Subdural hematoma of the spinal cord and widespread subarachnoid hemorrhage complicating anticoagulant therapy

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.

Stroke-like manifestation of a spontaneous spinal epidural hematoma with spontaneous resolution: a case report

BACKGROUND

This case report presents the case of a man with no known coagulopathy or preceding trauma, who spontaneously developed a spinal epidural hematoma (SEH). This is an uncommon condition which can have variable presentations including hemiparesis mimicking stroke, resulting in the potential for misdiagnosis and inappropriate treatment.

CASE PRESENTATION

A 28-year-old Chinese male with no past medical history presented with sudden onset neck pain associated with bilateral upper limbs and right lower limb subjective numbness but intact motor function. He was discharged after adequate pain relief but re-attended the emergency department with right hemiparesis. A magnetic resonance imaging of his spine revealed an acute cervical spinal epidural hematoma at C5 and C6. While admitted, he had spontaneous improvement of his neurological function and was eventually managed conservatively.

CONCLUSIONS

SEH, although uncommon, can be a mimic of stroke and it is important to avoid misdiagnosis as it is a time critical diagnosis, and administration of thrombolysis or antiplatelets can lead to unfavourable outcomes. Having a high clinical suspicion can help to guide us in the choice of imaging and interpretation of subtle signs to reach the correct diagnosis in a timely manner. Further research is required to better understand the factors that would favour a conservative approach as opposed to surgical treatment.

Postoperative spinal subdural hygroma without incidental durotomy: illustrative cases

BACKGROUND

Spinal subdural hygroma (SSH) is a rare pathological entity occurring as a complication of spinal surgery. It is different from spinal subdural hematoma due to blunt trauma, anticoagulation therapy, spinal puncture, and rupture of vascular malformations.

OBSERVATIONS

The authors presented five patients with SSH who received decompression for lumbar stenosis. None had incidental durotomy. All presented postoperatively with unexpectedly severe symptoms, including back and leg pain and weakness. Postoperative magnetic resonance imaging (MRI) revealed SSH with a characteristic imaging finding termed the “flying bat” sign. Four patients underwent evacuation of SSH, with immediate and complete resolution of symptoms in three patients and improvement in one patient. One patient improved without additional surgery. At surgery, subdural collections were found to be xanthochromic fluid in three patients and plain cerebrospinal fluid (CSF) in one patient.

LESSONS

Unexpectedly severe back and leg pain and weakness after lumbar or thoracic spine surgery should raise suspicion of SSH. MRI and/or computed tomography myelography shows the characteristic findings termed the flying bat sign. Surgical evacuation is successful although spontaneous resolution can also occur. The authors hypothesized that SSH is due to CSF entering the subdural space from the subarachnoid space via a one-way valve effect.

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.

Postoperative Spinal Subdural Lesions Following Lumbar Spine Surgery: Prevalence and Risk Factors

Study Design

Retrospective case–control study

Purpose

To clarify the prevalence and risk factors for spinal subdural lesions (SSDLs) following lumbar spine surgery.

Overview of Literature

Because SSDLs, including arachnoid cyst and subdural hematoma, that develop following spinal surgery are seldom symptomatic and require reoperation, there are few reports on these pathologies. No study has addressed the prevalence and risk factors for SSDLs following lumbar spine surgery.

Methods

We conducted a retrospective analysis of the magnetic resonance (MR) images and medical records of 410 patients who underwent lumbar decompression surgery with or without instrumented fusion for degenerative disorders. SSDLs were classified into three grades: grade 0, no obvious lesion; grade 1, cystic lesion; and grade 2, lesions other than a cyst. Grading was based on the examination of preoperative and postoperative MR images. The prevalence of SSDLs per grade was calculated and risk factors were evaluated using multivariate logistic regression analysis.

Results

Postoperative SSDLs were identified in 123 patients (30.0%), with 50 (12.2%) and 73 (17.8%) patients being classified with grade 1 and 2 SSDLs, respectively. Among these, one patient was symptomatic, requiring hematoma evacuation because of the development of incomplete paraplegia. Bilateral partial laminectomy was a significantly independent risk factor for SSDLs (odds ratio, 1.52; 95% confidence interval, 1.20–1.92; p<0.001). In contrast, a unilateral partial laminectomy was a protective factor (odds ratio, 0.11; 95% confidence interval, 0.03–0.46; p=0.002).

Conclusions

The prevalence rate of grade 1 SSDLs was 30%, with no associated clinical symptoms observed in all but one patient. Bilateral partial laminectomy increases the risk for SSDLs, whereas unilateral partial laminectomy is a protective factor.

Active extravasation of gadolinium-based contrast agent into the subdural space following lumbar puncture

A 38year-old male presented with cauda equina syndrome following multiple lumbar puncture attempts. Lumbar spine magnetic resonance imaging (MRI) showed a subdural hematoma and an area of apparent contrast enhancement in the spinal canal on sagittal post-contrast images. Axial post-contrast images obtained seven minutes later demonstrated an increase in size and change in shape of the region of apparent contrast enhancement, indicating active extravasation of the contrast agent. This is the first reported case of active extravasation of gadolinium-based contrast agent in the spine.

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.

Spinal cord changes after the evacuation of a spinal subdural haematoma

Spinal subdural haematoma is a rare entity. Only a few cases have been reported, mainly in patients with coagulopathies or bleeding diathesis, and also in patients undergoing anticoagulant therapy following surgery, trauma, or lumbar puncture. Symptoms of spinal cord compression produced by spinal subdural haematoma may progress rapidly causing complete and irreversible deficits. However, rapid diagnosis and surgical intervention can result in a good functional outcome for the patient. We report on a 41-year-old woman with a normal coagulation profile who developed a spinal subdural haematoma after a minor motor vehicle accident. Although initially asymptomatic, she developed a dense quadriparesis over a 36-h period. A magnetic resonance imaging study demonstrated a subdural mass compressing the spinal cord, and at surgery a spinal subdural haematoma was found. She was discharged to an inpatient rehabilitation facility. Follow-up at 1 year showed significant improvement in motor function, but absence of posterior column function. A follow-up magnetic resonance study demonstrated widening of the spinal cord, advanced myelomalacia and a large, central, multi-loculated syrinx.

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.

Spontaneous chronic spinal subdural hematoma associated with spinal arachnoiditis and syringomyelia

Spontaneous chronic spinal subdural hematoma is rare. We describe a case of spontaneous chronic spinal subdural hematoma associated with arachnoiditis and syringomyelia in a 76-year old woman who presented with a 14-year history of progressive myelopathy. MRI scan revealed a thoraco-lumbar subdural cystic lesion and a thoracic syrinx. The patient underwent thoracic laminectomy and decompression of the lesion, which was a subdural hematoma. A myelotomy was performed to drain the syrinx. Pathological examination revealed features consistent with chronic subdural membrane. This report attempts to elucidate the pathogenesis of chronic spinal subdural hematoma. We discuss possible etiological factors in light of the current literature and pathogenesis of both spinal subdural hematoma and syrinx formation.

Functional outcome after surgical treatment of spontaneous and nonspontaneous spinal subdural hematomas

Object. Because of the rarity of spinal subdural hematomas (SDHs), the literature offers scarce estimates of the outcome and predictive factors in patients suffering from these lesions. In addition, single-institution surgical series are still lacking. Therefore, the authors retrospectively evaluated the early and long-term functional outcomes measured in eight patients with spontaneous and nonspontaneous spinal SDHs in whom the clot had been evacuated.

Methods. The patients' charts were evaluated for origin of the lesion, risk factors, and neurological deficits at symptom onset and at 28 days after extirpation of the spinal SDH. Long-term clinical outcome (Barthel Index [BI]) was evaluated by administering a telephone questionnaire to the patient or a relative.

Only one patient with a spontaneous spinal SDH was identified. Four patients were undergoing anticoagulant therapy, and three patients had undergone a previous anesthetic/diagnostic spinal procedure. Twenty-eight days postoperatively, neurological deficits improved in six of eight patients; however, in two of the six patients, the improvement did not allow the patients to become independent again. In two patients, surgery did not affect the complete sensorimotor deficits. In the long-term survivors (median 45 months) a median BI of 55 was achieved. The latency between symptom onset and surgery did not correlate with functional outcome in this series. The preoperative neurological condition and location of the hematoma correlated positively with early and long-term functional outcome.

Conclusions. To the best of their knowledge, the present study is the largest single-institutional study of patients with surgically treated spinal SDHs. Despite some postoperative improvement of sensorimotor deficits in most patients, the prognosis is poor because 50% of the patients remain dependent. Their outcome was determined by the preoperative sensorimotor function and spinal level of the spinal SDH.

Spinal chronic subdural hematoma in a patient with ventriculo-peritoneal shunting after a minor trauma

STUDY DESIGN

Case report and review of literature.

OBJECTIVES

Intracranial chronic subdural hematoma (SDH) is a well-recognized complication of ventriculoperitoneal (VP) shunt. Spinal chronic SDH is very rarely associated with VP shunt.

SETTING

Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.

CASE REPORT

We describe a spinal chronic SDH, developing after a minor trauma, in a patient who underwent a VP shunt surgery for hydrocephalus 6 months previously. A good outcome was achieved after decompressive surgery.

CONCLUSION

Spinal chronic SDH should be considered in the diagnosis of progressive spinal compression, especially in the patients with VP shunt after minor trauma.

Use of topically applied rt-PA in the evacuation of extensive acute spinal subdural haematoma

Spontaneous spinal subdural haematoma is a rare cause of spinal cord compression, usually confined to a few vertebral levels. When the haematoma extends over several spinal segments, surgical decompression is a major undertaking. Recombinant tissue plasminogen activator (rt-PA) has previously been used in a number of surgical procedures, but not in the setting of acute spinal subdural haematoma. A minimally invasive technique of decompression, using topical rt-PA, is presented in two patients with extensive spinal intradural haematoma. Two patients receiving long-term anticoagulation therapy presented with acute-onset back pain progressing to paraparesis. Magnetic resonance imaging of the spine demonstrated spinal subdural haematomas extending over 15 vertebral levels in one patient and 12 in the other. An angiography catheter was introduced into the subdural space through a limited laminectomy. Thrombolysis and evacuation of haematoma was then achieved by intermittent irrigation of the subdural space with rt-PA, followed by saline lavage. Postoperative imaging demonstrated satisfactory decompression in both patients. There was significant improvement of neurological function in one patient. Topical application of rt-PA for spinal subdural haematoma allows evacuation of the haematoma through a limited surgical exposure. Decompression of the subdural space by this minimally invasive technique may be advantageous over extensive surgery by minimising surgical exposure, reducing postoperative pain and risk of neuronal injury. This technique may be useful in patients presenting with compression extending over several vertebral levels or poor surgical candidates.

Low back pain due to spinal chronic subdural hematoma mimicking intradural tumor in the lumbar area: a case report and literature review

Although magnetic resonance imaging has dramatically enhanced the ability to diagnose spinal mass lesions, some lesions remain difficult to diagnose. We report a spinal chronic subdural hematoma that comprised the cauda equina ventrally in the lumbar area in a 51-year-old man who was under anticoagulant therapy. Low back pain was the only symptom of the patient after sports activity. Surgical treatment was performed 2 months after the onset of symptoms. Intraoperative view showed chronic subdural hematoma with abnormal enlarged dural vascularization. The patient had no preoperative and postoperative neurologic deficit. Low back pain with sudden onset after minor trauma refractory to medical treatment must be investigated with magnetic resonance imaging in patients under anticoagulant therapy for spinal hematoma because of the possibility of spinal chronic subdural hematoma.

Spinal subdural hematoma revealing hemophilia A in a child: A case report

BACKGROUND: Intraspinal bleeding especially in the form of subdural hematoma is rare in hemophiliacs. In the present case, we report a neglected hemophilic A child with such a problem and discuss its management options. CASE PRESENTATION: A 9-year old hemophilic A boy presented with quadriparesis, confusion and meningismus after a fall 4 days previously. There was no sign of direct trauma to his back. His CT Scan and MRI showed spinal extramedullary hematoma extended from C5 to L2. We corrected the factor VIII level, but two days later, the patient's lower limbs weakened to 1/5 proximally as well as distally. We performed a laminectomy from T11 to L2, according to the level of the maximal neurological deficit and recent deterioration course. The subdural hematoma was evacuated. The hematoma in other spinal levels was managed conservatively. In the week following the operation, the patient's neurological status approached normal. CONCLUSION: This case calls attention to the clinical manifestation, radiological features and management options of the rarely reported intraspinal hematoma in hemophilic children. Although this case has been managed operatively for its hematoma in the thoracolumbar region, at the same time it can be considered a successful case of conservative management of intraspinal hematoma in the cervicothoracic region. Both conservative and surgical management could be an option in managing these patients considering their neurological course.

Nontraumatic acute spinal subdural hematoma

✓ Acute subdural spinal hematoma occurs rarely; however, when it does occur, it may have disastrous consequences. The authors assessed the outcome of surgery for this lesion in relation to causative factors and diagnostic imaging (computerized tomography [CT], CT myelography), as well as eventual preservation of the subarachnoid space.

The authors reviewed 106 cases of nontraumatic acute subdural spinal hematoma (101 published cases and five of their own) in terms of cause, diagnosis, treatment, and long-term outcome.

Fifty-one patients (49%) were men and 55 (51%) were women. In 70% of patients the spinal segment involved was in the lumbar or thoracolumbar spine. In 57 cases (54%) there was a defect in the hemostatic mechanism. Spinal puncture was performed in 50 patients (47%). Late surgical treatment was performed in 59 cases (56%): outcome was good in 25 cases (42%) (in 20 of these patients preoperative neurological evaluation had shown mild deficits or paraparesis, and three patients had presented with subarachnoid hemorrhage [SAH]). The outcome was poor in 34 cases (58%; 23 patients with paraplegia and 11 with SAH).

The formation of nontraumatic acute spinal subdural hematomas may result from coagulation abnormalities and iatrogenic causes such as spinal puncture. Their effect on the spinal cord and/or nerve roots may be limited to a mere compressive mechanism when the subarachnoid space is preserved and the hematoma is confined between the dura and the arachnoid. It seems likely that the theory regarding the opening of the dural compartment, verified at the cerebral level, is applicable to the spinal level too. Early surgical treatment is always indicated when the patient's neurological status progressively deteriorates. The best results can be obtained in patients who do not experience SAH.

In a few selected patients in whom neurological impairment is minimal, conservative treatment is possible.

Serial magnetic resonance imaging findings for a spontaneously resolving spinal subdural hematoma: case report

OBJECTIVE AND IMPORTANCE

Spinal subdural hematoma (SSDH) is a rare entity, and cases are usually managed as surgical emergencies. We describe a patient with a SSDH who demonstrated incomplete clinical resolution with nonsurgical management, despite continued anticoagulation treatment. We provide the most complete demonstration of the magnetic resonance imaging (MRI) characteristics of a large SSDH from its initiation to its radiological resolution.

CLINICAL PRESENTATION

A 61-year-old woman developed a large SSDH as a complication of a lumbar puncture. Her only neurological deficit was urinary retention.

INTERVENTION

Because of the extensiveness of the hematoma and the relative neurological preservation of the patient, she was treated conservatively. Serial MRI scans were obtained at 4, 7, 13, and 25 days. The evolution of deoxyhemoglobin in the hematoma to methemoglobin was observed. By 25 days, MRI scans showed virtual resolution.

CONCLUSION

SSDHs undergo MRI signal changes that are similar to those of brain hematomas. In certain cases, even large SSDHs demonstrate swift and dramatic spontaneous resolution, despite continued anticoagulation treatment. This report suggests that there is a role for conservative management for selected cases of SSDHs.

Iatrogenic spinal subdural haematoma

Spinal subdural haematoma is a rare condition, usually seen in association with lumbar puncture or a bleeding disorder. It carries a high morbidity and mortality, and successful treatment requires prompt surgical intervention. We present a case of mixed spinal subarachnoid and subdural haemorrhage complicating failed spinal anaesthesia combined with anti-coagulation in an elderly woman, together with a review of the literature.

Chronic spinal subdural hematomas. Report of two cases

Two patients with chronic spinal subdural hematomas are described. Both had a fluctuating clinical course, not previously documented in the literature. Surgical evacuation resulted in almost complete recovery. The pathogenesis of spinal subdural hematoma is discussed and the pertinent literature is reviewed.

Spontaneous spinal subarachnoid hemorrhage and subdural hematoma. Report of two cases

Two patients with spontaneous spinal subarachnoid hemorrhage are presented to emphasize the clinical and radiological features of this uncommon illness. Both had severe back pain at the onset. One patient had a subdural hematoma that compressed the conus medullaris and cauda equina, and was drained percutaneously; the other had clots in the subarachnoid space. The cerebrospinal fluid showed a polymorphonuclear pleocytosis that simulated septic meningitis. Complete spinal angiography failed to reveal a cause for the hemorrhages.

[Myelopathy induced by anticoagulant medication. Report of a case with spinal epidural hematoma]

A 51 year-old female patient, under anticoagulant therapy due to thrombophlebitis and pulmonary embolism, developed sudden paraplegia. Emergency myelogram showed a total block at L2 level and an epidural hematoma was removed at surgery, but the motor deficit remained unchanged post-operatively. The pertinent literature is reviewed, etiological considerations are made and emphasis is placed on early diagnosis and prompt treatment.