomy 21.

Conclusions

Only 20 cases of SSEH in infancy have been previously reported, and this is the first report of SSEH in an infant with developmental disabilities. Because of the non-specific symptoms and difficulty obtaining MRIs in infants, particularly in those with developmental disabilities, the diagnosis and treatment of SSEH may be delayed. However, early diagnosis with MRI and early evacuation of SSEH in patients with severe neurological impairments is important for good outcomes. Attention must be paid to postoperative spinal deformity in infants.

Spontaneous Resolution of Spinal Epidural Hematoma Resulting from Domestic Child Abuse: Case Report

Nonaccidental head injury, as seen in domestic child abuse cases, is often associated with spinal injury, and spinal subdural hematoma is the most frequent diagnosis. While spinal epidural hematomas are a rare occurrence, the incidence of spontaneous epidural hematomas occurring in nonaccidental head injury patients is even lower. Epidural hematomas often result in acute focal neurological deficits necessitating emergent neurosurgical intervention. In patients without focal neurological deficits, conservative management may allow for spontaneous resolution of the epidural hematoma. The authors present the case of a 2-year-old boy with a large spinal epidural hematoma resulting after an event of nonaccidental injury, specifically, domestic child abuse. This patient exhibited no focal neurological deficits and was managed conservatively without surgical clot evacuation. On a follow-up visit, repeat imaging studies demonstrated a stable resolution of spinal epidural hematoma, providing further support for the safety of conservative management in these patients.

Spontaneous thoracic epidural hematoma: a case report and literature review

Spinal epidural hematoma is a rare neurosurgical emergency in respect of motor and sensory loss. Identifiable reasons for spontaneous hemorrhage are vascular malformations and hemophilias. We presented a case of spontaneous epidural hematoma in an 18-year-old female patient who had motor and sensory deficits that had been present for 1 day. On MRI, there was spinal epidural hematoma posterior to the T2-T3 spinal cord. The hematoma was evacuated with T2 hemilaminectomy and T3 laminectomy. Patient recovered immediately after the surgery. Literature review depicted 112 pediatric cases (including the presented one) of spinal epidural hematoma. The female/male ratio is 1.1:2. Average age at presentation is 7.09 years. Clinical presentations include loss of strength, sensory disturbance, bowel and bladder disturbances, neck pain, back pain, leg pain, abdominal pain, meningismus, respiratory difficulty, irritability, gait instability, and torticollis. Most common spinal level was cervicothoracic spine. Time interval from symptom onset to clinical diagnosis varied from immediate to 18 months. Spinal epidural hematoma happened spontaneously in 71.8 % of the cases, and hemophilia was the leading disorder (58 %) in the cases with a definable disorder. Partial or complete recovery is possible after surgical interventions and factor supplementations.

Spontaneous cervical epidural hematomas with acute hemiparesis should be considered a contraindication for intravenous thrombolysis: a case report with a literature review of 50 cases

We herein report the case of a 63-year-old woman with an acute spontaneous cervical epidural hematoma who presented with acute hemiparesis and was successfully managed with surgery. Based on a literature review of 50 cases of spontaneous cervical epidural hematomas, we concluded that the relatively high frequency of hemiparesis (12 of 50 cases, 24%) is the result of the fact that epidural hematomas are predominantly distributed dorsolaterally in the region of the mid and lower cervical spine, leading to unilateral cervical cord compression. Clinicians should keep in mind that acute hemiparesis can be caused by spontaneous cervical epidural hematomas for which intravenous thrombolysis is contraindicated.

Spontaneous spinal epidural hematoma in infancy: review of the literature and the "seventh" case report

Spontaneous spinal epidural hematomas (SSEH) are a rare cause of spinal cord compression in childhood and especially in infancy. We reviewed the literature and describe a case of an 8-month-old boy with a large spontaneous cervico-thoracic epidural hematoma. With this review we want to detail the importance of early investigation, diagnosis and treatment in infants with SSEH. In our case the infant presented with irritability and crying and an ascending paralysis within four days. Magnetic resonance imaging (MRI) of the spine demonstrated an extensive epidural hematoma between C5 and L1, serious medullar compression and secondary cervical and thoracic medullar edema and hydromyelia. An emergency laminectomy was performed with evacuation of a well organized hematoma. There was a partial recuperation of the neurologic symptoms. Based on the scarce literature which only concerns seven case reports, SSEH is a rare cause of spinal compression in infancy. The presentation is often not specific and neurological symptoms are often lacking in the beginning. However early diagnosis with MRI and prompt neurosurgical intervention are important to improve outcome.

Spontaneous spinal epidural hematoma secondary to extradural arteriovenous malformation in a child: a case-based update

INTRODUCTION

The aim of this study was to report a rare pediatric case of spontaneous spinal epidural hematoma (SSEH) mimicking Guillain-Barré syndrome (GBS), secondary to an epidural arteriovenous malformation (AVM). Furthermore, a case-based update and insight into the entity is attempted.

METHODS

An 8-year-old male presented with progressing severe lower limb weakness and no traumatic history. Presentation was mimicking GBS with ascending symptoms. Magnetic resonance (MR) scan revealed a dorsal epidural mass, extending from C6-C7 to T2, compressing the spinal cord. Emergency laminoplasties and surgical evacuation of the hematoma were performed. An up-to-date review of reported SSEH cases in children was conducted, with emphasis on underlying vascular malformations (epidural AVMs in particular). Pathogenesis, predisposing factors, imaging, diagnosis, treatment and outcome are discussed.

RESULTS

The hematoma was successfully evacuated. A vascular membrane on the dura was peeled off and sent for histopathology. There was no evidence of intradural vascular penetration. The patient improved postoperatively and was able to walk with support 7 months later. Histology revealed closely packed thin-walled angiomatous structures with wide lumens (filled with red blood cells) with walls composed of collagen and smooth muscle fibers, findings consistent with AVM.

CONCLUSIONS

Non-traumatic SSEH is rare in the pediatric population. Although vascular malformations are suspected, they are extremely rarely identified histopathologically. This case represents one of the very few reports of pediatric SSEH caused by a histologically proven, purely epidural AVM. High index of clinical suspicion and low threshold for MR can lead to timely diagnosis and prompt treatment with good functional outcome.

Spinal epidural hematoma in a patient with hemophilia B presenting as acute abdomen

Spontaneous spinal epidural hematoma (SSEH) is a rare complication in patients of haemophilia. We report the case of a 9-year-old boy with severe haemophilia B who presented with acute abdomen of 5 days duration. Acute onset of neck/back pain,walking impairment and urinary retention has usually been described as symptom complex in SSEH. The hematoma was identified by magnetic resonance imaging of the spinal column. Our case calls attention to recognition of abdominal pain (with no other localizing features) as initial symptom of SSEH and prompt evaluation and management before more overt symptoms of spinal cord compression becomes evident.

Primary Involvement of Allografted liver in Post-Transplant Lymphoproliferative Disorders, Report of Two Pediatric Cases and Review of the Literature

Post-transplant lymphoproliferative disorder is a lymphocyte proliferating disease, usually of B cell origin, and rarely of T cell. Involvement of liver itself in liver transplant recipients as the primary organ is not common. Herein we report our experience in two patients who primarily presented in the allografted liver, both of whom were promptly diagnosed after liver biopsy and treated successfully .Now after a few months; both of the patients are alive with normal liver function tests and negative imaging studies.

Spontaneous resolution of paraparesis because of acute spontaneous thoracolumbar epidural hematoma

Symptomatic spontaneous spinal epidural hematoma(SSEH) is an uncommon cause of cord compression that commonly is considered an indication for emergent surgical decompression. We aimed to investigate a patient with a SSEH that completely resolved clinically and radiographically, without surgical treatment. The patient presented three days after the sudden onset of back pain, numbness, and weakness. Magnetic Resonance Imaging (MRI) revealed a posterior thoracolumbar epidural hematoma extending from the level of T10 to L2 with significant cord compression. Decompression was recommended but he refused surgery and was managed conservatively. One month later weakness totally recovered and hematoma was absent on MRI.

Spontaneous resolution of paraparesis because of acute spontaneous thoracolumbar epidural hematoma

Symptomatic spontaneous spinal epidural hematoma(SSEH) is an uncommon cause of cord compression that commonly is considered as an indication for emergent surgical decompression. We aimed to investigate a patient with a SSEH that completely resolved clinically and radiographically, without surgical treatment. The patient presented three days after the sudden onset of back pain, numbness, and weakness. Magnetic Resonance Imaging (MRI) revealed a posterior thoracolumbar epidural hematoma extending from the level of T10 to L2 with significant cord compression. Decompression was recommended but he refused surgery and was managed conservatively. One month later, weakness totally recovered and hematoma was absent on MRI.

Spontaneous Spinal Epidural Hematoma: A Retrospective Study on Prognostic Factors and Review of the Literature

Objectives

The spontaneous spinal epidural hematoma (SSEH) is a rare clinical entity. Patients typically present with sudden onset back pain followed by neurological deficits.

Methods

Diagnosis of SSEH is usually made with MRI and standard treatment is surgical evacuation. In 1996, Groen published the most comprehensive review on the SSEH in which he analyzed 333 cases. We review 104 cases of SSEH presented in the English literature since the last major review and add three of our own cases, for a total of 107 cases.

Results

Our patients presented with back pain and neurologic deficits. Two made excellent functional recovery with prompt surgical decompression while one continued to have significant deficits despite evacuation. Better postoperative outcome was associated with less initial neurological dysfunction, shorter time to operation from symptom onset and male patients.

Conclusion

We discuss the etiology of SSEH and report current trends in diagnosis, treatment, and outcome.

Spontaneous spinal epidural hematoma

Spontaneous spinal epidural hematoma (SSEH) is a relatively rare but significant spinal condition. Urgent surgical evacuation of a hematoma is generally indicated to prevent serious permanent neurological deficits. We encountered three cases of spontaneous spinal epidural hematomas associated with motor weakness that were treated successfully by surgical intervention.