Case Of Epidural Hematoma Research Articles

Hematoma epidural cervical yatrogénico: Presentación de un caso clínico y revisión de la literatura

Around 600 spinal epidural hematoma cases have been previously reported. Incidence of paraplegia after epidural anesthesia varies between 0,0005 and 0,02%. Several possible etiologies have been described in the literature, including surgery, trauma, anticoagulant therapy, arteriovenous malformations, pregnancy and lumbar puncture. Spinal and epidural anesthesic procedures represent the tenth most common cause. But in combination with anticoagulant therapy, the forementioned procedures increase its incidence until reaching the fifth most common etiological group. We report the case of an 80 year-old-man with a cervical epidural hematoma who had a good outcome with conservative management. 80 year-old-man that developed intense cervicalgia with lower limbs weakness showing complete paraplegia and arreflexia 2 hours after analgesic treatment with epidural cervical infiltration for cervicoartrosis. Cervical MRI showed epidural cervical hematoma between C4 and T1 levels. The patient is transferred to our facilities in order to perform surgery. But after showing fast recovery, medical conservative management was elected. After one month, the patient's condition has improved showing no neurological deficits and complete resorption is seen in MRI. Nowadays, trend is to perform surgery in patients with spinal hematoma and significant neurological deterioration during the first hours. However, good neurological outcomes can be achieved with conservative management, in well selected patients with non progressive, incomplete and partial deficits. Presently, we can not predict which is the best treatment for each case.

An Acute Cervical Epidural Hematoma as a Complication of Dry Needling

A retrospective case report. The objective of this article is to report an unusual complication of dry needling. Epidural hematomas after dry needling are quite unusual and only a few cases of epidural hematoma after acupuncture have been reported in the literature. We are presenting the first report of acute cervical epidural hematoma after dry needling. A 58-year-old woman presented with quadriparesis and neck pain. Magnetic resonance imaging of the spine revealed a hyperintense mass in the T2-weighted magnetic resonance image at the C2-T2 level, which proved to be an epidural hematoma. Symptoms related to the epidural hematoma resolved after decompression. Though rare, epidural hematomas are a possible complication when applying needling therapies. Therapists need to have precise knowledge of human anatomy, especially in the region where he or she will puncture. Continuous attention must be paid throughout the whole procedure.

Coagulation testing before epidural analgesia at delivery: Cost analysis

BackgoundThe usefulness of coagulation tests performed before epidural analgesia for surgery or to alleviate labour pain is controversial. The aims of this study were: 1) to evaluate the prevalence of abnormal tests in a large cohort of healthy pregnant women and their association with epidural hematoma; 2) to assess the approach of the anesthesiologists to women with abnormal tests; 3) to evaluate the cost of performing coagulation tests before epidural analgesia in all healthy pregnant women. MethodsData regarding epidural analgesia, epidural hematoma, PT, APTT, fibrinogen and platelet count were extracted from medical charts. ResultsThere was no case of epidural hematoma in 2546 pregnant women undergoing epidural analgesia. PT and APTT results were obtained in 2871 women; fibrinogen in 4063 women; platelet count in 5090 women. Three of them (0.1%) had a prolonged PT, 4 (0.14%) had a prolonged APTT, 27 (0.53%) had platelets ≤100×109/L and 37 (0.91%) had plasma fibrinogen levels <3 g/L. No further tests were requested by the anesthesiologists in these women. Only women with platelets <80×109/L were denied epidural analgesia. Based on the data from the literature on the frequencies of epidural hematoma after epidural analgesia, a total cost ranging from 4.5 to 40 million Euros to perform coagulation tests would be necessary to avoid one case of epidural hematoma. DiscussionUnselected coagulation tests before epidural analgesia are not recommended, because epidural hematoma is extremely rare in healthy pregnant women and the cost of screening is not justified.

Epidural haematoma: Rare complication after spinal while intending epidural anaesthesia with long-term follow-up after conservative treatment

Epidural anaesthesia (EA) is an extensively used procedure for many surgeries. Increase incidence of bleeding in the epidural space [epidural haematoma (EH)] is reportedly more common in patients with altered coagulation and patients on anticoagulation treatment. EH secondary to spinal while intending EA for caesarean section (C-section) in a healthy individual leading to transient or persistent neurological problems is very rare. We report a case of EH after spinal while intending EA for C-section in a healthy young female along with 5-yrs follow-up after conservative treatment.

Spinal epidural hematoma related to an epidural catheter in a cardiac surgery patient -A case report-

The addition of thoracic epidural anesthesia to general anesthesia during cardiac surgery may have a beneficial effect on clinical outcome. However, epidural catheter insertion in a patient anticoagulated with heparin may increase the risk of epidural hematoma. We report a case of epidural hematoma in a 55-year-old male patient who had a thoracic epidural placed under general anesthesia preceding uneventful mitral valve replacement and tricuspid valve annular plasty. During the immediate postoperative period and first postoperative day, prothrombin time (PT) and activate partial thromboplastin time (aPTT) were mildly prolonged. On the first postoperative day, he complained of motor weakness of the lower limbs and back pain. An immediate MRI of the spine was performed and it revealed an epidural hematoma at the T5-6 level. Rapid surgical decompression resulted in a recovery of his neurological abnormalities to near normal levels. Management and preventing strategies of epidural hematoma are discussed.

Epidural haematoma after epidural catheter removal under multiple anticoagulant therapy: report of two cases

We report two cases of epidural haematoma that probably developed after removal of the epidural catheter in patients receiving multiple anticoagulant and antiplatelet therapy. The first case is a 77-year-old male patient who underwent femoropopliteal artery bypass grafting surgery. The second case is a 77-year-old woman who underwent a semi-total replacement of the right hip, three days after she had a subtrochanteric fracture. Emergency laminectomy was performed in both patients but none experienced a full recovery.

Spinal epidural hematoma after epidural anesthesia in a patient receiving enoxaparin -A case report-

Spinal epidural hematoma is a rare but serious neurological complication of neuraxial anesthesia. Enoxaparin sodium is a low molecular weight heparin (LMWH) for use in preventing deep venous thrombosis in patients undergoing total hip arthroplasty and total knee arthroplasty. Hemorrhage is an uncommon but documented adverse reaction when using LMWH. We report a case of epidural hematoma after lumbar epidural anesthesia in a patient who administered enoxaparin in perioperative period.

MRI manifestations and differentiated diagnosis of postoperative spinal complications

To analyze MR manifestations of postoperative spinal complications and investigate the value of MRI in the diagnosis and differentiated diagnosis, 114 cases of spinal postoperative complications were analyzed retrospectively and compared with the clinical data. The results showed that the main postoperative spinal complications included spinal stenosis (n=33, consisting of 21 cases of epidural fibrosis and 12 cases of epidural hematoma or epidural abscess), lack of spinal stability (n=43), infection (n=23, consisting of 7 cases of para-spinal soft-tissue infection, 5 cases of vertebral discitis, 4 cases of vertebral and appendix infection, 3 cases of epidural abscess, 2 cases of myelitis, 2 cases of spinal arachnoiditis), others (n=28, consisting of 12 cases of inner fixation failure, 9 cases of epidural hematoma, 7 cases of cerebrospinal fluid gusher). It is concluded that MRI can specifically display all kinds of postoperative spinal complications, and is of significant value in the diagnosis and differentiated diagnosis of postoperative spinal complications.

Combined epidural and intracerebral hematomas after evacuation of bilateral chronic subdural hematoma

Bleeding after surgery for chronic subdural hematoma far from the operative site is a rare phenomenon with possibly serious consequences. We report a case of combined epidural and intracerebral hemorrhage immediately after evacuation of bilateral chronic subdural hematoma. The epidural hematoma was evacuated by emergency craniotomy, but the deep parenchymal hematoma was treated conservatively. The patient recovered progressively with a good outcome. Approximately 30 cases of chronic subdural hematomas complicated by intracerebral hematoma were previously reported, but only seven cases of epidural hematoma. These complications could be avoided if slow, gradual decompression is used during surgery. Clinicians should suspect its occurrence without delay when a postoperative neurological deterioration is demonstrated. Possible mechanisms are discussed.

Monitoring Quality and Safety in Anesthesia: Are Large Numbers Enough?

Monitoring Quality and Safety in Anesthesia: Are Large Numbers Enough?

Result of Neck Clipping and Coil Embolization as a Treatment for Unruptured Aneurysm

The report of the International Subarachnoid Aneurysm Trial (ISAT) study showed that coil embolization was superior to neck clipping as a treatment for subarachnoid hemorrhage (SAH) (1). Recently, some results of treatments for unruptured aneurysm via coil embolization and neck clipping have been reported (2,3).We compared the results of coil embolization and neck clipping in our institute. Generally better outcomes were obtained by endovascular surgery than by neck clipping. Postoperative ischemic strokes occurred in one case (1.8%) as a major stroke and in three cases (5.6% ) as a minor stroke among coil-treated cases, and in two cases(2.6%) as a major stroke, and in seven cases(9.0%) as a minor stroke among neck clipping cases. Other complications after these treatments were six cases of subdural effusion/hematoma, four cases of infection, two cases of epidural hematoma, one abducens nerve palsy, one hydrocephalus, and one acute myocardial infarction among 78 neck clipping cases, and two subcutaneous hematoma, one pseudoaneurysm at the puncture points, one direct carotid-cavernous fistula among 54 coil-treated cases. Four coil-treated cases, in which introduction of microcatheters to the aneurysm was impossible, were treated completely by neck clipping after endovascular treatments. In terms of modified Rankin Scale(mRS) three months after treatments, while mRS 3 was noted in only one case in the endovascular treatment group, there were one case of mRS 3, two cases of mRS 4, and two cases of mRS 5 in the neck clipping group. Duration of hospitalization averaged 11.9 days in the endovascular group and 24.1 days in the neck clipping group. The results of endosaccular enbolizations as treatment of the unruptured aneurysm seems to be better than neck clipping. However, not all cases of unruptured aneurysms can be treated by coil embolization due to the width of aneurysmal neck and relation of the aneurysm to parent arteries. Therefore, surgeons should also be able to perform neck clipping as an alternative modality.

Can Epidural Anesthesia and Warfarin be Coadministered?

Epidural hypotensive anesthesia can, in addition to imparting numerous intraoperative benefits, provide excellent postoperative pain control for patients having joint arthroplasties. However, because of the risk of epidural hematoma, epidural anesthesia is not coadministered with anticoagulation in some centers. We retrospectively ascertained, by chart review, the incidence of epidural hematoma in 11,235 patients having 12,991 knee arthroplasties at our institution who received oral anticoagulation and epidural anesthesia for their surgery. Warfarin was administered on the day of surgery. With the exception of 212 patients, the epidural catheter was removed within 48 hours of surgery. Based on clinical examinations, we detected no epidural hematomas. For 1030 patients (1038 knees) whose charts were reviewed in detail, the mean international normalized ratio at the time of removal of the epidural catheter was 1.54 (range, 0.93-4.25). We identified no other complications related to the coadministration of epidural anesthesia and warfarin. Although administration of epidural anesthesia in patients with coagulopathy can be detrimental, we recognized no cases of epidural hematoma causing neurologic symptoms in patients receiving controlled oral anticoagulation after total knee arthroplasty.

Incidence of epidural haematoma and neurological injury in cardiovascular patients with epidural analgesia/anaesthesia: systematic review and meta-analysis

BackgroundEpidural anaesthesia is used extensively for cardiothoracic and vascular surgery in some centres, but not in others, with argument over the safety of the technique in patients who are usually extensively anticoagulated before, during, and after surgery. The principle concern is bleeding in the epidural space, leading to transient or persistent neurological problems.MethodsWe performed an extensive systematic review to find published cohorts of use of epidural catheters during vascular, cardiac, and thoracic surgery, using electronic searching, hand searching, and reference lists of retrieved articles.ResultsTwelve studies included 14,105 patients, of whom 5,026 (36%) had vascular surgery, 4,971 (35%) cardiac surgery, and 4,108 (29%) thoracic surgery. There were no cases of epidural haematoma, giving maximum risks following epidural anaesthesia in cardiac, thoracic, and vascular surgery of 1 in 1,700, 1 in 1,400 and 1 in 1,700 respectively. In all these surgery types combined the maximum expected rate would be 1 in 4,700. In all these patients combined there were eight cases of transient neurological injury, a rate of 1 in 1,700 (95% confidence interval 1 in 3,300 to 1 in 850). There were no cases of persistent neurological injury (maximum expected rate 1 in 4,600).ConclusionThese estimates for cardiothoracic epidural anaesthesia should be the worst case. Limitations are inadequate denominators for different types of surgery in anticoagulated cardiothoracic or vascular patients more at risk of bleeding.

Injuries of the cervical spine in patients with ankylosing spondylitis: experience at two trauma centers

The cervical spine in a patient with ankylosing spondylitis (AS) (Bechterew disease) is exposed to maximal risk due to physical load. Even minor trauma can cause fractures because of the spine's poor elasticity (so-called bamboo spine). The authors conducted a study to determine the characteristics of cervical fractures in patients with AS to describe the standard procedures in the treatment of this condition at two trauma centers and to discuss complications of and outcomes after treatment. Between 1990 and 2006, 37 patients were surgically treated at two institutions. All patients were examined preoperatively and when being discharged from the hospital for rehabilitation. Single-session (11 cases) and two-session anterior-posterior (13 cases), anterior (11 cases), posterior (two cases), and laminectomy (one case) procedures were performed. The injury pattern, segments involved, the pre- and postoperative neurological status, and complications were analyzed. Preoperative neurological deficits were present in 36 patients. All patients experienced improvement postoperatively, and there was no case of surgery-related neurological deterioration. In patients in whom treatment was delayed because of late diagnosis, preoperative neurological deficits were more severe and improvement worse than those treated earlier. The causes of three deaths were respiratory distress syndrome due to a rigid thorax and cerebral ischemia due to rupture of the vertebral arteries. There were 12 perioperative complications (32%), three infections, one deep venous thrombosis, five early implant failures, and the three aforementioned fatalities. There were no cases of epidural hematoma. In all five cases in which early implant failure required revision surgery, the initial stabilization procedure had been anterior only. A comparison of complications and the outcomes at the two centers revealed no significant differences. The standard intervention for these injuries is open reduction, anterior decompression and fusion, and anterior-posterior stabilization; these procedures may be conducted in one or two stages. Based on the early implant failures that occurred exclusively after single-session anterior stabilizations (five of 10--a failure rate of 50%), the authors have performed only posterior and anterior procedures since 1997 at both centers. Diagnostic investigations include computed tomography scanning or magnetic resonance imaging of the whole spine, because additional injuries are common. The causative trauma may be very slight, and diagnosis may be delayed because plain radiographs can be initially misinterpreted. In cases in which diagnosis is delayed, patients present with more severe neurological deficits, and postoperative improvement is less pronounced than that in patients in whom a prompt diagnosis is established. Because of postoperative pulmonary and ischemic complications, the mortality rate is high. In the present series the mortality rate was lower than the mean rate reported in the literature.

Epidural Hematoma after Epidural Catheterization without Coagulopathy: A case report

Epidural hematoma after epidural catheterization is very rare but one of serious complications. Although true incidence and origin is unknown yet, coagulopathies and anticoagulant therapy are predominant risk factors. Other risk factors are NSAIDs treatment and ankylosing spondylitis. We experienced a case of epidural hematoma without any risk factors after epidural catheterization for postoperative pain control. We performed epidural catheterization before operation and postoperatively the patient received continuous epidural infusion for postoperative pain control. On the first operative day, the patient was noted to have developed complete paraplegia and hypoesthesia below L1 and anesthesia below L2 level. Immediately after noting we performed TL-spine MRI and epidural hematoma at T10 level was diagnosed and treated by decompressive laminectomy. But she has not fully recovered yet.

Traumatic epidural haematomas of nonarterial origin: analysis of 30 consecutive cases

The purpose was to analyse the clinical and radiological findings, and management approaches used in 30 consecutive cases of traumatic epidural haematoma of nonarterial origin treated at one centre. Medical records for 30 patients surgically treated for epidural haematoma of nonarterial origin between 1997 and 2003 were reviewed. Epidural haematoma of nonarterial origin was diagnosed based on computed tomography (CT) and the bleeding source was confirmed intra-operatively. Admission status, outcome, fracture location, haematoma location/size/volume, and additional intracranial pathology were among the data noted. Two groups were formed for analysis: venous sinus bleeding (group 1) and other venous sources (group 2). The 30 cases accounted for 25% of the total number of traumatic epidural haematomas (n = 120) treated during the same period. The epidural haematomas of nonarterial origin locations were transverse sigmoid sinus (n = 11; 36.7%), superior sagittal sinus (n = 6; 20%), venous lakes (n = 5; 16.6%), diploë (n = 5; 0.16%), arachnoid granulations (n = 2; 6.7%), petrosal sinus (n = 1; 3.3%). There were 12 postoperative complications in 9 patients: recurrence (n = 4; 13.3% of the 30 total), pneumonia (n = 4; 13.3%), meningitis (n = 2; 6.7%), hydrocephalus (n = 1; 3.3%) and subdural effusion (n = 1; 3.3%). All recurrence cases were re-explored. Six (20%) patients died. Glasgow Outcome Scale (GOS) scores (mean follow-up 13.3 +/- 7.8 months) revealed 22 (73.3%) patients with favourable results (GOS 4-5) and 8 (26.7%) had poor results (GOS 1-3). Cases of epidural haematoma of nonarterial origin differ from the more common arterial-origin epidural haematomas with respect to lesion location, surgical planning, postoperative complications, and outcome. Epidural haematoma of nonarterial origin should be suspected if preoperative CT shows a haematoma overlying a dural venous sinus or in the posterior fossa and convexity. The sinus-origin group had a high frequency of fractures which crossed the sinuses, and this might be diagnostically and surgically useful in such cases.

脊髄硬膜外血腫の治療経験

Three cases of spontaneous spinal epidural hematoma were treated conservatively. Each case was diagnosed by MRI. At the time of diagnosis, spontaneous neurological recovery had already started in each patient and they were therefore all treated conservatively. In each case, the size of the hematoma rapidly reduced on the follow-up MRI. Conservative treatment is safe in some cases of spinal epidural hematoma cases if neurological recovery starts early.

Prenatal Diagnosis of a Trauma-Related Fetal Epidural Hematoma

Prenatal diagnosis of fetal intracranial hemorrhage has important etiologic, management, and prognostic implications. Ultrasonography and magnetic resonance imaging (MRI) have been used to identify and evaluate this condition. We present the first reported case of epidural hematoma diagnosed prenatally. A 25-year-old para 3 was referred for evaluation of a suspected fetal intracranial abnormality following an alleged assault. Ultrasonography and MRI were used to diagnose an epidural hematoma prenatally. The fetus subsequently died in utero. Autopsy confirmed the presence of an epidural hematoma. Ultrasonography and MRI were useful in diagnosing a fetal epidural hematoma. Unfortunately, no known effective in utero therapy exists for this rare problem.

Epidural Hematoma After Anticoagulation with a Thoracic Epidural Catheter in Place: A Mere Coincidence?

In Response: We would like to express our appreciation to Dr. Hemmerling for taking the time to submit a Letter to the Editor regarding our case report on an epidural hematoma formation in a cardiac surgery patient. We would also like to address some of the issues that he raises and offer some suggestions. As Dr. Hemmerling has suggested, there are cases of epidural hematoma formation in the current literature unrelated to neuraxial anesthesia (1–4). While it is difficult to say with absolute certainty in this case, the development of this complication at this time was most likely related to the presence of the epidural catheter in association with marked coagulopathy in an ambulating patient. We agree that, since 57 hours had elapsed between catheter placement and the onset of neurologic symptoms, placement of the epidural catheter was not the cause of the hematoma. The combination of coagulopathic derangements in the postoperative period, created by the administration of therapeutic heparinization, the potent antithrombotic agent alteplase (used to flush the PICC line), and the thrombocytopenia, and the fact that the patient was ambulating, is the most likely cause of the hematoma at that specific time. The presenting symptom in this case was the sudden onset of radicular back pain. Blood was then noted in the lumen of the epidural catheter. It was not until after the prompt removal of the catheter by the PICU staff that neurologic deficits were noted in this patient. We feel that there are two possible explanations for this: 1) the epidural catheter may have acted as a vent for the increasing pressure in the epidural space, caused by the expanding hematoma, and 2) the removal of the catheter may have increased bleeding. Most likely, it was a combination of these two factors. In 47% of the cases of catheter related epidural hematomas reported by Vandermeulen et al. (5) in 1994 the hematoma occurred during removal of the catheter. We believe that the onset of symptoms was due to the formation of the hematoma and that delaying decompressive laminectomy in order to correct this patients coagulation system at this point would not have been the best course of action. Neurologic outcomes in patients that have developed an epidural hematoma are improved greatly if the definitive treatment, decompressive laminectomy, occurs within 8 hours from the onset of symptoms (5,6). We feel that the best course of action in future cases would be to leave the epidural catheter in place during diagnostic imaging, use it as a vent to drain blood from the forming hematoma if possible, while simultaneously attempting to correct coagulopathies, and arrange for definitive treatment as soon as possible. The catheter left in position could then serve as a guide to the surgeon in determining which spinal levels to approach We also stress the need for continued communication between all perioperative care providers particularly in those patients with postoperative epidural catheters. An understanding of the appropriate management of patients with epidural catheters and an awareness of potential complications, along with the proper management of these complications in these patients, is crucial for high quality care. David A. Rosen, MD Professor of Pediatrics and Anesthesia Denzil W. Hawkinberry, MD Resident in Anesthesia Department of Anesthesia Robert C. Byrd Health Science Center West Virginia University School of Medicine Morgantown, WV

MR imaging of epidural hematoma in the lumbar spine.

To bring attention to the MR imaging appearance of epidural hematoma (EDH) in the lumbar spine as a small mass often associated with disk herniation or an acute event. This paper will show our experience with this entity and describe criteria for its MR imaging appearance. Thirteen cases of prospectively diagnosed EDH of the lumbar spine were compared with 12 cases of prospectively diagnosed prominent epidural extrusion. Our criteria were retrospectively evaluated by the two authors for their presence or absence in each case. The chi-square test for nominal data was applied. MR imaging criteria utilized to distinguish EDH from disk herniation at our institution include: (1) signal different from disk, (2) high signal on T1-weighted images, either centrally or peripherally, (3) teardrop- or egg-shaped mass, in the sagittal plane, (4) size greater than half the vertebral body height in a craniocaudal dimension, (5) primarily retrosomatic epidural location, (6) plasticity - the mass is seen to conform closely to the contours of bone (e.g., in the lateral recess), (7) little or no disk space narrowing unless associated with disc herniation. Chi-square analysis demonstrated each criterion to significantly differentiate between EDH and extrusion. Only six of 13 EDH cases went to surgery in spite of their relatively large size. Two of six patients were diagnosed as having epidural clot consistent with hematoma at the time of surgery. The four patients who were not diagnosed at surgery revealed only small disk herniations or fragments of disk. The occurrence of EDH is more frequent than previously suspected. Spontaneous EDH is frequently associated with disk herniation and acute events such as sneezing or coughing. Most cases of spontaneous EDH will resolve prior to surgery with only the minority becoming chronic in order to be seen at surgery as an encapsulated mass. MR imaging can reliably identify EDH and distinguish between EDH and large disk extrusions.