Acute Spinal Epidural Hematoma Research Articles

An acute spinal epidural hematoma after acupuncture combined with dyspnea, dysarthria, bradycardia and hypothermia—a case report

Spinal epidural hemorrhage (EDH) after acupuncture is a rare disease and needs to be differentiated from stroke because it presents neurological deficits such as motor weakness. A 48-year-old patient taking anticoagulants developed posterior neck pain and progressive quadriplegia immediately after acupuncture. Upon arrival to the emergency room (ER), he complained of dyspnea, dysarthria, bradycardia, and hypothermia. Diffuse spinal EDH findings on spinal magnetic resonance imaging (MRI) were confirmed, and posterior decompression was performed emergently. The patient is currently recovering. Since dyspnea, dysarthria, bradycardia, and hypothermia complained of by this patient are not common symptoms of spinal cord injury, emergency medicine doctors should be careful not to miss the spinal cord injury through detailed history-taking and additional neurologic exam.

Stroke-like manifestation of a spontaneous spinal epidural hematoma with spontaneous resolution: a case report

BackgroundThis 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 presentationA 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.ConclusionsSEH, 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.

Neurological severity evaluation using magnetic resonance imaging in acute spontaneous spinal epidural haematomas.

This study aimed to elucidate the severity of neurological deficits in a large series of patients with acute spontaneous spinal epidural haematoma (SSEH) using magnetic resonance imaging (MRI). We included 57 patients treated for acute SSEH at 11 institutions and retrospectively analysed their demographic and MRI data upon admission. We investigated MRI findings, such as the haematoma length and canal occupation ratio (COR). The neurological severity of SSEH was assessed based on the American Spinal Injury Association score on admission. Of the 57 patients, 35 (61%) presented with severe paralysis. The MRI analysis showed that SSEH was often located in the cervical spine, dorsal to the spinal cord, and spread over more than three vertebrae. No differences in age, sex, and aetiology were found between patients with and without severe paralysis. The hypo-intensity layer encircling the haematoma, intra-haematoma heterogeneity, and increased CORs were observed more frequently in the severe paralysis group. Furthermore, pathological examination of a dissected haematoma from one patient with a hypo-intensity layer revealed a collagen layer around the haematoma, and patients with intra-haematoma heterogeneity were more likely to have a bleeding predisposition. In this large series of patients with SSEH, we identified some MRI features associated with severe paralysis, such as the hypo-intensity layer, intra-haematoma heterogeneity, and increased COR. Accordingly, patients with these MRI characteristics should be considered for early surgical intervention.

Successful Nonoperative Management of Acute Spontaneous Idiopathic Spinal Epidural Hematoma Presenting as Cauda Equina Syndrome

Spontaneous spinal epidural hematoma (SSEH) is a rare neurosurgical condition with an estimated incidence of 0.1 in 1,00,000 population.[1] It has been most commonly described in the older age group in the 4th or 5th decade of life and most commonly found in the dorsal or dorsolumbar region.[2] It can present with a variety of clinical symptomatology, depending upon the site and extent of hematoma, usually in the form of acute cervical or back pain along with rapid onset of neurological deficits, often within first 12 hours of ictus and often requiring urgent neurosurgical intervention. However, its first manifestation as cauda equina syndrome is rare. Emergent surgical evacuation has remained the gold standard of treatment,[3] and only a handful of cases reported successful recovery with conservative management, and that too primarily in patients with a diffuse SSEH associated with blood dyscrasias or coagulopathy.[4] We describe a case of a 25-year-old healthy male, who presented with history of sudden onset severe back pain, followed by rapidly progressive paraplegia and cauda equina syndrome, four days after lifting heavy weight. He had to be catheterized for urinary retention. He presented to our clinic 1 month after the onset of symptoms, and by then, partial recovery of sensory, motor and autonomic deficits had already ensued. The coagulation profile was within normal parameters. His MRI performed immediately after the onset of symptoms demonstrated a T2-hyperintense lesion in posterior epidural space at L2-3 vertebral level, which was suggestive of a focal epidural hematoma with significant secondary canal compromise ( [Fig. 1 A,B] ). There was no evidence of associated flow-voids to suggest an associated vascular malformation. Due to delayed referral of patient and subacute stage of epidural hematoma with partial spontaneous recovery at the time of presentation, decision was taken to manage it conservatively with symptomatic pain management and limb physiotherapy. He recovered nearly completely over the next 1 month, and he was able to walk with minimal support and regained bladder function (American Spinal Injury Association [ASIA] D). His interval MRI demonstrated complete resolution of epidural hematoma ( [Fig. 2 A,B] ).

Technical note: Novel use of recombinant tissue plasminogen activator for the evacuation of an acute extensive spinal epidural haematoma in a patient with coagulopathy

Spontaneous extensive spinal epidural haematoma poses a unique challenge for the neurosurgeon. Performing extensive laminectomies to remove all of the compressive haematoma can destabilise the patient’s spinal column, which may require fixation. This is further complicated in patients with significant coagulopathy. We present a novel use of recombinant tissue plasminogen activator (rt-PA) in a patient with therapeutic coagulopathy, presenting with myelopathy secondary to an acute extensive spinal epidural haematoma. To the best of our knowledge, this is the first case of acute multilevel spinal epidural haematoma that has been successfully evacuated via single level laminectomy and topically applied rt-PA.

Acute Epidural Hematoma Occurring After Removal of Percutaneous Spinal Cord Stimulator Trial Leads in a Cancer Patient with Chronic Thrombocytopenia: A Case Report

Background: While the possibility of spinal epidural hematoma (SEH) has been considered a complication of removal of spinal cord stimulator (SCS) leads, acute hematoma has not been described in the oncologic population. Objectives: We describe concerns of neuraxial procedures in cancer patients. This population represents a unique subset of patients as thrombocytopenia, as well as platelet dysfunction, are common complications of cancer and chemotherapy. The literature regarding the assessment and management of thrombocytopenia in patients undergoing neuraxial techniques is reviewed. Study Design: Case report. Setting: A major academic cancer hospital, Memorial Sloan Kettering Cancer Center. Methods: We report a case of acute SEH occurring in a patient 5 minutes after removal of SCS trial leads. The patient has a history of chronic thrombocytopenia and lymphoma. Results: Although the patient’s trial leads were placed without incident and platelets were “corrected” with transfusions, she presented with acute back pain and headache. Computed tomography (CT) imaging confirmed an epidural hematoma, which clinically resolved and led to no long-term sequelae. Limitations: Retrospective design, no possibility to establish a cause-effect relationship, and subject to risk of over-interpretation. Conclusions: We present a patient experiencing symptoms of acute neuraxial bleeding immediately following removal of SCS trial leads. The patient’s chronic thrombocytopenia was attributed to splenic sequestration, and therefore, was treated with platelet transfusions. The patient, however, had several risk factors for platelet dysfunction, as well. The use of point-of-care platelet function assays, such as platelet function analyzer and viscoelastic methodologies, would have perhaps helped to better elucidate the bleeding risk in this patient and help guide management. The discovery of platelet dysfunction would have precluded our patient from neuromodulation. Key words: Spinal cord stimulation, epidural hematoma, removal of spinal cord stimulator leads, dorsal column stimulation, acute epidural hematoma

Acute epidural hematoma due to spinal venous angioma: A case report

Abstract Background Spinal epidural cavernous angioma was reported about 4% of all spinal epidural tumors, mostly generating as a primary lesion in the vertebral bone. Spinal epidural hematoma (SEDH) due to angioma without primary origin was very rare, which reported in the English literatures was only 10 cases including our case. The main symptoms were numbness and pains and motor weakness owing to the acute compression signs of cord and roots. Emergency surgical treatment was required for the good surgical results. We present a rare case of cervical acute epidural hematoma due to ruptured venous angioma. Case presentation A 78-year-old man, who suffered from sudden severe right suboccipitalgia., and sent to our hospital. He also noticed progressive numbness and motor weakness over his bilateral upper and lower extremities after the onset. Cervical CT and MRI showed acute intracanal hematoma over the right side of the cervical spine at C2 to C6. Emergency operation was performed 13 h after the onset. His sensory and motor symptoms were disappeared quickly after the operation. Pathological examination revealed spinal epidural hematoma due to venous angioma. Conclusion This case presented with acute progressive deterioration of paresis and sensory disturbance, and required emergency operation. Early diagnosis and emergency surgical treatment are essential for the therapy of acute spinal epidural hematoma due to venous angioma.

Drainage of an acute spinal epidural hematoma that developed without risk factors in the thoracic spine using epidural needle -A case report-

Drainage of an acute spinal epidural hematoma that developed without risk factors in the thoracic spine using epidural needle -A case report-

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

OBJECTIVE The goal of this study was to identify factors that contribute to the formation of acute spinal epidural hematoma (SEH) by correlating etiology, age, site, clinical status, and treatment with immediate results and long-term outcomes. METHODS The authors reviewed their series of 15 patients who had been treated for SEH between 1996 and 2012. In addition, the authors reviewed the relevant international literature from 1869 (when SEH was first described) to 2012, collecting a total of 1010 cases. Statistical analysis was performed in 959 (95%) cases that were considered valid for assessing the incidence of age, sex, site, and clinical status at admission, correlating each of these parameters with the treatment results. Statistical analysis was also performed in 720 (71.3%) cases to study the incidence of etiological factors that favor SEH formation: coagulopathy, trauma, spinal puncture, pregnancy, and multifactorial disorders. The clinical status at admission and long-term outcome were studied for each group. Clinical status was assessed using the Neuro-Grade (NG) scale. RESULTS The mean patient age was 47.97 years (range 0-91 years), and a significant proportion of patients were male (60%, p < 0.001). A bimodal distribution has been reported for age at onset with peaks in the 2nd and 6th decades of life. The cause of the SEH was not reported in 42% of cases. The etiology concerned mainly iatrogenic factors (18%), such as coagulopathy or spinal puncture, rather than noniatrogenic factors (29%), such as genetic or metabolic coagulopathy, trauma, and pregnancy. The etiology was multifactorial in 11.1% of cases. The most common sites for SEH were C-6 (n = 293, 31%) and T-12 (n = 208, 22%), with maximum extension of 6 vertebral bodies in 720 cases (75%). At admission, 806 (84%) cases had moderate neurological impairment (NG 2 or 3), and only lumbar hematoma was associated with a good initial clinical neurological status (NG 0 or 1). Surgery was performed in 767 (80%) cases. Mortality was greater in patients older than 40 years of age (9%; p < 0.01). Sex did not influence any of these data (p > 0.05). CONCLUSIONS Factors that contribute to the formation of acute SEH are iatrogenic, not iatrogenic, or multifactorial. The treatment of choice is surgery, and the results of treatment are influenced by the patient's clinical and neurological status at admission, age, and the craniocaudal site.

Spontaneous Spinal Epidural Haematoma in a 34-week Pregnant Woman: A Case Report and Literature Review: 一個34週孕婦出現自發性脊髓硬膜外血腫：病例分析及文獻回顧

Acute spontaneous spinal epidural haematoma is uncommon; however, it can result in permanent neurological damage if not promptly treated. It occurs very rarely during pregnancy. We report a case of acute spontaneous spinal epidural hematoma in a 34-year-old primigravida woman at 34 weeks’ gestation who presented with sudden back pain and paraplegia. Emergency spinal decompression surgery was done with the continuation of pregnancy. We discuss the presentation and management of the rare condition with a review of the literature.

Acute Spontaneous Spinal Epidural Hematoma Secondary to Aspirin

Acute Spontaneous Spinal Epidural Hematoma Secondary to Aspirin

Unusual complication of coronary angiogram: Spinal epidural hematoma

Coronary angiogram is considered a relatively safe procedure but unusual complications do occur. Such an unusual case was happened post radial artery approach angiogram leading to severe co-morbidity to patient. We are reporting this case of a female patient who developed acute spinal epidural hematoma two hours after coronary angiogram.

急性脊髄硬膜外血腫に対する保存療法の適応と手術移行時期

Acute, progressive paralysis or bladder and bowel disturbance may occur with acute spinal epidural hematoma, but in some cases, the symptom spontaneously resolve. In this study, the clinical characteristics of acute spinal epidural hematoma were clarified, and the indications for and timing of surgery were investigated. Among the reported cases in Japan over a period of about 30 years until 2013, cases without paralysis or trauma, those with no epidural block or catheterization, and those involving the lumbar spine were excluded, and then, 11 factors that contributed to treatment outcomes were identified. One hundred twenty-one cases (8 of our own) were then carefully selected, including 62 treated conservatively (non-operative treatment) and 59 treated surgically. Univariate and multiple logistic regression analyses were conducted. Among the conservative treatment cases, (1) no anticoagulant therapy, (2) paralysis severity of C or D in Frankel classification, (3) and time of the start of recovery (within 15 hours) were the factors associated with spontaneous recovery. Chances for complete recovery from severe paralysis of severity A or B were significantly higher in patients who underwent surgery within 24 hours. We consider the period is the appropriate decision-making time to switch to surgical treatment. In this disease, signs of recovery should be observed for up to 15 hours from the onset of paralysis. If the possibility of non-surgical complete recovery is low, then a switch to surgery should be made within 24 hours.

Acute postoperative cervical spinal epidural hematoma.

The aim of this study was to assess the clinical presentation, causes or risk factors, treatment and outcomes of symptomatic acute postoperative cervical spinal epidural hematoma (APCSEH). The study retrospectively reviewed all patients who underwent open cervical spinal surgery between January 1, 2004 and October 31, 2008. Perioperative coagulation parameters, past medical history, age, gender, time to decompression, pre- and postoperative (decompression operation) neurological status, as well as the interval of hematoma formation and level of segments were reviewed. Potential risk factors for extradural hematomas were examined. Patients who were diagnosed with APCSEH underwent immediate surgical drainage of the hematoma. Over 2,338 cervical spinal surgeries were performed by the Orthopedic Spinal Disorder Group in our hospital between 2004 and 2008. Twelve (0.5%) cases of APCSEH were identified. Two-thirds of the patients had history of hypertensive disease or transitory hypertensive status after surgery. No patients had abnormal preoperative coagulation parameters, bleeding diathesis or developed intraoperative coagulopathy. All patients were treated with hematoma evacuation within 2 hours of the ultimately definitive diagnosis of hematoma. Acute postoperative cervical spinal epidural hematoma is a rare cause of postoperative neurological deterioration. Hypertensive disease and the method of multilevel cervical surgery appear to increase bleeding and predict formation of hematoma. Early diagnosis and evacuation of the hematoma can result in resolution of the neurological deficit.

Anesthetic management of a spontaneous spinal-epidural hematoma during pregnancy

Spontaneous spinal-epidural hematoma is uncommon and rare during pregnancy. We were presented with a 31-year-old patient who developed back pain with lower extremity paralysis at 36weeks of gestation. A magnetic resonance imaging scan demonstrated an acute spinal-epidural hematoma and therefore, an emergency cesarean delivery was performed followed by hemilaminectomy with hematoma removal. Anesthesia was initiated with a volatile-based technique which, following delivery of the baby, was changed to target-controlled infusions of propofol and remifentanil. Postoperatively, dopamine was infused to maintain the blood pressure within the high-normal range to optimize spinal cord perfusion. Successful anesthetic and postoperative management is described together with a review of the literature.

Acute Spinal Epidural Hematoma and Cranial Interdural Hematoma Due to a Rupture of a Posterior Communicating Artery Aneurysm: Case Report

We describe an unusual presentation of a ruptured aneurysm of the posterior communicating artery with an acute intracranial hematoma between the dural layers associated with an acute spinal epidural hematoma descending to L1. A 35-year-old woman presented 3 hours after ictus with a postcoital headache, neck stiffness, and bilateral abducens cranial nerve palsy. No other neurological deficits were present. Clinically, she had a subarachnoid hemorrhage World Federation of Neurosurgical Societies grade 1. CT scan demonstrates an acute subdural hematoma, extending from the right parasellar region, around the clivus, tentorium, and falx. Angio-CT showed a posterior communicating artery aneurysm and an anterior communicating artery aneurysm and an extension of the hematoma to the cervical spine. This justified a spinal and cerebral MRI that confirmed an extension of the hematoma to the epidural space at the cervical, thoracic, and lumbar levels. Three-dimensional digital subtraction angiography confirmed aneurysms on the right posterior communicating artery and on the anterior communicating artery. Both aneurysms were completely occluded by coiling. With reference to the concept of the cranial subdural compartment described in studies conducted using an electron microscope, this group of hematomas was classified as interdural. Ruptured aneurysm of the posterior communicating artery may cause cranial acute interdural hematoma with a typical subarachnoid hemorrhage clinical presentation, and it rarely can extend to spinal epidural space.

Relapsed spontaneous spinal epidural hematoma associated with aspirin and clopidogrel

An acute spontaneous spinal epidural hematoma (SSEH) is a rare spinal pathology. A 57-year-old man who had hypertension and had been on dual antiplatelet therapy with aspirin and clopidogrel for primary prevention presented with the sudden onset of mid back pain and monoplegia of the left lower extremity. Magnetic resonance imaging revealed an epidural hematoma, and the patient underwent emergency hemilaminectomy for evacuation. However, the symptoms worsened, and complete paraplegia developed. A second procedure to remove the recurrent hematoma was performed. No vascular malformation or other possible cause for SSEH was found other than the aspirin and clopidogrel medication. This case report describes relapsed SSEH caused by the combination of aspirin and clopidogrel medication and urges caution in prescribing dual antiplatelet agents.

Acute Spontaneous Cervical Spinal Epidural Hematoma with Spontaneous Resolution -A Case Report-

Acute Spontaneous Cervical Spinal Epidural Hematoma with Spontaneous Resolution -A Case Report-

Hemiparesis Caused by Cervical Spontaneous Spinal Epidural Hematoma: A Report of 3 Cases

We report three cases of spontaneous spinal epidural hematoma (SSEH) with hemiparesis. The first patient was a 73-year-old woman who presented with left hemiparesis, neck pain, and left shoulder pain. A cervical MRI scan revealed a left posterolateral epidural hematoma at the C3–C6 level. The condition of the patient improved after laminectomy and evacuation of the epidural hematoma. The second patient was a 62-year-old man who presented with right hemiparesis and neck pain. A cervical MRI scan revealed a right posterolateral dominant epidural hematoma at the C6-T1 level. The condition of the patient improved after laminectomy and evacuation of the epidural hematoma. The third patient was a 60-year-old woman who presented with left hemiparesis and neck pain. A cervical MRI scan revealed a left posterolateral epidural hematoma at the C2–C4 level. The condition of the patient improved with conservative treatment. The classical clinical presentation of SSEH is acute onset of severe irradiating back pain followed by progression to paralysis, whereas SSEH with hemiparesis is less common. Our cases suggest that acute cervical spinal epidural hematoma should be considered as a differential diagnosis in patients presenting with clinical symptoms of sudden neck pain and radicular pain with progression to hemiparesis.

Postoperative spinal epidural hematoma resulting in cauda equina syndrome: a case report and review of the literature

Spinal epidural hematoma is a well known complication of spinal surgery. Clinically insignificant small epidural hematomas develop in most spinal surgeries following laminectomy. However, the incidence of clinically significant postoperative spinal epidural hematomas that result in neurological deficits is extremely rare. In this report, we present a 33-year-old female patient whose spinal surgery resulted in postoperative spinal epidural hematoma. She was diagnosed with lumbar disc disease and underwent hemipartial lumbar laminectomy and discectomy. After twelve hours postoperation, her neurologic status deteriorated and cauda equina syndrome with acute spinal epidural hematoma was identified. She was immediately treated with surgical decompression and evacuation of the hematoma. The incidence of epidural hematoma after spinal surgery is rare, but very serious complication. Spinal epidural hematomas can cause significant spinal cord and cauda equina compression, requiring surgical intervention. Once diagnosed, the patient should immediately undergo emergency surgical exploration and evacuation of the hematoma.