Cervical epidural hematoma secondary to an extradural vascular malformation in an infant: case report

Treatment of spontaneous spinal epidural hematoma in children: analysis of 25 cases

INTRODUCTION

Spontaneous spinal epidural hematoma (SSEH) is a rare neurosurgical emergency, presenting as sudden onset of back pain and weakness of lower extremities. Many patients have no definite cause. Some cases of SSEH caused by vascular malformation have been reported. The treatment strategy remains controversial. This study aimed to analyze the causes of SSEH and proposed a treatment strategy according to clinical outcomes of patients at a single institution.

METHODS

A total of 25 cases of SSEH under 18 years of age treated between March 2004 and July 2021 were retrospectively analyzed.

RESULTS

The mean age of the first SSEH onset was 7.1 years. The most common location was cervicothorax. Nine patients suffered from multiple episodes. Twenty-three patients underwent spinal digital subtraction angiography (DSA), of which seven (30.4%) patients had positive findings: three cases had epidural artery venous fistula (AVF), two cases had epidural artery venous malformation (AVM), and two cases had abnormal concentration of contrast agent. Seventeen patients received surgery. Eleven patients (44%) were diagnosed as vascular malformation by either DSA or pathology. The follow-up rate was 80%, with 20 patients (80%) achieving satisfactory clinical outcome. Risk factors for poor clinical outcome included multiple episodes (p = 0.028) and higher Aminoff-Logue score (p = 0.005).

CONCLUSION

Spinal epidural vascular malformation is a significant cause of SSEH. Spinal DSA is necessary. Surgery should be recommended for patients with multiple episodes, positive findings on DSA, or severe neurological deficits. Conservation therapy can be considered for other patients, but long-time follow-up is necessary.

The Coexistence of Extradural Arteriovenous Fistula and Soft Tissue Arteriovenous Malformation Within the Same Metamere

BACKGROUND

Spinal arteriovenous shunts are a common spinal vascular disorder. However, they can have a misleading clinical presentation and poor prognosis. They are classified into 4 types according to shunt points and drainage route, among which extradural arteriovenous fistula (eAVF) is the most rare, comprising only 1% of all spinal arteriovenous shunts. We report an extremely rare case of coexistent eAVF at the craniocervical junction and soft tissue arteriovenous malformation within the same metamere.

CASE DESCRIPTION

A 30-year-old man presented with neck pain. T2-weighted magnetic resonance imaging revealed a flow void at the right craniocervical junction compressing the spinal cord. Angiography revealed eAVF at the craniocervical junction. The patient was treated via transvenous embolization. After the procedure, shunt flow and symptoms markedly decreased. During the operation, an extracranial arteriovenous malformation under the occipital skin was detected immediately after occluding the shunt point.

CONCLUSIONS

This case indicates that transvenous embolization can be an effective treatment for eAVF and supports some hypotheses of arteriovenous malformation development. Additionally, it emphasizes the importance of examining a lesion with multiple modalities, including angiography, three-dimensional angiography, and cone-beam computed tomography, to understand the anatomy of the lesion.

Large, spontaneous spinal subdural-epidural hematoma after epidural anesthesia for caesarean section: Conservative management with excellent outcome

Background:

Iatrogenic or spontaneous spinal hematomas are rarely seen and present with multiple symptoms that can be difficult to localize. Most spontaneous spinal hematomas are multifactorial, and the pathophysiology is varied. Here, we present a case of a scattered, multicomponent, combined subdural and epidural spinal hematoma that was managed conservatively.

Case Description:

A 38-year-old woman came to the emergency department (ED) complaining of severe neck and back pain. She had undergone a caesarean section under epidural anesthesia 4 days prior to her arrival in the ED. She was placed on heparin and then warfarin to treat a pulmonary embolism that was diagnosed immediately postpartum. Her neurological examination at presentation demonstrated solely the existence of clonus in the lower extremities and localized cervical and low thoracic pain. In the ED, the patient's international normalized ratio was only mildly elevated. Spinal magnetic resonance imaging revealed a large thoracolumbar subdural hematoma with some epidural components in the upper thoracic spine levels. Spinal cord edema was also noted at the T6-T7 vertebral level. The patient was admitted to the neurosurgical intensive care unit for close surveillance and reversal of her coagulopathy. She was treated conservatively with pain medication, fresh frozen plasma, and vitamin K. She was discharged off of warfarin without any neurological deficit.

Conclusions:

Conservative management of spinal hematomas secondary to induced coagulopathies can be effective. This case suggests that, in the face of neuroimaging findings of significant edema and epidural blood, the clinical examination should dictate the management, especially in such complicated 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 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.

Management of spinal epidural arteriovenous fistulas: interventional techniques and results

BACKGROUND

Spinal epidural arteriovenous fistulas (SEDAVF) are rare and poorly understood clinical entities.

MATERIALS AND METHODS

We report a series of five (three men, two women) consecutive cases treated at our center to analyze their characteristic and treatment strategies in their management. We report a successful technique of percutaneous embolization of fistulas in a patient with failed previous attempts.

RESULTS

All five patients were symptomatic; three patients presented with a history of back pain, which progressed to myelopathic symptoms, one patient had symptoms of persistent back pain, and one patient had intermittent numbness of the left arm and thigh. Of the three patients who had myelopathic symptoms, two were successfully treated with transarterial embolizations with Onyx copolymer. The third patient who had a prominent epidural venous pouch with numerous arterial feeders was embolized percutaneously with a flat detector CT guided navigation (XperCT) and real time fluoroscopic monitoring of the injected n-butyl cyanoacrylate glue, after previous unsuccessful attempts with surgery and arterial embolizations. All three myelopathic treated patients had complete angiographic remission of the fistulas and symptoms on follow-up (mean 7.2 months).

CONCLUSIONS

The diagnosis and treatment of SEDAVF can be challenging due to their rarity and intricate pathomechanics. Patients with severe pain or progression of symptoms or myelopathic symptoms need to be treated at the earliest opportunity, while asymptomatic patients can be closely monitored. Percutaneous embolization is an effective strategy to embolize SEDAVF associated venous pouch.

Spontaneous spinal epidural haematoma due to arteriovenous malformation in a child

Spontaneous spinal epidural haematoma (SSEH) is a rare clinical entity, especially in infants, in whom only a few cases have been reported. In a paediatric emergency setting, SSEH should be considered as part of the differential diagnosis for acute extremity weakness and paraesthesia. Epidural vascular malformations are often suspected in these cases but have rarely been demonstrated. The authors report herein a case of SSEH in a 9-year-old boy arising from an epidural vascular malformation. He initially presented with sudden intense cervicodorsal pain followed by hypotonic lower extremities and progressive motor weakness, with no sensory change. The MRI showed an acute extradural haematoma extending from C7 to T4 with compression of the spinal cord. After submission to decompression surgery, he presented full recovery in 1 month. The histopathological analysis revealed a vascular malformation.

Cauda equina syndrome in an eleven-month-old infant following sacrococcygeal teratoma tumor resection and coccyx excision: case report

STUDY DESIGN

A case report of cauda equina syndrome (CES) in an 11-month-old infant, following sacrococcygeal teratoma tumor resection and coccyx excision leading to a spinal epidural hematoma (SEH).

OBJECTIVE

To illustrate a rare case of CES and SEH in an infant, and discuss the need for sealing access to the spinal canal after sacrococcygeal surgical resection and reconstruction.

SUMMARY OF BACKGROUND DATA

To the authors' knowledge, this is the youngest patient reported to develop a SEH and CES, and the only patient reported in the literature to develop a SEH after coccyx excision.

METHODS

Seventeen days after undergoing sacrococcygeal tumor resection and coccyx excision, the patient presented to the emergency room with a large distended bladder, loss of rectal tone, and significant weakness in the lower extremities. Magnetic resonance imaging of the thoracic and lumbar spine showed a large lesion in the dorsal epidural space extending from T12 to the tip of the communicating with the prior operative site by means of the previous coccyx resection. The infant was emergently brought to the operating room for decompression.

RESULTS

The patient was discharged 6 days later with diminished neurologic function, but demonstrated significant improvement over the next 18 months and currently remains disease free and neurologically normal at age 7.

CONCLUSION

This case demonstrates the need for future examination of sacrococcygeal surgical resection and subsequent reconstruction of excised structures to decrease the risk of communication with the epidural space.

Spontaneous and idiopathic chronic spinal epidural hematoma: two case reports and review of the literature

Spinal epidural hematoma (SEH) represents the most frequent entity of acute or chronic spinal bleeding. Based upon pathogenesis, SEH can be classified as idiopathic, spontaneous, and secondary. The idiopathic forms are considered not to be attributed to any specific risk factors. Spontaneous SEH, accounting for 0.3–0.9% of all spinal epidural space occupying lesions, instead is associated with risk factors (such as substantial soft trauma or coagulation abnormalities). The chronic form, as our literature review revealed, is the rarest and its most frequent location is the lumbar spine. The pathophysiology of spontaneous and idiopathic SEH is still under debate: There are only a few reports in literature of chronically evolving SEH with progressively increasing pain and neurological impairment. Magnetic resonance imaging may be inconclusive for differential diagnosis. Here, we present two cases of lumbar chronic SEH with slow, progressive, and persistent lumbar radicular impairment. The first patient reported a minor trauma with slight back contusion and thus was classified as spontaneous SEH. In the second case not even a minor trauma was involved, so we considered it to be idiopathic SEH. In both cases preoperative blood and coagulation tests were normal and we did not find any other or co-factors in the patients’ clinical histories. MR imaging showed uncertain spinal canal obstructing lesions at L3 and L4 level in both cases. Surgical treatment allowed a correct diagnosis and resulted in full clinical and neuroradiological recovery after 1 year follow-up. Our aim is to discuss pathogenesis, clinical and radiological features, differential diagnosis and treatment options, on the background of relevant literature review.

Spinal extradural arteriovenous malformations with parenchymal drainage: venous drainage variability and implications in clinical manifestations

OBJECT

Although nontraumatic spinal arteriovenous malformations and fistulas (AVMs and AVFs) restricted to the epidural space are rare, they can lead to significant neurological morbidity. Careful diagnostic imaging is essential to their detection and the delineation of the pathological anatomy. Aggressive endovascular and open operative treatment can provide arrest and reversal of neurological deficits.

METHODS

The authors report on 6 cases of extradural AVMs/AVFs causing progressive myelopathy. Clinical findings, diagnostic evaluation, treatment, and outcome are discussed. Special consideration is given to the anatomy of the lesions and the operative techniques used to treat them. A review of the literature concerning extradural vascular malformations is also presented.

RESULTS

All 6 cases of extradural AVMs had an extradural fistulous location with intradural medullary venous drainage. These cases illustrate progressive myelopathy through cord venous congestion (hypertension) that can be caused by an extradural nidus or fistula. In 4 cases, a large epidural lake was identified on angiography. At surgery, the epidural lake was obliterated and medullary drainage interrupted. All patients had stabilization of their neurological deficits and successful obliteration of the AVM/AVF was obtained.

CONCLUSIONS

Extradural AVMs and AVFs are a poorly described entity with published clinical experience limited to sporadic case reports and small series. Although these lesions have a purely extradural location of arteriovenous shunting and early venous drainage, they can be responsible for acute and progressive neurological symptoms similar to those caused by their dural-based intradural counterparts. With careful imaging recognition of the pathological anatomy, surgical and endovascular techniques can be used for the treatment of extradural AVMs affording effective and durable obliteration with stabilization or reversal of neurological symptoms. Venous drainage directly correlates the pathologic mechanisms of presentation. Specific attention must be paid intraoperatively to the epidural lake common to both variants so that recurrence is avoided.

Spontaneous spinal epidural hematoma in an infant : a case report and review of the literature

Spontaneous spinal epidural hematoma (SSEH) is rare in children, especially in infants, in whom only 12 cases have been reported. Because of the nonspecificity of presenting symptoms in children, the diagnosis may be delayed. We report herein a case of SSEH in a 20-month-old girl who initially presented with neck pain, and developed lower extremity motor weakness and symptoms of neurogenic bladder 2 weeks prior to admission. The magnetic resonance imaging showed an epidural mass lesion extending from C7 to T4, and the spinal cord was severely compressed by the mass. After emergency decompressive surgery the neurologic function was improved immediately. Two months after surgery, the neurological status was normal with achievement of spontaneous voiding. We suggest that surgical intervention can provide excellent prognosis in case of SSEH in infants, even if surgery delayed.

Spontaneous spinal epidural haematoma in a 15-month-old boy presenting with a wry neck: a case report

A 15-month-old boy presented with a 2-day history of a wry neck (bent to the left side) with no definite trauma. He had bilateral upper limb weakness and was afebrile, conscious, and stable. There was no spontaneous movement in both upper limbs. Magnetic resonance imaging of the cervical and thoracic spine demonstrated an extensive spontaneous spinal epidural haematoma from C3 to T8. 23 hours after admission, the patient underwent an emergency right-sided C3 to T8 hemi-laminectomy and haematoma evacuation. The patent's strength gradually recovered and he attained full power 3 weeks after operation. Spontaneous spinal epidural haematoma is a rare disease in children. A high index of suspicion is essential for its effective management as the interval to operation is the most important prognostic factor.

Sacral insufficiency fracture complicated by epidural haematoma and cauda equina syndrome in a patient with multiple myeloma

We report the case of a patient with multiple myeloma (MM) and extensive lytic bone disease who presented with a short history of back pain and leg weakness. Magnetic resonance imaging (MRI) of the lumbar spine revealed a sacral insufficiency fracture complicated by an epidural haematoma. Bleeding tendency in this case can be accounted for by platelet function defects, often described in plasma cell disorders in the absence of obvious coagulation abnormalities. Surgical intervention was contraindicated as a result of poor overall patient performance status (poor surgical candidate due to extensive myelomatous bone disease, previous vertebral compression fractures requiring orthopaedic stabilisation, and requiring opiate analgesia for bone pain) and management was conservative. Patients presenting with back pain and documented bone disease in the setting of myeloma should be managed with a high index of clinical suspicion and considered for urgent MR imaging to avoid missing this serious and potentially reversible complication. We report the undescribed causative association between sacral insufficiency fracture and lumbo-sacral epidural haematoma. We illustrate the MRI signal and contrast enhancement pattern of an acute presentation of epidural haematoma.

Thoracic spine extradural arteriovenous fistula

BACKGROUND

Spinal extradural arteriovenous fistula is a rare, disabling, but potentially treatable disease. Only 27 cases have been reported so far in the past 40 years.

CASE DESCRIPTION

An 18-year-old adolescent girl developed repeated back pain and mild paraplegia after a training course. Magnetic resonance imaging revealed a vessel-like lesion at the spinal extradural space, compressing the spinal medulla at the T5 level. Angiography disclosed a focal fistula fed by branches of the intercostal artery. The vascular mass was surgically removed and confirmed pathologically.

CONCLUSION

Spinal extradural arteriovenous fistulas have an arterial supply that originates outside the spinal dura, with venous draining into the spinal extradural venous plexus. They may lead to myelopathy, radiculopathy, or spontaneous extradural hematoma, due to dilated vein compression, blood stealing, or spinal venous hypertension. Extradural hematoma needs emergency laminectomy and clot evacuation. And extradural arteriovenous fistulas should be treated actively by embolization, surgical resection, or both. Appropriate treatment will stabilize the patient or result in neurological improvement.

A case of nontraumatic spinal epidural hematoma caused by extradural varix: consideration of etiology

BACKGROUND CONTEXT

Many cases of nontraumatic spinal epidural hematoma (SEH) have been reported, although the etiology of SEH remains unclear.

PURPOSE

Our purpose was to report a rare case of nontraumatic acute SEH caused by extradural varices and to discuss the etiology of this entity.

STUDY DESIGN/SETTING

Case report.

PATIENT SAMPLE

A 27-year-old man.

OUTCOME MEASURES

Resolution of the patient's paraplegia, and pathological examination of the epidural vein of the patient and three other patients with cervical spondylosis.

METHODS

Not applicable.

RESULTS

The patient recovered from paresis of both hands, although paraplegia remains complete. Pathological examination of the patient revealed abnormal veins that had thickened walls, varying caliber, and internal elastic lamina. In two of the three patients with cervical spondylosis, abnormally dilated veins resembling those in the SEH patient were observed.

CONCLUSIONS

We describe a rare case of SEH caused by extradural varices. It is speculated that spinal epidural veins can possibly develop an abnormal structure and fragility as seen in the present case and in spondylotic cases.

Cervical epidural haematoma with clivus fracture: case report

Clivus fractures are rare and severe entities, usually associated with vascular or cranial nerve lesions and frequently diagnosed postmortem. Cervical epidural haematomas can be traumatic or spontaneous, manifested in acute or chronic form, and are treated surgically in the majority of cases, although the conservative treatment also can be indicated to patients with incomplete and non-progressive deficits. The authors report the case of a female patient, 8 years old, victim of trampling in public way by a high velocity motorized vehicle, admitted in Glasgow 7, anisocoric pupils (left pupil midriatic), whose radiological investigation showed a transverse fracture of the clivus, cervical epidural haematoma and diffuse axonal injury. The patient was submitted to intracranial pressure monitorization, sedation and conservative treatment with dexamethasone, with good outcome. The authors also present a literature review.

Angiographically occult epidural arteriovenous fistula of the craniocervical junction

BACKGROUND

Spinal dural and intradural arteriovenous fistulas (AVFs) have been the subject of numerous reports but purely epidural AVFs causing venous congestion within the spinal cord are rare.

CASE DESCRIPTION

We describe a patient with an exclusively epidural arteriovenous fistula and congestive myelopathy. There are three interesting features of this case as described below: 1) The presence of a purely epidural AVF of the cranio-cervical junction. According to our knowledge this is the first case of an AVF in this location. 2) The lesion was angiographically occult. This was probably because of the extremely slow flow of the fistula. 3) Despite the negative angiograms, exploratory surgery was conducted because of positive clinical and MR findings.

CONCLUSIONS

Epidural AVF/AVM of the foramen magnum should be considered in the differential diagnosis in patients with chronic myelopathy, even if cranial and spinal angiograms are negative. In these cases, we recommend that if clinical and radiological investigations strongly suggest the presence of an arteriovenous fistula, surgical exploration should be performed.

Spontaneous vertex extradural hematoma: considerations about causes. Case report and review of the literature

A 36-year-old woman with an uneventful medical history was admitted to the emergency department following an initial generalized seizure. Neuroimaging workup disclosed a homogeneous mass at the vertex, which first was diagnosed as vertex meningioma. Anticonvulsant drug therapy was administered and the patient was discharged. Two months later the patient was examined in our neurosurgery department for additional therapeutic recommendations. A repeated neuroimaging examination showed considerable regression of the lesion. The findings on magnetic resonance imaging were consistent with those of a regressing extradural hematoma (EDH). A complete blood-coagulation study displayed no evidence of abnormality. Thorough questioning of the patient revealed no history of pericranial infection or head trauma occurring within the last 2 years. The final diagnosis was spontaneously occurring vertex EDH. In this report the authors describe the clinical and neuroimaging features of the case as well as the management strategy, and discuss etiological aspects within the context of a careful review of the literature.

Acute cervical epidural hematoma: case report

A 74 year-old patient with a nocturnal onset of neck and chest pain was brought to an emergency clinic. Physical examination and cardiac assessment were normal. Three hours after the addmittance, a flaccid paralysis of the four limbs supervened. Suspecting of an unusual onset of central nervous system infection, a lumbar puncture was performed, yielding 20 ml of normal cerebrospinal fluid. Thirty oinutes after the puncture, the patient completely regained neurological funcion. He was then referred to a General Hospital where a computed tomography (CT) scan was done showing a large cervical epidural bleeding in the posterolateral region of C4/C5 extending to C7/Th1, along with a C6 vertebral body hemangioma. A magnetic resonance imaging revealed the same CT findings. A normal selective angiography of vertebral arteries, carotid arteries and thyreocervical trunk was carried out. Spontaneous spinal epidural hematoma (ASSEH) is a rare but dramatic cause of neurological impairment. In this article we report a fortunate case of complete recovery after an unusual spine cord decompression. We also review the current literature concerning diagnosis and treatment of ASSEH.

[Spontaneous extradural spinal hematoma. Case report]

We report a case of a 55-year-old woman, that has a mild hypertension, in use of a betablocker drugs, who had a sudden spinal cord compression syndrome with intense cervical pain, tetraplegia and sensitivity level in C4. Extradural spinal hematoma of the cervical spine was diagnosed by magnetic resonance. The patient underwent a laminectomy and aspiration of the hematoma. The patient is on physiotherapy and presents progressive motor and sensitivity improvement.

Spontaneous spinal epidural hematoma associated with thrombolysis and anticoagulation therapy: report of three cases

Three patients with a spontaneous spinal epidural hematoma are presented, one of which is exceptional because it could be attributed to thrombolysis with alteplase. The other two were correlated with oral anticoagulant therapy. Our second case suggests that Morbus Kahler may be an underlying pathology in spinal extradural hematoma. In the third patient neither an obvious 'locus minoris resistentiae' nor a pathological coagulation test could be held responsible for the spontaneous bleeding. All three patients underwent laminectomy and evacuation of the hematoma. Although two of our cases are examples of complete recuperation after late operative intervention, early surgery is preferable. Permanent clinical attention together with a low threshold to perform magnetic resonance imaging (MRI) leads to a quicker diagnosis of spinal epidural hematoma. We show that administration of gadolinium may facilitate correct preoperative localization of the hematoma because there may be contrast enhancement of the hematoma. Finally, the postoperative policy concerning thromboembolic prophylaxis is discussed.

Spontaneous spinal epidural hematoma with spinal cord compression complicating plasma cell myeloma. A case report

STUDY DESIGN

A case is reported in which a patient had acute paraplegia with sensory loss caused by a spontaneous epidural hematoma that was ascribed to bleeding of pre-existing myeloma lesions of the thoracic vertebrae.

OBJECTIVES

To highlight the causes of secondary epidural hematomas with special attention to pre-existing vertebral or epidural lesions.

SUMMARY OF BACKGROUND DATA

There are no apparent previous reports of epidural spinal hematomas ascribed to underlying malignant diseases. Benign dysplasia, such as hemangioma or Paget's disease, has been implicated in a few cases.

METHODS

A case of spontaneous dorsal epidural hematoma is reported in a patient followed up for plasma cell myeloma with osteolytic lesions in the lower thoracic spine. There was no history of major trauma or coagulation disorders. Complete loss of motor and sensory function in both lower limbs was noted, with sphincter dysfunction. Magnetic resonance imaging of the thoracic spine showed a large posterolateral epidural hematoma responsible for spinal cord compression.

RESULTS

The patient failed to improve despite surgical decompression within 6 hours of symptom onset. He died 13 days later of refractory bacterial pneumonia. A large epidural hematoma adjacent to myelomatous lesions of the thoracic vertebrae was found at autopsy.

CONCLUSIONS

This is the first reported case of spontaneous epidural hematoma ascribed to underlying malignant disease, with confirmation of the diagnosis by postmortem examination. Possible mechanisms include tumor-related epidural inflammation and fragility of epidural venous plexuses.

Spontaneous spinal epidural hematoma in children

Spontaneous spinal epidural hematoma is rare in children. It is usually confined to the dorsal epidural space. Ventral spontaneous spinal epidural hematoma (SSEH) is rarer, with only two previous reports. The authors present three children, two with dorsal and one with ventral spinal epidural hematoma, and review the literature. No etiology of the hematoma was found in the authors' patients and there was no history of trauma. A review of 24 patients of children younger than 18 years of age reported in the literature and the authors' three patients revealed that the cervicothoracic region was the most common site of SSEH, the mode of onset was frequently subacute, and there was no male preponderance as has been reported in adults. We found that the initial symptoms were often nonspecific, leading to a delay in diagnosis, especially in younger children. Follow-up data revealed that 15 of the 27 patients recovered completely, 11 had residual neurologic deficits, and one patient died. Irritability and neck pain with restricted movements of the cervical spine in an afebrile child may be early signs of SSEH and often precede onset of neurologic deficits by several hours to days. These signs should alert the clinician to consider spinal epidural hematoma and the need for urgent magnetic resonance imaging (MRI) of the spine for early diagnosis and treatment to minimize morbidity.

Spinal epidural vascular malformation presenting in association with a spontaneously resolved acute epidural hematoma. Case report

A 16-year-old boy developed acute neck pain and severe quadriparesis after mild rotatory movement of his neck. Magnetic resonance imaging revealed a cervical epidural hematoma that resolved spontaneously within a few days. Vertebral angiography demonstrated a small vascular malformation in the upper cervical epidural space. The vascular mass on the dural surface was totally resected and confirmed to be an arteriovenous malformation. This case represents the importance of including routine angiography in designing therapeutic strategy for cases of spinal epidural hematoma with spontaneous resolution.

Nontraumatic spinal epidural hematoma: report of four cases and review of the literature

OBJECTIVE AND IMPORTANCE

Spontaneous spinal epidural hematoma is a rare entity. We report four cases of nontraumatic spinal epidural hematomas observed from 1990 to 1994.

CLINICAL PRESENTATION

In two cases, the causes were determined to be an acquired coagulopathy and a vascular malformation; in the other two cases, no causes were detected. We reviewed 85 cases in the literature, with particular emphasis on the various causes detected (coagulopathy, vascular malformations, tumor) and the diagnostic methods used.

INTERVENTION

All the patients were investigated by computed tomography and magnetic resonance imaging and underwent surgery.

CONCLUSION

We considered the expression "nontraumatic epidural hematoma" to be less ambiguous than "spontaneous spinal epidural hematoma," which is the one that is usually used in the literature and corresponds to various definitions. In the absence of any signs suggestive of vascular malformation on magnetic resonance imaging, preoperative angiography is not essential and need not delay the surgical procedure, because the timing of the surgery, together with the preoperative clinical state, determines the quality of the clinical result.

Increasing irritability with sudden onset of flaccid weakness

Spontaneous spinal epidural hematoma (SSEH), is a rare and potentially fatal condition that responds favorably to early surgical intervention and should be considered in the differential diagnosis of spinal cord compression. There are few reported cases in children. We present a case of spontaneous spinal epidural hematoma in an 18-month-old child and review the literature.