Intrathecal Hematoma Research Articles

A case of massive intrathecal hematoma of the rectus abdominis secondary to acute severe carbon monoxide poisoning

Acute carbon monoxide poisoning can cause hypoxic injury to multiple organs. Neurological impairment and cardiac dysfunction are common manifestations of severe poisoning patients, but hemorrhagic complications are rare in clinic. The clinical diagnosis and treatment of a case of massive intrathecal hematoma of the rectus abdominis secondary to acute severe carbon monoxide poisoning was reported. The pathophysiological mechanism and treatment strategy of rectus sheath hematoma secondary to acute severe carbon monoxide poisoning was analyzed, in order to improve the understanding of hemorrhagic complications of carbon monoxide poisoning. This case suggests that for patients with a history of cardiovascular disease and taking anticoagulants, clinicians should be alert for the risk of bleeding when making medical decisions.

Intrathecal hematoma following epidural blood patch: An alternative mechanism to intrathecal puncture.

Intrathecal blood after a percutaneous epidural blood patch is a known complication, one that has been previously attributed to inadvertent needle tip position in the subarachnoid space. We present two cases with imaging confirmation of an alternative mechanism, one that includes blood transferring from the epidural space to the subarachnoid space through a pre-existing dural defect.

Intrathecal hematoma as a neuraxial complication of lumbar cerebrospinal fluid drainage for endovascular repair of a thoracic aortic aneurysm.

Intrathecal hematoma as a neuraxial complication of lumbar cerebrospinal fluid drainage for endovascular repair of a thoracic aortic aneurysm.

Intrathecal hematoma and sacral radiculitis following repeat epidural blood patch.

Postdural puncture headache (PDPH) is an incapacitating complication that can occur following spinal anesthesia and with inadvertent dural puncture during epidural anesthesia. We present a case of a 32-year-old G2P1 female who was admitted for induction of labor and received epidural catheter placement for analgesia. After an inadvertent dural puncture and development of a PDPH, the patient was offered conservative measures for the first 48 hours without improvement. An epidural blood patch (EBP) was placed achieving only moderate relief. Two days later, a second EBP was performed and the patient developed severe back pain which radiated bilaterally to her buttocks. Magnetic resonance imaging (MRI) demonstrated the presence of blood in the intrathecal space. This could be the cause of sacral radiculitis, an uncommon complication of an EBP. This suggests that EBPs could potentially cause neurologic symptoms which may be more common than people previously thought. As complicated outcomes have followed both conservative and aggressive management, MRI can be an early diagnostic tool in such cases and a multidisciplinary approach should be taken.

Outcomes of a Spinal Drain and Intraoperative Neurophysiologic Monitoring Protocol in Thoracic Endovascular Aortic Repair

Adjuncts for early detection and treatment of spinal cord ischemia (SCI) in thoracic aortic surgery are supported by robust clinical experience in open repair. The utility of cerebrospinal fluid (CSF) drainage and neurophysiologic monitoring (NPM) in thoracic endovascular aortic repair (TEVAR) is less clear. The purpose of this investigation is to determine the influence of a selective institutional spinal cord protection protocol using prophylactic NPM and CSF on outcomes for standard TEVAR. Patients undergoing standard TEVAR entered into a prospectively maintained database from a single institution from 2007 to 2016 were retrospectively reviewed. Preoperative characteristics, aneurysm extent, and etiology were reviewed. Utilization of CSF drains including volume of fluid removed, duration of drainage, and catheter-related complications were collected. NPM data were reviewed to determine the influence on intraoperative management. Exact logistic regression was used to identify independent predictors of SCI. Of 223 patients undergoing TEVAR, 130 met inclusion criteria for the study. CSF drains were used in 71 patients (54.6%), and 56 of 130 (43%) had NPM. SCI occurred in 7 patients (5.4%), of whom 5 had partial or complete recovery. Median time to symptoms of SCI was delayed in all cases (median 52hr, range 8-312), and none of the 4 of 7 patients with adjunct NPM demonstrated intraoperative changes. Intraoperative changes in NPM occurred in 26 (46%), and represented unilateral leg ischemia in all but 2 cases. In both patients, changes consistent with SCI were associated with intraoperative hypotension and resolved with blood pressure augmentation. Neither patient developed postoperative SCI. Median length of stay (22 vs. 9days, P=0.012), operative room time (262 vs. 209, P=0.040), and perioperative mortality (28.6% vs. 4.1%, P=0.046) were significantly higher for patients with SCI versus those without. Length of aortic coverage was found to be the sole independent predictor of SCI (odds ratio 8.2, P=0.026). Complications related to CSF drainage occurred in 4 patients (5.6%) with major complications occurring in 2 patients (2.8%), including 1 with an intrathecal hematoma and permanent bilateral paraparesis. Selective use of prophylactic CSF drainage in TEVAR was associated with moderate risk and questionable benefit. The use of neurophysiological monitoring allowed for early detection and treatment of spinal ischemia, but its utility is limited by logistical factors and to the minority of patients with intraoperative spinal ischemic events.

Intrathecal Hematoma and Arachnoiditis Mimicking Bacterial Meningitis After an Epidural Blood Patch

(Int J Obstet Anesth 2017;32:77–78) Epidural blood patch (EBP) is the most effective method to treat postdural puncture headache and has a low rate of complications. However, severe complications such as cauda equina syndrome and seizures have rarely been reported. This case report describes a woman who underwent an EBP and later presented with symptoms concerning for meningitis, but was ultimately found to have arachnoiditis from an intrathecal hematoma.

A complication of an epidural blood patch

C. Subdural hematoma. Epidural blood patch (EBP) is generally accepted as an effective and relatively low risk therapeutic option for post dural puncture headache, as well spontaneous spinal cerebrospinal fluid (CSF) leak in patients not responding to conservative management [[1]Mokri B. Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks.Headache. 2013; 53: 1034-1053Crossref PubMed Scopus (196) Google Scholar]. Subdural hematoma (SDH) after EBP is a very rare complication. As in the case described by Verduzco et al., our patients also demonstrated an eight segment spread of the hematoma [[2]Verduzco L.A. Atlas S.W. Riley E.T. Subdural hematoma after an epidural blood patch.Int J Obstet Anesth. 2012; 21: 189-192Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. There are generally three predominant theories for development of SDH after EBP [3Riley C.A. Spiegel J.E. Complications following large–volume epidural blood patches for postdural puncture headache.J Clin Anesth. 2009; 21: 355-359Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 4Devroe S. Van de Velde M. Demaerel P. et al.Spinal subdural hematoma after an epidural blood patch.Int J Obstet Anesth. 2015; 24: 288-289Abstract Full Text Full Text PDF Scopus (10) Google Scholar]. One is that the initial dural puncture with the Tuohy needle created a means of communication between the epidural and subdural spaces. The other is that the Tuohy needle was in the subdural space during the EBP with the blood injected into the subdural space. A third possibility is that both events occurred simultaneously. Intrathecal injection of an EBP has also been reported following accidental dural puncture with MRI demonstrating the intrathecal hematoma [[5]Kalina P. Craigo P. Weingarten T. Intrathecal injection of epidural blood patch.Emerg Radiol. 2004; 11: 56-59Crossref PubMed Scopus (38) Google Scholar]. A complication of an epidural blood patchJournal of Clinical NeuroscienceVol. 31PreviewA 58-year-old woman presented 1 week following an epidural blood patch (EBP) performed due to spontaneous cerebrospinal fluid (CSF) leak (diagnosed by intracranial MRI findings of CSF hypotension obtained for headaches). A spine MRI was performed as part of the continuing work-up to identify the source of the CSF leak (Fig. 1). She was otherwise asymptomatic. Full-Text PDF

Sonographically Guided Lumbar Puncture in Pediatric Patients

Our aim with this study was to develop a user-friendly method for pediatric sonographically guided lumbar punctures so that we can visualize intrathecal anatomy, confirm intrathecal injection at the time of injection, and, most importantly, avoid ionizing radiation to a child's already radiosensitive pelvis. Sonographically guided lumbar puncture was prospectively performed in children aged 7 weeks to 16 years. All attempts (n = 9) were successful. We were able to identify relevant anatomy (including the conus in children 10 years and younger), confirm intrathecal injection, visualize intrathecal hematoma, and avoid radiation. Sonography is a promising modality for image-guided lumbar punctures without radiation in children.

Acute Intrathecal Hematoma Following Neuraxial Anesthesia

Acute Intrathecal Hematoma Following Neuraxial Anesthesia

Post-traumatic lumbar subdural hematoma

A 20-year-old man presented with increasing low back and leg pain 4 days after he jumped and landed on his back during snowboarding. The straight-leg raising test was positive at 30°. Neurologic examination revealed decreased sensation in both legs and paralysis of the toes of both feet. Radiographs of the lumbar spine revealed normal findings. The patient's symptoms grew worse over time, and he was admitted to our hospital 7 days after the trauma. A sagittal magnetic resonance imaging (MRI) scan of the spine revealed the presence of an intrathecal hematoma that extended from the L3 to S1 vertebrae (Fig. 1).

Treatment of Post‐Dural Puncture Headache With Bilateral Greater Occipital Nerve Block

(Headache 2010;50:869-881) Epidural blood patch is an effective treatment with a low complication rate. It is also an invasive method that can cause permanent neurological sequelae such as early and late back pain, radiculopathy, spinal-subdural hematoma, spinal-epiarachnoid hematoma, intrathecal hematoma, arachnoiditis, and infection. We report a case in which a postdural puncture headache resolved within 2 minutes of a greater occipital nerve block, a minimally invasive and easy procedure with a low complication rate. This case report suggests that a greater occipital nerve block may be a successful alternative treatment for patients with post-dural puncture headache.

Intraoperative Spinal Subarachnoid Hematoma in a Patient With Cervical Ossification of the Posterior Longitudinal Ligament

Case report. To report a surgically treated case of cervical ossification of the posterior longitudinal ligament (OPLL), in which a spinal subarachnoid hematoma (SSAH) developed intraoperatively but was successfully treated. Previous reports have indicated that trauma, lumbar puncture, vascular lesions such as arteriovenous malformation, neoplastic lesions, and coagulopathy can cause SSAH. To the best of our knowledge, there has been no report that describes the occurrence of SSAH during anterior decompression surgery of the cervical spine. A 52-year-old man with cervical myelopathy caused by OPLL underwent surgery for anterior decompression from C2/3 to C6/7. Immediately after the OPLL floating procedure, cerebrospinal fluid leakage and massive bleeding occurred at right edge of the OPLL at the C3-C4 level. After hemostasis, the dura mater at the C5-C6 levels bulged rapidly and became cyanotic. Intraoperative ultrasonographic images showed a high-intensity mass lesion on the ventral side of the spinal cord, indicating an intrathecal hematoma. We incised the dura, found the hematoma under the intact arachnoid, and removed it. We then found that the bleeding occurred from the radicular artery along the right C4 root. After hemostasis, we performed anterior spine fusion from C2-C7. After surgery, the patient's myelopathy was improved, and no neurologic deficit related to the subarachnoid hematoma was found. This experience suggests that when anterior decompression surgery is performed for cervical OPLL patients, we should consider the possible occurrence of an SSAH. Intraoperative ultrasonography is a useful tool for detecting SSAHs.

Arachnoiditis and communicating hydrocephalus as a complication of epidural blood patch

Epidural blood patch (EBP) is propagated for postdural puncture headache with reported success rates between 70 and 98% [1]. EPB is considered a safe procedure, and sideeffects, besides transient local back and leg pain, have been rarely described [2]. We report a case of a patient with symptoms of a communicating hydrocephalus, which occurred after an EBP was performed 2 weeks earlier. This 26-year-old male was first seen in November 2008 because of severe pain at the dorsal aspect of the left leg which had suddenly started 5 days earlier. Previous medical history was unremarkable. At neurological examination a positive straight left leg raising test, decreased reflex of the left Achilles tendon and an impaired sensation in the S1 dermatoma were found. MRI of the lumbar spine showed no abnormalities. Because the symptoms persisted, and radiculitis was considered, a lumbar puncture was performed. CSF analysis showed no pleiocytosis (1 mm), no erythrocytes, and a normal protein level (19 mg/dl). Cytomegalovirus, Epstein Barr, and Borrelia antibodies were negative. Subsequently he developed severe headache which worsened by standing and was relieved in the supine position. Because the headache did not improve 1 week after the lumbar puncture, he underwent an EBP at the L4–5 level using the loss of resistance to saline technique [3]. No cerebrospinal fluid could be aspirated and 20 ml of autologous blood was slowly injected. Immediately after the procedure he complained of paraesthesia in both legs, which resolved after 30 min. Initially the headache resolved, but 2 weeks later worsened, now also present in the supine position. At neurological examination there was no meningismus and no papiloedema. MR imaging of the brain (Fig. 1) showed communicating hydrocephalus and no venous sinus thrombosis or subarachnoidal hemosiderin depositions. Lumbar puncture was repeated, with an opening pressure of 26 cm H2O. After drainage of 30 ml of yellowish cerebrospinal fluid the headache immediately improved. CSF analysis confirmed the presence of bilirubin with no erythrocytes, pleiocyosis (39 mm) and elevated protein (1,000 mg/dl). MRI of the lumbar-thoracic region revealed extensive clumping of nerve roots and linear enhancement of the surface of the nerve roots and spinal cord, consistent with arachnoiditis (Fig. 2). A ventriculoperitoneal drainage was performed which immediately resolved the headache. In our patient arachnoiditis and communicating hydrocephalus were probably caused by intrathecal injection of blood during the EBP, confirmed by the presence of bilirubin in the second CSF analysis. However, we cannot exclude a causative role of the prior lumbar puncture, which previously has been correlated with lumbar arachnoiditis [4]. Another cause of both events and the prior S1 lumbar radiculopathy seems unlikely, because of the initial normal MR and CSF analysis. With epidural anesthesia a 3% incidence of inadvertent injection of drugs into the subarachnoid space has been reported [5]. One case of intrathecal hematoma and arachnoiditis after an attempted EBP has been described [6]. Another report presented a case of neurological deterioration due to further increasing intracranial pressure after EBP in a patient with pre-existent hydrocephalus [7]. For intracranial subarachnoidal hemorrhage (SAH) it has been shown that the amount of N. Al Maach O. J. M. Vogels T. L. Bollen P. H. Wessels (&) Department of Neurology, St Antonius Hospital Nieuwegein, PO Box 2500, 3430 EM Nieuwegein, The Netherlands e-mail: p.wessels@antoniusziekenhuis.nl

MR imaging of the spine in nonaccidental trauma

An 8-week-old boy arrived intubated and was found to have a traumatic head injury, a coccygeal wound and multiple bruises. CT of the head showed a left parietal skull fracture with underlying subacute and chronic subdural hematomas. Ophthalmologic exam showed bilateral retinal hemorrhages. The hospital advocacy team suspected nonaccidental trauma after reviewing the history, physical exam and imaging findings. MRI of the brain showed bilateral frontal parietal cytotoxic edema and subdural subacute, chronic and subgaleal hematomas (not shown). MRI of the spine reveals a posterior intrathecal hematoma (probably subdural) with a fluid-fluid level consistent with blood product deposition (Fig. 1, arrows). Note also the diffuse swelling and hemorrhage in the subcutaneous tissues (Fig. 1, arrowheads) and ribs fracture with bone remodeling (Fig. 1, asterisk). The identification of the anatomic landmarks represented by the extradural fat (Fig. 2, arrow) and dura mater (Fig. 2, arrowheads) confirmed the intrathecal nature of the hematoma. The child was discharged home to protective care with the mother. Fig. 1 MRI spine. T2-W axial image

Neurological Deficits after Epidural Steroid Injection: Time Course, Differential Diagnoses, Management, and Prognosis Suggested by Review of Case Reports

Background. Neurological deficits after epidural steroid injection (ESI) are rare but occur despite meticulous technique. Some neurologic deficits reverse spontaneously, others reverse only with timely interventions, and some are permanent. Etiologies vary. Objectives. Assess the immediate diagnostic and treatment steps to undertake when a patient experiences a severe neurologic deficit so that the best neurologic recovery can be obtained. Design. The literature was systematically reviewed for case reports and case series describing neurologic deficit after ESI. Outcome Measures. From these reports, the mechanism, temporal onset, permanence or reversibility of the deficit, and assessment and management were recorded and analyzed. Results. Thirty-three cases of neurological deficits were identified: 19 permanent deficits and 14 reversible. Infarction was significantly associated with permanent deficits (P ≤ 0.008) and presented just after injection (P ≤ 0.03), compared with “noninfarct” groups. Temporal onset of differential diagnoses (subdural and intrathecal injection, hematoma, and vascular punctures) overlap. When deficits did not resolve consistent with inadvertent subdural/intrathecal injection, timely initial magnetic resonance imaging (MRI) should be carried out to diagnose mass lesions, which have an optimal 8-hour window for effective surgical intervention. Mass lesions have an excellent prognosis for recovery (83%) compared with infarctions (9%) (P ≤ 0.005). Conclusions. Faced with deficits after ESI that do not resolve, the physician will need access to MRI, or similar radiographic studies, and subsequent neurosurgical consultation and facilities if MRI results indicate a decompressible lesion. Respiratory insufficiency with quadriplegia and loss of consciousness can occur, and in the worst of scenarios, the physician would also need the capability to ventilate the patient.

Chronic Back Pain Secondary to a Calcified Epidural Blood Patch

Chronic Back Pain Secondary to a Calcified Epidural Blood Patch

Post-traumatic Glioma: Report of two Cases

We report two cases of brain glioma that developed in the scar of an old brain trauma. The first is that of a 40-year-old man who presented with severe headaches; CT and MRI showed a large mass in the right parietal region. The tumor was unresectable and surgical biopsy showed a glioblastoma multiforme. The patient had suffered a cranial trauma in a road accident 20 years previously with an intrathecal hematoma in the right parietal region. The second case concerns a 60-year-old man who, 15 years after severe head injury in a road accident, developed a glioblastoma multiforme which was localized in the scar of the brain contusion. These cases fulfill the established criteria for a traumatic origin of brain tumors and add further support to the relationship between cranial trauma and the onset of glioma. As stated by other authors, an association between head trauma and brain tumor risk cannot be ruled out and should be studied further.