Distinguishing true from pseudo hematoma in the cervical spinal canal using postmortem computed tomography

Spinal cord injury is difficult to detect directly on postmortem computed tomography (PMCT) and it is usually diagnosed by indirect findings such as a hematoma in the spinal canal. However, we have encountered cases where the hematoma-like high-attenuation area in the cervical spinal canal was visible on PMCT, while no hematoma was observed at autopsy; we called it a "pseudo hematoma in the cervical spinal canal (pseudo-HCSC)." In this retrospective study, we performed statistical analysis to distinguish true from pseudo-HCSC. The cervical spinal canal was dissected in 35 autopsy cases with a hematoma-like high-attenuation area (CT values 60-100 Hounsfield Unit (HU)) in the spinal canal from the first to the fourth cervical vertebrae in axial slices of PMCT images. Of these 22 had a hematoma and 13 did not (pseudo-HCSC). The location and length of the hematoma-like high-attenuation and spinal cord areas were assessed on reconstructed PMCT images, true HCSC cases had longer the posterior hematoma-like area and shorter the spinal cord area in the midline of the spinal canal (P < 0.05). Furthermore, we found that true HCSC cases were more likely to have fractures and gases on PMCT while pseudo-HCSC cases were more likely to have significant facial congestion (P < 0.05). We suggest that pseudo-HCSC on PMCT is related to congestion of the internal vertebral venous plexus. This study raises awareness about the importance of distinguishing true HCSC from pseudo-HCSC in PMCT diagnosis, and it also presents methods for differentiation between these two groups.

Clinical Features, Management, and Prognostic Factors of Spontaneous Epidural Spinal Hematoma: Analysis of 24 Cases

BACKGROUND

Spontaneous spinal epidural hematoma (SSEH) is a rare neurosurgical emergency. It presents as acute spinal cord compression and usually requires surgical decompression. The patients who will benefit most from decompression surgery are unknown, and the factors associated with prognosis remain controversial. The purpose of our study was to identify the clinical features, treatments, and main factors related to the prognosis of SSEH.

METHODS

We reviewed the records of 24 patients treated for SSEH from September 2010 to January 2016 at West China Hospital. Clinical features, radiologic images, treatment methods, and clinical outcomes were reviewed retrospectively. To ascertain which factors were related to outcomes, statistical analysis was performed.

RESULTS

Among 24 patients, 19 presented with severe initial neurologic deficits (American Spinal Injury Association grade A-C) underwent decompressive surgery, and the remaining patients (initial American Spinal Injury Association grade D or E) received conservative treatment. Among the 19 patients in the operation group, seven (36.8%) had good outcomes, whereas 12 (63.2%) had poor outcomes. All patients in the conservative group had good outcomes.

CONCLUSIONS

SSEH is a rare but serious illness. It is more likely that SSEH arises from a ruptured internal vertebral venous plexus. The initial neurologic status is the determining factor influencing the treatment method and clinical outcome. The number of involved segments cannot be used to decide the treatment method or predict prognosis. Patients with shorter operative intervals appear to have better neurologic recovery.

The Transdural Course of Radicular Spinal Cord Veins--A Microangiographical and Microscopical Study

PURPOSE

This study focuses on the following questions: What are the morphological features at the transdural course of radiculomedullary veins? How are these short transdural segments that may harbour pathological arteriovenous shunts connected to the internal vertebral venous plexus? Is the conception of a reflux-impeding mechanism at the transdural segment indispensable and convincing?

METHODS

A total of 102 radiculospinal veins were studied microscopically at various levels of the spinal canal using serial paraffin and semi-thin sections. In addition, 26 vessels were investigated microangiographically following orthograde (12) or attempted retrograde (14) opacification of the intradural venous segment with barium sulphate. After paraplast-embedding, contact-microradiographs were taken using high-resolution spectroscopic plates.

RESULTS

At their transdural course, the veins showed narrowing of their lumen accompanied by changes in the vessel wall composition and a tortuous course. Two structurally distinct arrangements of the transdural segment could be identified: A slit type was seen in 60% of the veins studied and a bulge- or nodular type was seen in 35% of the veins. In total, 5% of cases could not be assigned to either one of these types. Reflux to radicular veins from the outside of the dura mater could be produced in 2 out of 14 specimens. The extradural venous plexus, which primarily receives the radicular vein, was composed more frequently of lacunar spaces rather than plexiform blood vessel convolutions. Rare observations were fibrotic, blind ending radiculomedullary veins and continuation of a distinct venous blood vessel after crossing the dura.

CONCLUSIONS

Reflux from the epidural plexus to radicular veins is not reliably stopped at the dural level and possibly physiological. Different arrangements of the transdural course of the veins appear to be at least appropriate to modulate flow. The purpose for two different types of radicular vein exit is unclear. The clinical impact of disturbed reflux-control is uncertain, which is in stark contrast to the severe consequences resulting from dural arteriovenous shunts. The functional role of the probably predominant epidural venous plexus for the spinal cord blood circulation remains poorly understood.