Spinal epidural hematomas: personal experience and literature review of more than 1000 cases

Spontaneous Spinal Hematoma in Patients Using Antiplatelets and Anticoagulants: A Systematic Review

BACKGROUND

Spontaneous spinal hematoma (SSH) is a debilitating complication in patients taking either antiplatelet (AP) or anticoagulation (AC) medications. SSH is rare and, therefore, a systematic review is warranted to re-examine and outline trends, clinical characteristics, and outcomes associated with SSH formation.

METHODS

PubMed, EMBASE, Scopus, and Web-of-Science were searched. Studies reporting clinical data of patients with SSH using AC medications were included. In addition, clinical studies meeting our a priori inclusion criteria limited to SSH were further defined in quality through risk bias assessment.

RESULTS

We included 10 studies with 259 patients' pooled data post-screening 3083 abstracts. Within the cohort (n = 259), the prevalence of idiopathic, nontraumatic SSH with concomitant treatment with AC medications was greater 191 (73.75%) compared with AP treatment (27%). The lumbar spine was the most common site of hematoma (41.70%), followed by the cervical (22.01%) and thoracic (8.49%) spine. Most patients had surgical intervention (70.27%), and 29.73% had conservative management. The pooled data suggest that immediate diagnosis and intervention are the best prognostic factors in clinical outcomes. American Spinal Injury Association grading at initial symptom onset and post-treatment showed the greatest efficacy in symptomatic relief (87.64%) and return of motor and sensory symptoms (39.19%).

CONCLUSIONS

Our review suggested that AC medications were related to SSH in most patients (74%), followed by APs (27%) and combined ACs + APs (1.9%). We recommend prompt intervention, a high suspicion for patients with neurologic deficits and diagnostic imaging before intervention to determine a case-specific treatment plan.

Imaging review of the atypical spinal epidural space pathologies

Pathologies affecting the spinal epidural space (SES) comprise various abnormalities. However, they all have the potential to cause thecal sac narrowing or spinal cord compression. In this review, we group these pathologies into degenerative, infective, neoplastic, vascular, traumatic, and others, focusing on their imaging features. Degenerative pathologies of the SES range from disc to facet disease, with a particular emphasis on the less common degenerative pathologies in this review. Infective pathologies affecting the epidural space include spondylodiscitis and associated epidural phlegmon and abscess. Neoplasms arising from typical SES components include neurofibroma, hemangioma, and liposarcoma. MRI is the best modality to assess the anatomy and abnormalities of the epidural space. MRI, combined with computed tomography, or a radiograph, is useful for the evaluation of bones or radiopaque foreign bodies.

Post-Operative Spinal Epidural Hematoma: Are We Discontinuing Aspirin Early Enough?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

(1) To compare the risk of Spinal Epidural Hematoma (SEH) associated with specific pre-operative and post-operative anticoagulation (AC) and antiplatelet medications (APM). (2) To define the incidence of SEH and identify risk factors for SEH in our population.

METHODS

Thoracolumbar surgeries between October 2009 and March 2020 were collected. Patients who underwent incision and drainage of a symptomatic SEH were identified. AC and APM was recorded 14 days pre-operatively and post-operatively. Demographics and intra-operative factors were recorded. Relative risk with 95% confidence interval was used, with Bonferroni-corrected P-values <.05 used for significance.

RESULTS

9307 surgeries were identified. 177 (1.9%) patients returned to the OR within 30 days, 37 of whom (.39%) returned due to SEH. Seven patients were on either AC or APM pre-op, and sixteen post-op. Five were on aspirin pre-operatively (RR 3.2, 95% CI 1.25-8.22, P = .015). Risk was not increased in patients on multiple agents. No AC or APM demonstrated increased risk of hematoma post-operatively, despite trends toward significance with multiple agents. The use of a drain and complicated hypertension were associated with increased risk of SEH.

CONCLUSIONS

Pre-operative aspirin is associated with increased risk of SEH, even when appropriately discontinued. Appropriately dosed post-operative anticoagulation does not increase the risk of SEH, though being on multiple agents trends toward statistical significance and should be better studied. Surgeons should be vigilant and carefully monitor patients on pre-operative antiplatelet medications for spinal epidural hematoma.

Prognosis and outcome of chronic pain after spontaneous spinal epidural hematoma

OBJECTIVE

Chronic pain is a common symptom experienced by patients after spontaneous epidural hematoma (SSEH), and it seriously affects their quality of life. The outcome and prognosis of chronic pain after SSEH are rarely reported. Thus, we conduct this study to present the outcomes and explore prognostic factors of chronic pain in patients with SSEH.

METHODS

We retrospectively reviewed patients diagnosed with SSEH and invited them to complete the American Spinal Injury Association (ASIA) and Neuropathic Pain Symptom Inventory (NPSI) scales. Pearson χ2 and binary logistic regression were used to explore prognostic factors related to chronic pain after SSEH.

RESULTS

A total of 55 patients were reviewed; 21 patients (38.2%) were lost to follow-up, 3 patients (5.4%) died, and 31 patients (56.4%) completed the scales, with a mean follow-up time of 20.6 ± 17.3 months. The ASIA and NPSI results showed significant improvement after surgery. Pearson χ2 showed that timely surgery (≤ 12 h) was related to better outcomes (p < 0.05, Fisher test), and binary logistic regression revealed that patients with a preoperative NPSI score of 11-20 were prone to achieving significant pain relief (OR 23.67, 95%CI 1.11-503.48, p = 0.04).

CONCLUSION

Chronic pain is a common symptom during follow-up after SSEH, and timely intervention is suggested to obtain satisfactory outcomes. Patients who receive emergent surgery within 12 h or who have a preoperative NPSI score of 11-20 may achieve significant relief of chronic pain.

MRI and clinical findings in 133 dogs with recurrent deficits following intervertebral disc extrusion surgery

BACKGROUND

Recurrence of neurological signs following surgery for intervertebral disc herniation (IVDH) is reported, yet many cases lack MRI-confirmed diagnosis. This study describes the MRI and clinical findings in dogs presenting with recurrence of neurological signs following surgical treatment of IVDH.

METHODS

Medical records of dogs that underwent decompressive surgery for IVDH followed by a subsequent MRI within 12 months were retrospectively reviewed.

RESULTS

One hundred and thirty-three dogs were identified, all of which initially presented with intervertebral disc extrusion (IVDE). Of these, 109 (81.9%) had a recurrent IVDE, and 24 (18.1%) had an alternative diagnosis that included haemorrhage (n = 10), infection (n = 4), soft tissue encroachment (n = 3), myelomalacia (n = 3) or other (n = 4). Same-site IVDE recurrence or alternative diagnoses were significantly more likely to present within 10 days postoperatively. Thirty-nine percent of dogs presenting with 'early recurrence' had an alternative diagnosis. Type of surgery, fenestration, neurological grade or IVDE site was not significantly associated with the subsequent MRI diagnosis.

LIMITATIONS

Limitations include the retrospective study design, the exclusion of conservatively managed recurrences, the variable length of follow-up and differences in the clinicians' surgical experience.

CONCLUSION

The most common cause for the recurrence of neurological signs following decompressive spinal surgery was IVDE. Just over one-third of dogs presenting with early recurrence had an alternative diagnosis.

Conservative Treatment for Spontaneous Resolution of Postoperative Symptomatic Thoracic Spinal Epidural Hematoma-A Case Report

Introduction: Postoperative epidural hematomas of the cervical and thoracic spine can pose a great risk of rapid neurological impairment and sometimes require immediate decompressive surgery. Case Report: We present the case of a young patient operated on for stabilization of a two-level thoracic vertebra fracture who developed total paralysis due to an epidural hematoma postoperatively. The course of epidural hematoma was quickly reversed with the help of a conservative technique that prevented revision surgery. The patient regained complete neurologic function very rapidly, and has been well on every follow-up to date. Conclusion: There is a role of similar maneuvers as described in this case to be employed in the management of postoperative epidural hematomas. However, prolonged watchful waiting should still be discouraged, and patients should remain ready for revision surgery if there are no early signs of rapid recovery.

Unilateral bi-portal endoscopy for unilateral L5 nerve injury due to post-traumatic epidural hematoma at T12/L1 level: A case report and literature review

INTRODUCTION AND IMPORTANCE

Spinal epidural hematoma (SEH) is an uncommon condition that can result in severe neurological problems and needs to be treated as soon as possible. The incidence of traumatic SEH is 0.5 %-1.7 %, but increases to 9 % in patients with rheumatic diseases. Surgical treatment options include open surgery and minimally invasive surgery. We reported a post-traumatic SEH at T12/L1 level combined with L5 nerve injury and treated by UBE technique. To our knowledge, there was no reported cases like this.

CASE PRESENTATION

A 38-year-old man with left leg weakness and severe back pain after fell down while cycling. Physical examination suggested left hip abduction was 2/5 strength, left dorsiflexion of hallux dorsal extension was 0/5 strength and the left ankle dorsiflexion was 2/5 strength. Magnetic resonance images (MRI) of lumbar spine showed a two-leveled hematoma extending from T12 to L1. After 1 year of surgery, the patient's symptoms had largely disappeared and he was able to perform daily activities independently.

CLINICAL DISCUSSION

An epidural hematoma at the L1 level is can cause symptoms of the L5 nerve root alone, which may be due to anatomical reasons. Complete removal of the epidural hematoma is necessary to restore the function of the nerve. We report a case of successful removal of an epidural hematoma using the UBE technique with good postoperative results.

CONCLUSIONS

The single nerve injury can occur with a thoracolumbar segmental hematoma, and UBE technology could be used to remove epidural hematoma.

Case Report and Literature Review: Lumbar Disc Extrusion Misdiagnosed as an Epidural Hematoma

Accurate differentiation between epidural hematomas and lumbar disc extrusion is essential due to the potential overlap in clinical presentations. We present a case report highlighting a significant challenge in which a massive lumbar disc extrusion was mistaken for an epidural hematoma. This is a case report of a 38-year-old male patient who developed cauda equina syndrome four days after experiencing an audible cracking in the lower back during weightlifting activity. Magnetic resonance imaging (MRI) was inconclusive, unable to distinguish between an extruded nucleus pulposus and a spinal epidural hematoma. Subsequently, an urgent operation revealed a large herniated disc at the L4-L5 level, ruling out any hematoma. The patient's post-operative follow-up showed significant improvement, with almost complete recovery of motor and sensory functions. This case emphasizes the challenges faced when distinguishing between epidural hematomas and lumbar disc herniations, particularly on MRI. The lumbar disc herniation's substantial size, cranial and caudal migration on multiple levels, and signal intensity contributed to the misdiagnosis, underscoring the importance of careful interpretation and awareness of such complexities.

Delayed Diagnosis of Cervical Epidural Hematoma in a 3-Year-Old Boy: A Case Report

CASE

A 3-year-old boy presented to the emergency department with torticollis after a fall. With normal cervical radiographs and neurologic exam, he was diagnosed with cervical strain and discharged. After 2-week progressive symptoms, he was referred to a pediatric spine surgeon. Magnetic resonance imaging (MRI) revealed a cervical epidural hematoma, which was then surgically evacuated. He recovered fully and remains symptom-free 2 years later.

CONCLUSION

Pediatric spinal epidural hematoma is a rare condition with potentially serious outcomes yet often nonspecific symptoms. Timely management based on a comprehensive evaluation of symptoms and imaging findings is crucial in improving patient outcomes.

Insidious onset of spontaneous spinal epidural hematoma in immune thrombocytopenic purpura: a case-based review

INTRODUCTION

Spontaneous spinal epidural hematoma (SSEH) can result from various etiologies with a variable degree of neurological deficits. Here, we describe a rare case of SEH secondary to immune thrombocytopenic purpura (ITP) in a child and review the literature of SSEH caused by ITP.

CASE REPORT

A 9-year-old female who presented with rapid neurological decline, including bowel and bladder incontinence and paraparesis. A SSEH was observed extending from C2 to T6, causing a mass effect on the spinal cord. Her platelet count was only 7000/µL. Multidisciplinary care was established with neurosurgery, pediatric hematology, and pediatric surgery. The patient was managed emergently with splenectomy and surgical evacuation, with multilevel laminectomy and laminoplasty for evacuation of the hematoma. After a short course of rehabilitation, the patient regained all neurological function.

CONCLUSION

We report the first case of cervicothoracic SSEH secondary to ITP in a child managed with emergent splenectomy and surgical evacuation with multilevel lamoplasty. We also described the methods of timely diagnosis, urgent management, and overall prognosis of patients with this condition.

Traumatic Spinal Epidural Hematoma With Significant Neurologic Findings: A Case Report

Traumatic spinal epidural hematoma (TSEH) is a rare neurosurgical emergency. Our case report centers around a young 34-year-old female brought into our emergency department after a front and rear motor vehicle collision. Clinical deterioration and imaging studies revealed a large spinal epidural hematoma extending from levels C5 to T2. The patient was subsequently transferred to a different hospital for further management. This case involved a multidisciplinary approach by the combined effort of emergency medicine physicians, neurosurgeons, orthopedic trauma surgeons, general surgeons, radiologists, intensive care specialists, anesthesiologists, paramedics and nurses.

Health-Related Quality of Life and Functional Status Following Intensive Neurorehabilitation in a Patient after Severe Head Injury with Spinal Epidural Hematoma: A Case Report

Spinal epidural hematoma (SEH) is a very rare condition associated with trauma or occurring as a complication of lumbar puncture and can appear spontaneously. It manifests with acute pain and neurological deficits, leading to severe and permanent complications. This study aimed to assess changes in health-related quality of life and functional status following long-term intensive neurorehabilitation in a patient after severe sport-related head injury with a related SEH. The 60-year-old male patient experienced bilateral weakness of lower limbs, loss of sensation, and sphincter dysfunction. A laminectomy was performed, followed by a slight superficial and deep sensation improvement. The patient underwent intensive neurological rehabilitation treatment. The proprioceptive neuromuscular facilitation (PNF) method, PRAGMA device exercises, and water rehabilitation were provided. The study outcomes were assessed using the validated questionaries World Health Organization Quality-of-Life Scale (WHOQOL-BREF) and Health-Related Quality of Life (HRQOL-14) for health-related quality of life as well as the Functional Independence Measure (FIM) and Health Assessment Questionnaire (HAQ) for functional status. A beneficial clinical improvement was observed following the intensive rehabilitation using PNF techniques, training with a PRAGMA device, and water exercises in the case of SEH. The patient's physical condition significantly improved, with an increase in the FIM score from 66 to 122 pts. (by 56 pts.) and in the HAQ score from 43 to 16 pts. (by 27 pts.). Additionally, the QOL level increased after rehabilitation, with an increase in the WHOQOL-BREF from 37 to 74 pts. (by 37 pts.) and a decrease in unhealthy or limited days, as assessed using the HRQOL-14, from 210 to 168 (by 42 days). In conclusion, the improvement in QOL and functional level in the SEH patient were associated with high-intensity rehabilitation, simultaneous integration of three therapeutic modalities, and committed patient cooperation.

Ultraearly Hematoma Evacuation (<12 Hours) Associated with Better Functional Outcome in Patients with Symptomatic Spontaneous Spinal Epidural Hematoma

BACKGROUND

Early decompressive surgery within 24 hours improves the functional outcome of patients with traumatic spinal cord injury; however, little is known about the effect of early surgery for spontaneous spinal epidural hematoma (SSEH). In this study, we aimed to investigate the effectiveness of ultraearly hematoma evacuation (<12 hours) for SSEH.

METHODS

Patients with SSEH treated with surgical hematoma evacuation at our institution between January 2000 and July 2021 were retrospectively analyzed. Neurologic function was evaluated using the American Spinal Injury Association Impairment Scale (AIS). AIS grades A-C were defined as severe, and grades D and E as mild. AIS grades D and E at the final follow-up were considered favorable outcomes. Preoperative status and postoperative treatment results were compared between patients who had hematoma evacuation within 12 hours of onset and those who underwent surgery after 12 hours.

RESULTS

Twenty-five consecutive patients were included in the analysis. Preoperatively, 23 patients (92.0%) had severe AIS. Fourteen (56.0%) patients underwent early surgery. At the final follow-up, 21 patients (84.0%) achieved favorable outcomes. Patients treated with ultraearly surgery had significantly better outcomes (100% vs. 63.6%, P = 0.03). Additionally, the time from onset to surgery was significantly shorter in patients with AIS improvement by 2 or more grades than that in patients with AIS improvement of 1 or less (median 8 hours vs. 14 hours, P = 0.0001).

CONCLUSIONS

Ultraearly surgery within 12 hours for SSEH was associated with better functional outcomes.

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.

Spontaneous Cervical Epidural Hematoma Following COVID-19 Illness Presenting to a Chiropractor: A Case Report

Cervical epidural hematoma (CEH) is a rare and potentially fatal condition in which blood accumulates in the epidural space of the cervical spine. A 64-year-old man presented to a chiropractor with a two-week history of sudden-onset neck pain, shoulder pain, occipital headache, and numbness in the shoulders and upper extremities. He had recovered from a mild course of coronavirus disease 2019 (COVID-19) illness one month prior. The patient's primary care provider had previously prescribed a nonsteroidal anti-inflammatory drug for his neck pain. However, his symptoms worsened, and he visited the emergency department where he had unremarkable cervical spine radiographs and was discharged with a diagnosis of neck strain. The chiropractor ordered cervical spine magnetic resonance imaging (MRI), revealing a ventral CEH extending from C2 to C5. The chiropractor referred the patient to a nearby hospital for urgent management. The patient was admitted and observed, progressively improved, and did not require surgery. After 10 weeks in the hospital the patient was asymptomatic, a follow-up MRI revealed resolution of the CEH, and the patient was discharged. While the current case highlights a temporal relationship between COVID-19 and CEH, further research is needed to determine if COVID-19 is a risk factor for this condition. Clinicians who encounter patients with spinal disorders must be able to recognize the clinical features of CEH and refer these patients for emergency care and/or neurosurgical evaluation.

Neck pain and absence of cranial nerve symptom are clues of cervical myelopathy mimicking stroke: Two case reports

BACKGROUND

Cervical myelopathy is a potential stroke imitator, for which intravenous thrombolysis would be catastrophic.

CASE SUMMARY

We herein present two cases of cervical myelopathy. The first patient presented with acute onset of right hemiparesis and urinary incontinence, and the second patient presented with sudden-onset right leg monoplegia. The initial diagnoses for both of them were ischemic stroke. However, both of them lacked cranial nerve symptom and suffered neck pain at the beginning of onset. Their cervical spinal cord lesions were finally confirmed by cervical computed tomography. A literature review showed that neck pain and absence of cranial nerve symptom are clues of cervical myelopathy.

CONCLUSION

The current report and the review remind us to pay more attention to these two clues in suspected stroke patients, especially those within the thrombolytic time window.

Nonsteroidal anti-inflammatory drugs (NSAID) do not increase blood loss or the incidence of postoperative epidural hematomas when using minimally invasive fusion techniques in the degenerative lumbar spine

Objective

Nonsteroidal anti-inflammatory drugs (NSAID) are essential in surgeons' armamentarium for pain relief and antiphlogistic effects. However, spine surgeons are concerned about the drugs' impact on coagulation, fearing hemodynamic instability due to blood loss and neurological complications due to postoperative hematoma. Furthermore, there are no clear guidelines for the use of these drugs.

Materials and methods

In this retrospective subgroup analysis of a prospective observational study, we investigated 181 patients who underwent minimally invasive spinal fusions in degenerative lumbar spine pathologies. 83 patients were given NSAID perioperatively, 54 of which were female and 29 male. Of these patients who took NSAID, 39 were on NSAID until at least one day before surgery or perioperatively, whilst the others discontinued their NSAID medication at least three days before surgery. Differences in perioperative blood loss, as well as complication rates between patients with and without NSAID treatment, were investigated.

Results

A significantly higher amount of blood loss during surgery and the monitoring period was encountered in patients whose spine was fused in more than one level, regardless of whether NSAID medication was taken or not and up until what point. Furthermore, it was found that taking NSAID medication had no effect on the incidence of postoperative epidural hematomas.

Conclusion

Perioperatively taking NSAID medication does not increase blood loss or the incidence of postoperative hematoma in patients undergoing minimally invasive lumbar spinal fusion surgery.

Prognostic Factors and Treatments Efficacy in Spontaneous Spinal Epidural Hematoma: A Multicenter Retrospective Study

Background and Objectives

Spontaneous spinal epidural hematoma (SSEH) is an uncommon but serious condition with a high morbidity rate. Although SSEH is related to numerous risk factors, its etiology remains unclear. There is a paucity of data on its prognostic factors. We aim to evaluate prognostic factors for SSEH in this study.

Method

A retrospective study was performed on patients who were admitted for SSEH in 3 academic neurosurgical centers from January 2010 to June 2021. Clinical parameters, including clinical condition on admission, anticoagulants use, imaging modality, the timing and type of surgery performed, and outcomes, were collected. Prognostic factors were analyzed. The Frankel scale was used to assess the clinical condition.

Results

A total of 105 patients with SSEH were retrieved from medical records, with a mean age of 51.3 years. Eighty-three patients (79%) complained of acute onset of severe neck or back pain. Eighty-two patients (78%) suffered from moderate to severe neurologic deficits (Frankel scale A–C). Anticoagulation usage was found in 20% of cases. Lower thoracic spine (p = 0.046), use of anticoagulants (p = 0.019), sphincter function disfunction (p = 0.008), severe neurologic deficits at admission (p < 0.001), and rapid deterioration (<1 hour, p = 0.004) were found to be associated with poor outcomes. Surgical decompression was performed in 74 (70%) cases. The univariate and multivariate analysis revealed that preoperative severe neurologic deficits (p = 0.005) and extended paraplegia time (>12 hours, p = 0.004) were independent adverse prognostic factors. The univariate analysis revealed that lower thoracic spine location (p = 0.08) and rapid progression (<6 hours, p = 0.005) were correlated with poor prognosis, but the multivariate analysis failed to identify them as independent prognostic factors.

Discussion

Adverse prognostic factors for SSEH might include thoracic segment location, use of anticoagulation, severe neurologic deficits on admission, sphincter dysfunction, and rapid progression. Preoperative neurologic deficit and extended paraplegia time were strongly correlated with the prognosis in the subset of patients who underwent surgical decompression. Timely surgical decompression is recommended for patients with moderate/severe neurologic deficits or progressive neurologic deterioration.

Clinical and Microbiologic Outcomes of Central Nervous System Cryptococcosis: Re-examining the Need for a 2-Week Cerebrospinal Fluid Analysis

BACKGROUND

Cryptococcus spp. infection involving the central nervous system (CNS) is associated with poor outcomes. Current guidelines recommend repeating a cerebrospinal fluid (CSF) fungal culture after 2 weeks of treatment to evaluate for clearance. However, this practice has not clearly been associated with outcomes.

OBJECTIVES

We sought to assess the relationship between CSF fungal clearance at 2 weeks and 12-month mortality in patients with CNS cryptococcosis.

METHODS

This is a retrospective cohort study from 2011-2020 of patients with CNS cryptococcosis. Factors associated with 12-month mortality were assessed with Fisher's exact test for categorical variables and Mann-Whitney test for continuous variables.

RESULTS

Among 51 patients with CNS cryptococcosis, 42 (82.4%) were initially CSF culture positive. Among 27 patients with follow-up CSF culture at 2 weeks, 6 (22.2%) had a positive result. Factors associated with a positive CSF culture at 2 weeks were an initial CSF cryptococcal antigen titer ≥1:2560, fungemia, and an elevated intracranial pressure requiring therapeutic lumbar punctures. The 12-month mortality rate was 33.3% and this was significantly associated with baseline fungemia, extra-CNS cryptococcal involvement and requirement of intensive care unit level of care. Lack of CSF culture clearance by 2 weeks was not associated with 12-month mortality.

CONCLUSIONS

CNS cryptococcosis has a high mortality rate. A markedly elevated CSF cryptococcal antigen and opening CSF pressure was associated with lack of CSF culture clearance at 2 weeks of treatment. Severe disseminated disease and cryptococcemia were associated with 12-month mortality.

Prevalence and clinical features of thoracolumbar intervertebral disc-associated epidural hemorrhage in dogs

Background

Intervertebral disc‐associated epidural hemorrhage (EH) in dogs is a poorly understood neurological condition.

Objective

To compare the clinical presentation, magnetic resonance imaging (MRI) changes, and clinical outcome of dogs with acute thoracolumbar intervertebral disc herniation (TL‐IVDH) with and without EH.

Animals

One hundred sixty client‐owned dogs that underwent MRI and hemilaminectomy for acute TL‐IVDH at a private practice in Colorado, including 63 dogs with EH and 97 dogs without EH.

Methods

Retrospective review of medical record data from 160 dogs presenting sequentially to a single practice with acute TL‐IVDH that underwent MRI and hemilaminectomy surgery.

Results

Sixty‐three of 160 (39%) dogs had confirmed EH. French Bulldogs were significantly overrepresented (23/63; odds ratio [OR]: 4.1; 95% confidence interval [CI]: 1.8‐9.0; P < .001) of the EH cases. Dogs with EH were more likely to present with clinical signs less than 48 hours than were dogs without EH (24‐48 vs 48‐72 hours; OR: 2.4; 95% CI: 1.2‐4.6; P = .02) and were more likely to be nonambulatory on presentation (OR: 2.1; 95% CI: 1.0‐4.1; P = .04). Dogs with EH were more likely to have <50% cross‐sectional spinal cord compression than dogs without EH (OR: 2.3 vs. 0.4; 95% CI: 1.2‐4.4 and 0.2‐0.9, respectively), longer longitudinal spinal cord compression (3 spaces vs 1 space, P < .001), and greater intrinsic spinal cord change (grade 3/severe vs grade 1/mild; P < .001) based on MRI. The location of the intervertebral disc herniation in French Bulldogs with EH was more likely to be thoracolumbar (OR: 10.8; 95% CI: 2.1‐55.7; P = .03).

Conclusions and Clinical Importance

French Bulldogs have a high prevalence of intervertebral disc‐associated EH. Dogs with EH have a shorter clinical course and are more likely to be nonambulatory on initial presentation.

Extradural hemorrhagic spinal cavernous angioma in a paucisymptomatic child: A rare case with review of the current literature

Background:

Cavernous angiomas, also referred to as cavernous hemangiomas or cavernomas (CMs), are vascular malformative benign neoplasms that may develop in any part of the central nervous system. Spinal CMs are uncommon (overall incidence rate of 0.04–0.05%). Pure epidural CMs account for 1–2% of all spinal CMs and 4% of all spinal epidural tumors. Diagnosis is extremely rare in the pediatric age. To the best of our knowledge, only 10 cases have been described so far. The treatment of choice is microsurgical resection.

Case Description:

We describe here the rare case of a cervicothoracic hemorrhagic spinal epidural cavernoma in a paucisymptomatic, 8-year-old female Bangladeshi child. C7–T2 laminectomy with excision of a scarcely defined, capsulated dark red lesion was performed with good recovery.

Conclusion:

Spinal epidural cavernomas are rare. Childhood presentation is even rarer. The reason could be found in a greater “compliance” and to a rarer occurrence of acute bleeding in children, thus resulting in a delayed diagnosis. Surgical excision is the gold standard of treatment.

Risk Factors for Incidence of Postoperative Spinal Epidural Hematoma Following Multilevel Microendoscopic Laminectomy

Introduction

Due to the narrow portal of entry, microendoscopic laminectomy (MEL) is associated with a risk of postoperative spinal epidural hematoma (POSEH). This risk might be higher when performing multiple-level (m-) MEL. The purpose of this study is to clarify the incidence rate of POSEH following single-level (s-) and m-MEL by each interlaminar level and identify the risk factors for POSEH following m-MEL.

Methods

A total of 379 patients underwent MEL of the lumbar spine (s-MEL, n=141; m-MEL, n=238). We determined the incidence of POSEH following s-MEL and m-MEL by each interlaminar level. For m-MEL, we clarified the correlation between POSEH and possible risk factors, such as operative findings, the sequence of operated interlaminar levels, and the preoperative cross-sectional dural area (CSA) on magnetic resonance imaging.

Results

The incidence rate at L2/3 was significantly higher than that at L3/4 and L4/5. Patients who underwent L2/3 decompression at the end of the procedure showed a higher incidence of POSEH at the L2/3 level. Preoperative spinal stenosis was associated with POSEH at the L2/3 level, and CSA of 56 mm² was a predictive factor for POSEH. Logistic regression analysis revealed that both were significant risk factors.

Conclusions

In patients undergoing m-MEL, the incidence of POSEH is highest at the L2/3 level, and treatment of the L2/3 level at the end of the procedure and the presence of spinal stenosis are risk factors for POSEH.

Cervical epidural hematoma with Brown-Sequard syndrome caused by an epidural injection: a case report

Epidural hematoma with Brown-Sequard syndrome caused by an epidural injection is a rarely found condition in the emergency department (ED). We report an unusual case of Brown-Sequard syndrome in a 55-year-old man who presented at the ED with right-sided weakness and contralateral loss of pain and temperature sensation after a cervical epidural injection for shoulder pain. Cervicla spine magnetic resonance imaging showed an epidural hematoma from C4 to C6. After admission, his right hemiparesis and contralateral sensory loss improved within eight days, and surgical decompression was not required. Diagnosing spinal lesions in the ED is challenging, especially in patients with acute neurological signs requiring immediate evaluation for stroke. In this case, definite hemiparesis and some contralateral sensory loss were noted. Therefore, a potential spinal lesion was suspected rather than a stroke. This case emphasized the importance of conducting a focused neurological examination after history taking.

Spinal hematoma after total knee arthroplasty: a case report

Spinal anesthesia is a common procedure performed in orthopedic surgery, and it is regarded as secure and safe. Although puncture-related complication of spinal anesthesia has a very low incidence, it would lead to dramatic neurological damage (tetra- or paraplegia). Early diagnosis and surgical decompression are mandatory to promote a better outcome. We present a case of acute spinal hematoma from T11 to L3, triggered by laborious anesthesia puncture after total knee arthroplasty. A prompt surgical decompression within few hours after diagnosis allowed rapid functional recovery and avoided permanent paraplegia.

Spinal epidural hematoma after spinal manipulation therapy: Report of three cases and a literature review

BACKGROUND

Spinal manipulation therapy (SMT) has been widely used worldwide to treat musculoskeletal diseases, but it can cause serious adverse events. Spinal epidural hematoma (SEH) caused by SMT is a rare emergency that can cause neurological dysfunction. We herein report three cases of SEH after SMT.

CASE SUMMARY

The first case was a 30-year-old woman who experienced neck pain and numbness in both upper limbs immediately after SMT. Her symptoms persisted after 3 d of conservative treatment, and she was admitted to our hospital. Magnetic resonance imaging (MRI) demonstrated an SEH, extending from C6 to C7. The second case was a 55-year-old man with sudden back pain 1 d after SMT, numbness in both lower limbs, an inability to stand or walk, and difficulty urinating. MRI revealed an SEH, extending from T1 to T3. The third case was a 28-year-old man who suddenly developed symptoms of numbness in both lower limbs 4 h after SMT. He was unable to stand or walk and experienced mild back pain. MRI revealed an SEH, extending from T1 to T2. All three patients underwent surgery after failed conservative treatment. The three cases recovered to ASIA grade E on day 5, 1 wk, and day 10 after surgery, respectively. All patients returned to normal after 3 mo of follow-up.

CONCLUSION

SEH caused by SMT is very rare, and the condition of each patient should be evaluated in full detail before operation. SEH should be diagnosed immediately and actively treated by surgery.

ACR Appropriateness Criteria® Myelopathy: 2021 Update

Myelopathy is a clinical diagnosis with localization of the neurological findings to the spinal cord, rather than the brain or the peripheral nervous system, and then to a particular segment of the spinal cord. Myelopathy can be the result of primary intrinsic disorders of the spinal cord or from secondary conditions, which result in extrinsic compression of the spinal cord. While the causes of myelopathy may be multiple, the acuity of presentation and symptom onset frame a practical approach to the differential diagnosis. Imaging plays a crucial role in the evaluation of myelopathy with MRI the preferred modality. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Therapeutic strategy for acute spinal cord paralysis by epidural hematoma derived from the application of non-operative observation and the optimal timing to convert to surgical intervention

Some cases of acute spinal cord paralysis by epidural hematoma have made complete recovery through natural progression. This group cannot be ignored in choosing a therapy. We have considered the applications of non-operative observation and the optimal timing to convert to surgical intervention. Of the 454 cases reported, cases that were of trauma/post-operative, undergone epidural block, lumbosacral level, paralysis-free, were excluded. 10 clinical items were identified as factors related to the outcome of therapy, and a total of 142 cases (73 surgical and 69 non-surgical/observation cases) which included all items in its record, were extracted for this study. 104 cases that made complete recovery from spinal paralysis (CR) includes 65 cases without surgical intervention (NOP-CR). Using "paralysis recovery start time (PRST)", ROC analysis was conducted to show the diagnostic time needed to detect the cases of CR and NOP-CR. Clinical characteristics of CR and NOP-CR were identified using multiple logistics regression analysis. CR probability were higher at PRST < 15 h from the onset and NOP-CR was even higher at < 11 h. Three clinical items: incomplete motor paralysis, no use of anti-coagulant therapy, and PRST within 15 h were found to be the characteristics of CR and NOP-CR. The case with all 3 items; especially PRST within 11 h from onset, is applicable to non-operative observation. Immediate surgical intervention at 6-hours is recommended in cases that presented with unchanged complete motor paralysis. Observation treatment is discontinued and converted to surgery if motor usefulness is not regained at 15-hours.

Dural tear from diagnostic lumbar puncture followed by long-term morbidity: a case report

Background

Lumbar punctures are performed in different medical settings and are a key procedure in the diagnosis of several neurological conditions. Complications are rare and generally self-limiting. There are no reports of symptomatic accumulation of fluid in the epidural space after lumbar puncture in adults and there are no studies on long-term outcome after post dural puncture headache (PDPH).

Case

A lumbar puncture was performed in a 29 y.o. slender woman with unspecific symptoms to rule out neuro-infection. Next day MRI showed substantial accumulation of CSF in the epidural space from C2 to the sacrum dislocating the spinal chord in the spinal canal. The condition was ameliorated by epidural blood-patching. At 5 months she was still impaired by severe orthostatic headache.

Conclusions

The only plausible explanation for the massive CSF leak was a dural tear occurring during multiple attempts of lumbar puncture. Anterior dislocation of the spinal chord due to CSF leak is not a recognised complication to lumbar puncture. This complication was followed by long-term disability in our case. The diagnosis can be made by MRI. A difficult procedure with several attempts and use of traumatic technique may increase risk of this complication.

Spinal Epidural Hematoma After Percutaneous Kyphoplasty: Case Report and Literature Review

Objective

To present the case of a patient on long-term anticoagulants who developed acute spinal epidural hematoma (SEH) after percutaneous kyphoplasty (PKP) without signs of major cement extravasation to the spinal canal.

Methods

A 64-year-old woman with long-term oral antiplatelet drugs underwent the L1 PKP. Immediately after the operation, the back pain improved significantly without neurological deficit. However, 12 hours later, she developed progressive weakness of the bilateral lower limbs. No intraspinal cement leakage was obvious on the postoperative lumbar radiograph and computed tomography.

Results

An emergency MRI examination revealed a high signal aggregation in front of the spinal cord from T12 to L1, indicating spinal cord compression. The SEH was verified and removed during the laminectomy from T12-L1. Following the decompression surgery, the neurological deficit of the lower limbs improved. On follow-up after 6 months, the muscle strength of the bilateral lower limbs had returned to normal.

Conclusion

For the patient with long-term oral antiplatelet drugs or coagulation malfunction, the transpedicle approach or that via the costovertebral joint with a smaller abduction angle is recommended to reduce the risk of injury to the inner wall of the pedicle. For progressive aggravation of neurological dysfunction after surgery, SEH formation should be suspected despite the absence of intraspinal bone cement leakage. Secondary emergency decompression should be considered to avoid permanent damage to spinal cord nerve function caused by continuous compression.

Traumatic lumbar disc extrusion mimicking spinal epidural hematoma: Case report and literature review

Background

Because the neurological presentation of spinal epidural hematomas (SEH) is often not specific, they may be misdiagnosed as acute lumbar disk herniations. Here, we present a case in which a traumatic disc extrusion mimicked an epidural hematoma and reviewed the appropriate literature.

Case Description

A 27-year-old male sustained a high-energy fall. The lumbar MRI scan showed a L4-S1 ventral medium/high signal intensity mass on the T1- and high signal intensity lesion on T2-weighted images; the original diagnosis was spinal epidural hematoma. However, at surgery, consisting of a left L4 and L5 hemilaminectomy with L4-L5 and L5-S1 laminotomy, an extruded lumbar disc was encountered at the L4-L5 level and removed; no additional pathology or SEH was found at either level.

Conclusion

On MR, SEH may mimic acute lumbar disk herniations. Depending on the clinical symptoms/signs, surgical intervention will both correctly confirm the diagnosis and relieve neural compression.

Natural history and management of spinal cord arteriovenous shunts in pregnancy: A monocentric series of 10 consecutive cases with emphasis on endovascular treatment

PURPOSE

Intradural spinal cord arteriovenous shunts (IDSCAVS) are rare and constitute a challenging situation if symptoms occur during pregnancy. We present a series of ten such cases referred to our center: five cervical, four thoracic and one lumbar.

METHODS

We retrospectively reviewed our global series of 215 IDSCAVSs between 2002 and March 2020 and found ten patients who had presented during pregnancy. Clinical, radiological and therapeutic data were studied.

RESULTS

Seven shunts were AVM type niduses and three were micro AV-fistulae. All were associated with pial venous reflux and six hemorrhagic cases had pseudo aneurysms. Symptoms occurred mainly during the third trimester, 80% of patients presented with hemorrhage and spinal cord dysfunction. We embolized seven patients and proposed surgery in one, always after delivery: all recovered well. One woman declined treatment; one other was operated in emergency but did not improve. Mean follow-up was 3.9 years (0.5-19 years).

CONCLUSIONS

Despite this small group of patients, our initial experience of IDSCAVSs diagnosed during pregnancy indicates that embolization is an effective management strategy if performed after delivery and a recovery period. Results indicate that IDSCAVSs seem to have a low risk of early rebleedings after the ictal event and may be closely followed up until delivery. The results obtained show good clinical outcome without long-term rebleeds. Women with known IDSCAVSs should not be discouraged from becoming pregnant, however it seems wise to embolize them before pregnancy in order to offer protection against risks during pregnancy.

Cervical spine subdural hematoma: A rare radiographic abnormality in a trauma patient

Spinal subdural hematomas (SSDH) are a rare radiographic finding that can lead to significant long-term disability. Many clinicians are unfamiliar with this condition and the available treatment options. This article describes one approach to managing a patient with an SSDH.

A Case Report: An Acute Spinal Epidural Hematoma after Acupuncture Mimicking Stroke

BACKGROUND

Spinal epidural hematoma (SEH) after acupuncture is rare and may present with acute or subacute onset and varied symptoms, making it difficult to diagnose. This condition can mimic acute stroke, so it is vital to establish a clear diagnosis before considering thrombolytic therapy, which could be disastrous if applied inappropriately.

CASE REPORT

We describe a 52-year-old man who presented to our emergency department (ED) with acute onset of unilateral weakness of the limbs for 3.5 h immediately after receiving acupuncture at the bilateral neck and back. The acute stroke team was activated. In the ED, computer tomography angiography from the aortic arch to the head revealed spinal epidural hematoma. The patient was admitted to the ward for conservative treatment and was discharged with subtle residual symptoms of arm soreness 5 days later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acute spinal epidural hematoma rarely presents with unilateral weakness of the limbs, mimicking a stroke. Because inappropriate thrombolysis can lead to devastating symptoms, spinal epidural hematoma should be excluded when evaluating an acute stroke patient with a history of acupuncture who is a possible candidate for thrombolytic therapy.

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.

Lumbar Intervertebral Disc Herniation Masquerading as an Epidural Hematoma: A Case Report and Review of the Literature

CASE

A 50-year-old man developed acute back and bilateral leg pain after minor trauma. Laboratory tests and routine radiographs were unremarkable. Magnetic resonance imaging (MRI) showed a 5 × 15 × 42-mm longitudinally oriented mass behind the L2-L3 interspace that obliterated the subarachnoid space and displaced the nerve roots. The mass was isointense on T1-weighted imaging and showed mixed low and high signals on T2-weighted imaging. Based on the clinical history and the imaging findings, a provisional diagnosis of spinal epidural hematoma (SEH) was made. A laminectomy was performed at L2-L3; intraoperatively, a large disc herniation was found at L2-L3, with no evidence of hematoma.

CONCLUSION

MRI findings of SEH and disc herniation have been well described in the literature. To our knowledge, this is the third report of intraoperatively confirmed disc herniation with MRI findings suggestive of SEH These discordant MRI and intraoperative findings illustrate that an SEH and a disc herniation may not always be distinguishable on MRI and may require surgical confirmation.

Epidural Hematoma After Trans-Sacral Epiduroscopic Laser Decompression: A Case Report

Objective: In this study, we report a patient who developed lumbar epidural hematoma after trans-sacral epiduroscopic laser decompression (SELD). Background: SELD is a nonoperative minimally invasive spinal procedure, in which a herniated lumbar disk can be ablated by laser. Because of the rich epidural venous plexus, the procedure might have a risk of epidural hematoma. Materials and methods: A 57-year-old woman underwent the SELD procedure for the treatment of lower back and right buttock pain due to disk protrusion at L5-S1. One day after the procedure, complete motor weakness was observed in the right leg. Results: Lumbar magnetic resonance imaging revealed epidural hematoma at the L1-L5 levels, compressing the thecal sac. Using a posterior approach, decompressive subtotal laminectomy on L1 and total laminectomy on L2-L5 with evacuation of the hematoma were performed. Two months postoperatively, near complete resolution of the motor weakness in the right leg was observed. Conclusions: Clinicians should keep in mind the likelihood of epidural hematoma after SELD.

Spinal epidural hematoma in a patient on chronic anticoagulation therapy performing self-neck manipulation: a case report

Background

Spinal epidural hematoma is a rare condition usually secondary to trauma and coagulopathy. To the best of our knowledge, we present the first case of a patient with an iatrogenic hypercoaguable state performing self-neck manipulation, which resulted in a spinal epidural hematoma and subsequent quadriparesis.

Case presentation

A 63-year-old man presented to the emergency department with worsening interscapular pain radiating to his neck 1 day after performing self-manipulation of his cervical spine. He was found to be coagulopathic upon admission, secondary to chronic warfarin therapy for the management of atrial fibrillation. Approximately 48 h after the manipulation, the patient became acutely quadriparetic and hypotensive. Urgent magnetic resonance imaging revealed a multilevel spinal epidural hematoma from the lower cervical to thoracic spine.

Conclusions

Partial C7, complete T1 and T2, and partial T3 bilateral laminectomy was performed for evacuation of the spinal epidural hematoma. Following a 2-week course of acute inpatient rehabilitation, the patient returned to his baseline functional status. This case highlights the risks of self-manipulation of the neck and potentially other activities that significantly stretch or apply torque to the cervical spine. It also presents a clinical scenario in which practitioners of spinal manipulation therapy should be aware of patients undergoing anticoagulation therapy.

Risk of brain herniation after craniotomy with lumbar spinal drainage: a propensity score analysis

OBJECTIVE

Lumbar spinal drainage (LSD) during neurosurgery can have an important effect by facilitating a smooth procedure when needed. However, LSD is quite invasive, and the pathology of brain herniation associated with LSD has become known recently. The objective of this study was to determine the risk of postoperative brain herniation after craniotomy with LSD in neurosurgery overall.

METHODS

Included were 239 patients who underwent craniotomy with LSD for various types of neurological diseases between January 2007 and December 2016. The authors performed propensity score matching to establish a proper control group taken from among 1424 patients who underwent craniotomy and met the inclusion criteria during the same period. The incidences of postoperative brain herniation between the patients who underwent craniotomy with LSD (group A, n = 239) and the matched patients who underwent craniotomy without LSD (group B, n = 239) were compared.

RESULTS

Brain herniation was observed in 24 patients in group A and 8 patients in group B (OR 3.21, 95% CI 1.36-8.46, p = 0.005), but the rate of favorable outcomes was higher in group A (OR 1.79, 95% CI 1.18-2.76, p = 0.005). Of the 24 patients, 18 had uncal herniation, 5 had central herniation, and 1 had uncal and subfalcine herniation; 8 patients with other than subarachnoid hemorrhage were included. Significant differences in the rates of deep approach (OR 5.12, 95% CI 1.8-14.5, p = 0.002) and temporal craniotomy (OR 10.2, 95% CI 2.3-44.8, p = 0.002) were found between the 2 subgroups (those with and those without herniation) in group A. In 5 patients, brain herniation proceeded even after external decompression (ED). Cox regression analysis revealed that the risk of brain herniation related to LSD increased with ED (hazard ratio 3.326, 95% CI 1.491-7.422, p < 0.001). Among all 1424 patients, ED resulted in progression or deterioration of brain herniation more frequently in those who underwent LSD than it did in those who did not undergo LSD (OR 9.127, 95% CI 1.82-62.1, p = 0.004).

CONCLUSIONS

Brain herniation downward to the tentorial hiatus is more likely to occur after craniotomy with LSD than after craniotomy without LSD. Using a deep approach and craniotomy involving the temporal areas are risk factors for brain herniation related to LSD. Additional ED would aggravate brain herniation after LSD. The risk of brain herniation after placement of a lumbar spinal drain during neurosurgery must be considered even when LSD is essential.

Cervicothoracic epidural hematoma in a toddler with miosis, ptosis, nonspecific symptoms, and no history of major trauma: case report

INTRODUCTION

Spinal epidural hematomas are uncommon in children. The diagnosis can be elusive as most cases present without a history of trauma, while symptoms can be atypical.

CASE REPORT

We encountered a 35-month-old male presenting with nonspecific symptoms and no history of trauma. He later developed unilateral miosis and ptosis; MRI discovered a subacute cervicothoracic epidural which was promptly evacuated. The patient made an excellent recovery.

COCLUSIONS

We emphasize the frequent absence of identifiable trauma and the importance of thorough imaging when this entity is suspected. Miosis and ptosis, likely representing a partial Horner syndrome, is an extremely rare presentation, this being one of the only reported cases.