Concurrent intracranial and spinal subdural hematomas: postoperative intracranial progression following surgical evacuation of spinal subdural hematoma: A case report and literature review

Spinal subdural hematoma is a rare condition whereas intracranial chronic subdural hematoma is well-recognized and documented in clinical settings. Despite various theories that have been proposed, the exact pathogenesis of spinal subdural hematoma remains to be elucidated. Herein, we report a rare case of spinal subdural hematoma with a co-existing intracranial chronic subdural hematoma and deduce its etiology using histopathological findings. A 76-year-old Japanese man with slight hemiparesis due to intracranial chronic subdural hematoma underwent burr hole surgery with successful drainage of the hematoma. The patient could not walk unassisted after the surgery. Spinal magnetic resonance imaging was performed, revealing a subdural hematoma extending from the T11 to S2 levels. The patient subsequently underwent the evacuation of spinal subdural hematoma 12 days after initial surgery. Intraoperatively, we identified a dark liquefied hematoma with capsule formation. Histological examination of the resected capsule revealed loose fibrovascular tissues comprising capillaries, collagen fibers, a small number of macrophages, and hemosiderin deposits. These findings were very similar to the pathology of intracranial chronic subdural hematoma so the pathogenesis of spinal subdural hematoma in this case was considered identical to that of subacute or chronic subdural hematoma. The patient was transferred to a rehabilitation hospital, and 4 months after the lumbar surgery, no recurrence was observed in the magnetic resonance imaging examination. Subacute or chronic spinal subdural hematoma may result from various pathogeneses that clinicians should consider for correct diagnosis and appropriate management. Our case provides important insights into the pathogenesis of subacute or chronic spinal subdural hematoma.

Chronic spinal subdural hematoma is an extremely rare condition. We recently encountered a case of symptomatic thoracolumbar chronic spinal subdural hematoma in an older patient caused by a fall. The patient was a man in his 80s with a history of cerebral infarction, who was receiving oral antiplatelet therapy. He was hospitalized for conservative treatment for a brain contusion and mild acute subdural hematoma, and was discharged home after 6 days. However, 9 days after the injury, the patient developed back pain, weakness in both lower limbs, and urinary incontinence and was brought to our hospital. A computed tomography scan on admission displayed a high-density area in the thoracolumbar spinal canal, and magnetic resonance imaging 2 weeks after the fall displayed a spinal subdural hematoma from 8th thoracic to sacral 2nd, with a hyperintensity signal on T1weighted image and T2 weighted image and partial low intensity on T2* imaging. On day 22 after the injury, lumbar drainage was performed, and a motor-oil-like hematoma was aspirated. A total of 330 mL of hematoma content was drained for 3 days. Immediately after treatment, the patient's back pain and lower limb weakness improved, and imaging confirmed the disappearance of the spinal subdural hematoma. Most reported cases to date of chronic spinal subdural hematoma were treated with invasive laminectomy for hematoma removal. In the present case, the authors suspected this condition from the late subacute stage of onset and were able to cure the patient with minimum invasive lumbar drainage after diagnosis of liquefaction of the hematoma by magnetic resonance imaging.

Spinal subdural hematoma is a rare condition. Herein, we present a case of simultaneous intracranial and spinal subdural hematoma. An 81-year-old woman went to a local hospital for a 2-m fall 1 month before her visit to our institution, and computed tomography (CT) showed no unusual findings. However, due to subjective lower extremity weakness and severe radiating pain in the legs, brain CT and lumbar-spine CT re-imaging was performed during follow-up. Follow-up showed subacute spinal subdural hematoma in the brain and spine. The patient was transferred to our hospital and underwent bilateral burr-hole trephination and posterior lumbar decompression with spinal subdural hematoma removal. Upon follow-up, the spinal subdural hematoma was significantly reduced, and the patient’s symptoms recovered. In this report, we discuss a case of simultaneous spinal and intracranial subdural hematoma. Keywords: Spinal subdural hematoma; Intracranial subdural hematoma

A 39-year old female presented with chronic spinal subdural hematoma manifesting as low back pain and radiating pain from both legs. Magnetic resonance imaging (MRI) showed spinal subdural hematoma (SDH) extending from L4 to S2 leading to severe central spinal canal stenosis. One day after admission, she complained of nausea and severe headache. Computed tomography of the brain revealed chronic SDH associated with midline shift. Intracranial chronic SDH was evacuated through two burr holes. Back pain and radiating leg pain derived from the spinal SDH diminished about 2 weeks after admission and spinal SDH was completely resolved on MRI obtained 3 months after onset. Physicians should be aware of such a condition and check the possibility of concurrent cranial SDH in patients with spinal SDH, especially with non-traumatic origin.

IntroductionSpinal subdural hematoma is rare and can cause serious neurological symptoms. Sometimes, idiopathic spinal subdural hematoma can spontaneously occur without any identifiable underlying etiologies. In this report, we present such an uncommon case of paraplegia caused by idiopathic spinal subdural hematoma that was successfully managed by laminectomy.Case presentationA 45-year-old Chinese woman presented with sudden onset of progressive asthenia and numbness in both lower extremities, accompanied by difficulty in micturition. An initial non-contrast spinal magnetic resonance imaging at a local hospital suggested a spinal subdural tumoral hematoma at the T9 level. She was referred to our hospital and an emergency laminectomy from T8 to T10 was performed 22 hours after onset of her initial symptoms. However, nothing but a hematoma was identified during the operation, and a final diagnosis of spontaneous acute spinal subdural hematoma was concluded. She had partial return of sensations and voluntary movement after the operation.ConclusionsOn imaging findings, spinal subdural hematoma could manifest as focal and independent from the dura matter, and, therefore, it should be included in the differential diagnosis of medullary compressive lesions.

Lumbar Subdural Hematoma Detected After Surgical Treatment of Chronic Intracranial Subdural Hematoma

Spontaneous Spinal Subdural Hematoma of Intracranial Origin Presenting as Back Pain

A case report with a literature review is presented. To describe and review the clinical presentations, characteristic findings from imaging studies, and treatment of traumatic spinal subdural hematoma. Traumatic spinal subdural hematoma is uncommon, and only eight cases have been reported in the literature. Concomitant intracranial and spinal subdural hematoma in the same patient has not been well studied. A case of concomitant spinal and intracranial subdural hematoma is reported as well as a review of the literature. Including our patient, we found that five of the nine patients with traumatic spinal subdural hematoma also had intracranial hematoma. We hypothesize that the mechanism of traumatic spinal subdural hematoma may be associated with intracranial events. Recognition of blood products in magnetic resonance imaging scans is important to distinguish spinal subdural hematoma from other spinal lesions. It is generally agreed that prompt laminectomy with evacuation of hematoma should be performed before irreversible damage to the spinal cord occurs. However, including our patient, three of the nine reported cases with thoracic or lumbar subdural hematoma resolved spontaneously with conservative treatment. This 12-year-old boy illustrated the rapid spontaneous resolution of traumatic subdural hematoma in both left hemisphere and lumbar spine with conservative treatment. This report suggests a possible role of conservative management for traumatic lumbar subdural hematoma, especially when the patients already have neurologic recovery.

Concomitant Intracranial Chronic Subdural Hematoma and Spinal Subdural Hematoma: A Case Report and Literature Review

A 24-year-old woman presented with concomitant spinal and bilateral intracranial subdural hematomas (SDHs) after hitting her head and lower back in a fall while snowboarding. She developed lower back pain and posture headache. Magnetic resonance imaging revealed bilateral intracranial SDHs and spinal SDH. Her symptoms improved and all hematomas resolved gradually without treatment, and completely disappeared by 5 months after the accident. Simultaneous intracranial SDH and spinal SDH have been reported in only 18 patients, including ours, of whom 6 had suffered trauma. The mechanism of concomitant SDHs has not been clarified, but migration of the hematoma from the intracranial to spinal sites may be an important mechanism. In our patient, low cerebrospinal fluid pressure syndrome and double trauma may also have been involved.

Concomitant posterior fossa and spinal subdural hematoma (SDH) is an extremely rare disease entity. We present a chronic rheumatic valvular heart disease patient with atrial fibrillation on warfarin, diagnosed with posterior fossa and cervical spinal acute subdural hematoma (ASDH). The posterior fossa hematoma was managed surgically because the patient exhibited signs of increased intracranial pressure (ICP), while the cervical spine SDH was managed conservatively with a very good outcome. Surgical management of the symptomatic posterior fossa SDH with observation of the spinal SDH can be an option of management in this rare complication of oral anticoagulant therapy.

Spontaneous Spinal and Intracranial Subdural Hematoma

Post-traumatic subdural spinal hematomas: Two case reports and systematic review of the literature

BackgroundConcurrent spinal subdural hematoma (SSDH) and cranial subdural hematoma (CSDH) have been sporadically reported. However, concurrent SSDH and CSDH with intracerebral hemorrhage (ICH) is extremely rare.Case DescriptionA previously healthy 19-year-old man presented with symptoms of intracranial hypertension and back pain with radiculopathy without focal neurologic deficits. Craniospinal magnetic resonance imaging (MRI) detected bilateral CSDHs, cerebral contusions, and lumbosacral, anterior SSDH simultaneously, 1 week after isolated head trauma and unremarkable cranial computed tomography (CT). A positive “inverted Mercedes-Benz sign” in axial T1 and T2 sequences confirmed the diagnosis. We report the first case of contemporaneously diagnosed SSDH and CSDH with cerebral contusions following head trauma without spinal trauma, whereby all pathologies were managed conservatively. Furthermore, we performed a review of pertinent literature available in PubMed. Twelve cases with contemporaneous diagnosis of CSDH and SSDH within a narrow diagnostic timeframe of ≤48 hours were published since 2005. All but one was male with a mean age of 41.5 years (range, 11–70 years). Fifty percent reported cranial trauma. Nine cases (66.7%) had headaches, and 10 patients (83.3%) reported radiculopathy. Nine patients (66.7%) reported cranial and spinal symptoms. All 5 patients (41.7%) treated conservatively for both pathologies showed complete clinical and radiological resolution at follow-up.ConclusionsOur case exemplifies the effectiveness and favorable outcome of conservative management in neurologically intact SSDH with radiculopathy. Twelve cases of concurrent CSDH and SSDH diagnosed within a timeframe of ≤48 hours were included in the review. We discuss three theories proposed in the literature explaining pathomechanisms of traumatic SSDH and its plausible causational relationship with CSDH. SSDH can occur with all types of intracranial hemorrhage. Lower thresholds for ordering cranial imaging upon evidence of traumatic SSDH could allow detection of occult CSDH. Spinal imaging should be conducted in head trauma patients with spinal symptoms regardless of neurologic status to exclude possible SSDH. Older patients with higher risk of rebleeding often receive surgical evacuation of CSDHs. Extensive SSDHs with neurologic deficits are surgically evacuated to relieve neural compression. Conservative management of CSDH and/or SSDH is reasonable in younger patients without deficits. Regardless of management strategies, prognosis is generally good with very low complication rates.

Dear Sir, I read with great interest the article by Kim et al. [1] mentioning the risk factors for delayed surgical evacuation of acute subdural hematoma (SDH) in mild head injury patients who were initially treated by non-surgical means and would like to add a few comments. In patients with traumatic brain injury, the decision to evacuate acute SDH is based predominantly on the patient’s GCS score, pupillary examination, and CT scan findings. The guidelines laid down by the Brain Trauma Foundation in 2006 for the management of acute SDH are universally followed [2]. The Brain Trauma Foundation lays great emphasis on the thickness of acute SDH and the degree of midline shift in guiding surgery for patients with traumatic brain injury [2]. As per the Brain Trauma Foundation guidelines, acute SDHmore than 10 mm thick or a midline shift greater than 5 mm on imaging, irrespective of the patients GCS score, needs surgical evacuation [2]. However, volume of the hematoma has not been considered as a guiding parameter in patients with acute SDH. In fact, the Brain Trauma Foundation emphasizes calculating the volume of hematoma in order to decide surgical evacuation of extradural hematoma only [2]. Patients with mild head injury (GCS score of 13 to 15) having acute SDH are more likely to have hematoma thickness of less than 10 mm and midline shift of less than 5 mm [1]. By calculating the volume of hematoma in patients with mild head injury having acute SDH, neurosurgeons will be able to predict which hematomas are likely to enlarge and hence are likely to need evacuation. In the series published by Mathew et al. [3], 23 patients with mild head injury having acute SDH were initially subjected to non-operative management. In six of these patients who needed delayed surgical evacuation of the acute SDH, the volume of the hematoma was significantly larger than the group that was managed conservatively [3]. In the authors’ series, also the volume of the hematoma was an independent risk factor for the development of delayed hematoma enlargement [1]. The authors need to be commended for re-introducing volume of the hematoma as a decisive parameter in predicting hematoma enlargement apart from thickness of the hematoma and degree of midline shift in patients with acute SDH and good neurological status.