Thunderclap headache as a presentation of spontaneous spinal epidural hematoma with spontaneous recovery

Spontaneous spinal epidural hemorrhage and sentinel headache-A case report

OBJECTIVES/BACKGROUND

Expand the differential diagnosis of sentinel headache to include spontaneous spinal epidural hematoma (SSEH) and reinforce the need for lumbar puncture in the evaluation of thunderclap headache. SSEH is a rare clinical presentation especially in the absence of bleeding tendencies. Clinicians recognize SSEH with typical presenting signs and symptoms including regional paraspinal muscular contraction and pain along with myelopathy. Although thunderclap headache usually does not connote vascular rupture in the spinal epidural compartment, SSEH may rarely present with sentinel headache and later evolve into a myelopathy.

RESULTS AND CONCLUSION

Sentinel headache may be the sole symptom following spontaneous spinal epidural hemorrhage preceding both myelopathic and meningeal signs and symptoms. SSEH can best be diagnosed by lumbar puncture at this early moment potentially averting spinal cord injury.

Spontaneous resolution and complete recovery of spontaneous cervical epidural hematoma: Report of two cases and literature review

OBJECTIVE

To present the natural course and treatment modalities of spontaneous cervical epidural hematoma (SCEH), by reporting two rare cases with spontaneous resolution in both clinical and radiologic findings without surgery.

MATERIAL AND METHODS

One patient presenting with acute right side hemiparesis and another showing pure cervical radiculopathy were diagnosed with SCEH on magnetic resonance imaging (MRI). Both were both treated non-operatively. We also conducted a literature review of 19 cases of spontaneous spinal epidural hematoma (SSEH).

RESULTS

These two patients achieved complete resolution in terms of both neurologic function and radiologic findings within 21 days after onset. In the literature review, 63.2% of cases experienced neurologic improvement in the first 24h, 78.9% achieved complete neurologic recovery within 1 month, and radiological images showed complete resolution of hematoma in the first month for 73.7% of patients.

CONCLUSIONS

Atypical cervical SSEH can mimic cerebral stroke or a ruptured cervical disc. A high index of clinical suspicion followed by MRI examination is critical for diagnosis. Prompt surgical decompression and evacuation of the hematoma is generally regarded as first-line treatment. However, for patients without or with only slight neurologic symptoms, or showing early and sustained neurologic improvement, non-surgical therapy with close observation is a viable alternative. Both neurologic and radiologic resolution can be expected within the first month following onset in most cases of spontaneous resolution of SSEH.

Spinal epidural hematoma mimicking subarachnoid hemorrhage: A case study

BACKGROUND

Spontaneous spinal epidural hematoma (SSEH) is a rare spinal cord disorder requiring urgent diagnosis and prompt treatment to prevent irreversible neurological damage. Subarachnoid hemorrhage (SAH), usually presenting with headache and neck stiffness, is also a worldwide neurosurgical emergency. In this case study, a patient on clopidogrel presented with an SSEH mimicking a spontaneous SAH.

CASE DESCRIPTION

A 74-year-old female presented with severe headache and neck pain which ultimately attributed to a cervicothoracic SSEH resulting in cord compression. Notably, there was a long delay in establishing the diagnosis of SSEH as her symptoms mimicked a SAH. Although the patient ultimately underwent spinal surgery followed by intense rehabilitation, the diagnostic delay resulted in a poor neurological outcome.

CONCLUSIONS

Patients with spontaneous cervicothoracic epidural hematomas may occasionally present with symptoms of severe headache and neck pain/stiffness mimicking an SAH. Long diagnostic delays in establishing SSEH may result in irreversible cord damage.

A systematic review of causes of sudden and severe headache (Thunderclap Headache): should lists be evidence based?

Background

There are many potential causes of sudden and severe headache (thunderclap headache), the most important of which is aneurysmal subarachnoid haemorrhage. Published academic reviews report a wide range of causes. We sought to create a definitive list of causes, other than aneurysmal subarachnoid haemorrhage, using a systematic review.

Methods

Systematic Review of EMBASE and MEDLINE databases using pre-defined search criteria up to September 2009. We extracted data from any original research paper or case report describing a case of someone presenting with a sudden and severe headache, and summarized the published causes.

Results

Our search identified over 21,000 titles, of which 1224 articles were scrutinized in full. 213 articles described 2345 people with sudden and severe headache, and we identified 6 English language academic review articles. A total of 119 causes were identified, of which 46 (38%) were not mentioned in published academic review articles. Using capture-recapture analysis, we estimate that our search was 98% complete. There is only one population-based estimate of the incidence of sudden and severe headache at 43 cases per 100,000. In cohort studies, the most common causes identified were primary headaches or headaches of uncertain cause. Vasoconstriction syndromes are commonly mentioned in case reports or case series. The most common cause not mentioned in academic reviews was pneumocephalus. 70 non-English language articles were identified but these did not contain additional causes.

Conclusions

There are over 100 different published causes of sudden and severe headache, other than aneurysmal subarachnoid haemorrhage. We have now made a definitive list of causes for future reference which we intend to maintain. There is a need for an up to date population based description of cause of sudden and severe headache as the modern epidemiology of thunderclap headache may require updating in the light of research on cerebral vasoconstriction syndromes.