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.
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.
Acute hemiparesis is a common initial presentation of ischemic stroke. Although hemiparesis due to spontaneous spinal epidural hematoma (SSEH) is an uncommon symptom, a few cases have been reported and misdiagnosed as cerebral infarction.
Case reports of SSEH with acute hemiparesis.
In these two cases, acute stroke was suspected initially and administration of intravenous alteplase therapy was considered. In one case, the presentation was neck pain and in the other case, it was Lhermitte's sign; brain magnetic resonance imaging (MRI) and magnetic resonance angiography were negative for signs of ischemic infarction, hemorrhage, or arterial dissection. Cervical MRI was performed and demonstrated SSEH.
Clinicians who perform intravenous thrombolytic treatment with alteplase need to be aware of this possible contraindication.
Spontaneous spinal epidural hematoma; Hemiparesis; Tetraparesis; Lhermitte's sign; Cerebral infarction; Intravenous thrombolytic treatment; Magnetic resonance imaging; Computerized tomography; Alteplase
We describe a case of acute lumbar epidural hematoma at the L2-3 level complicated by paraplegia, which occurred after coagulation disorder because of massive bleeding intraoperatively in cesarean section. The preoperative coagulation laboratory finding was in normal range and so we tried combined spinal epidural anesthesia. Uterine atony occurred in the operation, and there was persistant bleeding during and after the operation. After the operation, she complained of paresthesia on her both legs and was diagnosed with epidural hematoma (EDH) by radiologic examination. Emergency laminectomy on lumbar spine was carried out for hematoma evacuation and decompression of the epidural space at once. In our experience, massive bleeding during surgery may potentially increase the risk of EDH postoperatively.
Blood coagulation disorder; Cesarean section; Epidural anesthesia; Epidural hematoma; Postpartum hemorrhage; Spinal anesthesia
Spontaneous spinal epidural hematoma is a relatively rare but potentially disabling disease. Prompt timely surgical management may promote recovery even in severe cases.
We report a 34-year-old man with a 2-hour history of sudden severe back pain, followed by weakness and numbness over the bilateral lower limbs, progressing to intense paraparesis and anesthesia. A spinal magnetic resonance imaging scan was performed and revealed an anterior epidural hematoma of the thoracic spine. He underwent an emergency decompression laminectomy of the thoracic spine and hematoma evacuation. Just after surgery, his lower extremity movements improved. After 1 week, there was no residual weakness and ambulation without assistance was resumed, with residual paresthesia on the plantar face of both feet. After 5 months, no residual symptoms persisted.
The diagnosis of spontaneous spinal epidural hematoma must be kept in mind in cases of sudden back pain with symptoms of spinal cord compression. Early recognition, accurate diagnosis and prompt surgical treatment may result in significant improvement even in severe cases.
Spinal epidural hematoma is a rare complication associated with pain control procedures such as facet block, acupuncture, epidural injection, etc. Although it is an uncommon cause of acute myelopathy, and it may require surgical evacuation. We report four patients with epidural hematoma developed after pain control procedures. Two procedures were facet joint blocks and the others were epidural blocks. Pain was the predominant initial symptom in these patients while two patients presented with post-procedural neurological deficits. Surgical evacuation of the hematoma was performed in two patients while in remaining two patients, surgery was initially recommended but not performed since symptoms were progressively improved. Three patients showed near complete recovery except for one patient who recovered with residual deficits. Although, spinal epidural hematoma is a rare condition, it can lead to serious complications like spinal cord compression. Therefore, it is important to be cautious while performing spinal pain control procedure to avoid such complications. Surgical treatment is an effective option to resolve the spinal epidural hematoma.
Spinal epidural hematoma; Pain control procedure; Surgical evacuation
The main complication of cerebral cavernous angioma is hemorrhage. Ischemic stroke as a complication of cerebral cavernous angioma has rarely been described, and hemorrhage after ischemic Wallenberg's syndrome has not been reported before.
A 45-year-old woman presented with perioral numbness, hoarseness, dysphagia, and worsening of her previous sensory symptoms. The patient had been taking aspirin for 3 years after suffering from ischemic Wallenberg's syndrome with left paresthesia as a residual symptom. Brain computed tomography revealed an acute medullary hematoma in the previously infarcted area. Follow-up magnetic resonance imaging revealed a cavernous angioma in the right medulla.
We presume that cerebral cavernous angioma was responsible for both the ischemia and the hemorrhage, and we also cautiously speculate that the aspirin contributed to the development of hemorrhage in the previously infarcted area.
cavernous angioma; hemorrhage; ischemia; medulla oblongata
Spontaneous spinal epidural haemorrhage is a rare condition. The initial clinical manifestations are variable. Nonetheless, most spinal cord lesions result in paraparesis or quadriparesis, but not hemi-paresis, if motor function is involved. We report on a 69-year-old man who presented initially with right-side limb weakness. He was initially misdiagnosed at emergency room with a cerebral stroke and treated inappropriately with heparin. One day after admission, correct diagnosis of acute spinal epidural haematoma was based on the repeated neurological examination and cervical magnetic resonance imaging study. The patient underwent emergency surgical decompression and hematoma removal. The pathogenesis of the haematoma could have been due to hypertension, increased abdominal pressure and anticoagulant therapy. We emphasize that patients with hemi-paresis on initial presentation could have an acute spinal epidural haemorrhage. We also draw the misdiagnosis to the attention of the reader because early recognition of spontaneous spinal epidural haematoma is very important for prompt and appropriate treatment to improve the overall prognosis.
Spontaneous spinal epidural haemorrhage; Hemi-paresis; Cerebrovascular disease
Compressive femoral and lateral femoral cutaneous neuropathies from an iliacus hematoma are unusual presentation. We report a case of a 16-year-old boy who developed right femoral and lateral femoral cutaneous neuropathies as a complication of traumatic ipsilateral iliacus hematoma formation. The patient complained of numbness in the right thigh and calf as well as right leg weakness, and pain in the right inguinal area. Nerve conduction study and needle electromyography identified the neuropathies. After the electrodiagnostic studies, the pelvic bone MRI revealed a large, 9×5×4.5 cm right iliacus hematoma. As a result, diagnosis of a right iliacus hematoma compressing the femoral and lateral femoral cutaneous nerves was made, and the patient underwent an operation to remove the hematoma. Symptoms and neurological signs showed notable improvement after surgical decompression. Subsequent follow-up electrodiagnostic studies after 11 weeks demonstrated regeneration evidence.
Femoral neuropathy; Meralgia paresthetica; Iliacus hematoma
Thrombolysis is strongly recommended for patients with significant neurologic deficits secondary to acute ischemic stroke. Extracranial bleeding is a rare but major complication of thrombolysis.
A 78-year-old woman presented with acute ischemic stroke caused by occlusion of the basilar artery. Clinical recovery was observed after successful recanalization by intravenous thrombolysis and intraarterial thrombectomy. However, the patient complained of sudden abdominal pain following the intervention and a newly developed abdominal wall mass was found. CT scan and selective angiography confirmed active bleeding from the left epigastric artery into the abdominal muscle layer and the bleeding was successfully managed by selective embolization of the bleeding artery.
We report a rare case of abdominal wall hemorrhage after thrombolysis for acute ischemic stroke. The findings indicate that abdominal wall hemorrhage should be considered as a differential diagnosis in the presence of abdominal discomfort after thrombolysis for acute ischemic stroke.
Abdominal wall hemorrhage; Extracranial hemorrhage; Thrombolysis
For the last 15 years, alteplase (recombinant tissue plasminogen activator) has been used widely throughout the world for the treatment of acute ischemic stroke. Although considered to be safe and effective, like all drugs, alteplase has side effects.
This retrospective cohort study was conducted in the intensive care unit of the department of internal medicine in a mid-size peripheral acute hospital in Germany. Patients with acute ischemic stroke who underwent alteplase-induced thrombolysis were investigated.
Among the 1017 patients admitted for stroke investigation, 23 (2.26%) received thrombolytic therapy consisting of intravenous alteplase. Of these, six patients (26.09%) experienced complications, ie, four (17.39%) had intracerebral hemorrhage, one (4.35%) developed orolingual angioedema, and one (4.35%) had a hematoma on the right arm. After treatment with alteplase, two (33.33%) patients in the study group (n = 6) died because of intracerebral hemorrhage and one (16.67%) died because of aspiration pneumonia. One (5.88%) patient in the control group (n = 17) died of cerebral edema.
The incidence of stroke and number of patients treated with alteplase in the examined hospital subunit has not increased in recent years. Also, in this study, no statistically significant difference was found in the incidence of various complications occurring during treatment for acute ischemic stroke with alteplase, but intracerebral hemorrhage was the most common complication.
alteplase; complications; acute ischemic stroke; safety; efficacy
After publication of the results of the National Institute of Neurological Disorders and Stroke study, the application of intravenous thrombolysis for ischemic stroke was launched and has now been in use for more than 10 years. The approval of this drug represented only the first step of the therapeutic approach to this pathology. Despite proven efficacy, concerns remain regarding the safety of recombinant tissue-type plasminogen activator for acute ischemic stroke used in routine clinical practice. As a result, a small proportion of patients are currently treated with thrombolytic drugs. Several factors explain this situation: a limited therapeutic window, insufficient public knowledge of the warning signs for stroke, the small number of centers able to administer thrombolysis on a 24-hour basis and an excessive fear of hemorrhagic complications. The aim of this review is to explore the clinical efficacy of treatment with alteplase and consider the hemorrhagic risks.
rt-PA; acute ischemic stroke; intracranial hemorrhage
Purpose: Bleeding is the major side effect of thrombolysis with alteplase (tissue plasminogen activator, t-PA) used for the treatment of acute ischemic stroke. Life-threatening intracranial, retroperitoneal, gastrointestinal, respiratory, and genitourinary bleeding can occur with the use of t-PA. Vitreo-retinal bleeding in the context of acute ischemic stroke treatment has not been reported in the literature before and therefore is not posed as a potential risk during decision making. Here we describe the first reported case of vitreo-retinal hemorrhage due to alteplase administration in a patient with acute ischemic stroke. Summary: An 84-year-old white male presented to the emergency room with complaints of right arm and leg weakness. The onset of symptoms was approximately 30 min prior to presentation to the emergency room. After ruling out contraindications including the presence of hemorrhage on head CT scan, patient was administered alteplase within 2 hours of symptom onset. Four hours after the administration of alteplase, the patient developed right-sided vision changes. A repeat CT scan demonstrated a newly developed right intraocular hemorrhage. Throughout the hospital course, patient’s neurological status improved, but he continued to have right-sided visual loss. Conclusion: Clinicians should be aware of the potential for ocular hemorrhage especially in high-risk patients. The likelihood of a subsequent vision-loss needs to be therefore discussed with the patient and family in such situations.
stroke; alteplase; ocular; retinal; hemorrhage; thrombolysis; t-PA
Spontaneous intracranial hypotension (SIH), typically presents with orthostatic headache, low pressure on lumbar tapping, and diffuse pachymeningeal enhancement on magnetic resonance imaging. SIH is often accompanied by subdural fluid collections, which in most cases responds to conservative treatment or spinal epidural blood patch. Several authors advocate that large subdural hematoma with acute deterioration merits surgical drainage; however, few have reported complications following craniotomy. We describe a complicated case of SIH, which was initially diagnosed as acute subarachnoid hemorrhage with bilateral chronic subdural hematoma (SDH), due to unusual presentation. Burr hole drainage of subdural hematoma was performed due to progressive decrease of consciousness, which then resulted in a huge postoperative epidural hematoma collection. Prompt hematoma evacuation did not restore the patient's consciousness but aggravated downward brain herniation. Trendelenburg position and spinal epidural blood patch achieved a rapid improvement in patient's consciousness. This case indicates that the surgical drainage for chronic SDH in SIH can lead to serious complications and it should be cautiously considered.
Chronic subdural hematoma; craniotomy; spontaneous intracranial hypotension; subarachnoid hemorrhage
Bilateral extradural hematomas have only rarely been reported in the literature. Even rarer are cases where the hematomas develop sequentially, one after removal of the other. Among 187 cases of operated epidural hematomas during past 4 years in our hospital, we found one case of sequentially developed bilateral epidural hematoma.
An 18-year-old conscious male worker was admitted to our hospital after a fall. After deterioration of his consciousness, an emergency brain CT scan showed a right temporoparietal epidural hematoma. The hematoma was evacuated, but the patient did not improve afterwards. Another CT scan showed contralateral epidural hematoma and the patient was reoperated. Postoperatively, the patient recovered completely.
This case underlines the need for monitoring after an operation for an epidural hematoma and the need for repeat brain CT scans if the patient does not recover quickly after removal of the hematoma, especially if the first CT scan has been done less than 6 hours after the trauma. Intraoperative brain swelling can be considered as a clue for the development of contralateral hematoma.
bialteral; epidual; hematoma
Background. Recurrent ischemic stroke is associated with adverse neurological outcome in patients with atrial fibrillation. There is very scarce information regarding the neurological outcome of atrial fibrillation patients undergoing repeated systemic thrombolysis after early recurrent ischemic stroke. Clinical Case and Discussion. We describe a case of a 76-year-old woman with known paroxysmal atrial fibrillation who was admitted because of an acute right middle cerebral artery ischemic stroke and who underwent repeated systemic thrombolysis within 110 hours. The patient underwent systemic thrombolysis after the first ischemic stroke with almost complete neurological recovery. On the fourth day after treatment, an acute left middle cerebral artery ischemic stroke was diagnosed and she was treated with full-dose intravenous recombinant tissue plasminogen activator. A hemorrhagic transformation of the left middle cerebral artery infarction was noted on follow-up cranial computed tomographic scans. The patient did not recover from the second cerebrovascular event and died 25 days after admission. Conclusion. To the best of our knowledge, this is the second case reporting the adverse neurological outcome of a patient with diagnosis of atrial fibrillation undergoing repeated systemic thrombolysis after early recurrent ischemic stroke. Our report represents a contribution to the scarce available evidence suggesting that repeated systemic thrombolysis for recurrent ischemic stroke should be avoided.
A 67-year-old man with degenerative lumbar spinal stenosis and a medical history significant for coronary artery disease underwent routine lumbar surgical decompression. The objective of this study was to report a case of postoperative epidural hematoma associated with the use of emergent anticoagulation, including the dangers associated with spinal decompression and early postoperative anticoagulation.
After anticoagulation therapy for postoperative myocardial ischemia, the patient developed paresis with ascending abdominal paraesthesias. Immediate decompression of the surgical wound was carried out at the bedside. Magnetic resonance imaging revealed a massive spinal epidural hematoma extending from the middle of the cervical spine to the sacrum. Emergent cervical, thoracic, and revision lumbar laminectomy without fusion was performed to decompress the spinal canal and evacuate the hematoma.
Motor and sensory function returned to normal by 14 days postoperatively, but bowel and bladder function continued to be impaired. Postoperative radiographs showed that coronal and sagittal spinal alignment did not change significantly after extensive laminectomy.
Full anticoagulation should be avoided in the early postoperative period. In cases requiring early vigorous anticoagulation, patients should be closely monitored for changes in neurologic status. Combined cervical, thoracic, and lumbar laminectomy, without instrumentation or fusion, is an acceptable treatment option.
Spinal stenosis, lumbar; Spinal decompression; Anticoagulation; Epidural hematoma; Laminectomy
Spinal epidural hematomas (SEHs) are rare complications following spine surgery, especially for single level lumbar discectomies. The appropriate surgical management for such cases remains to be investigated. We report a case of an extensive spinal epidural hematoma from T11-L5 following a L3-L4 discectomy. The patient underwent a single level L4. A complete evacuation of the SEH resulted in the patient's full recovery. When presenting symptoms limited to the initial surgical site reveal an extensive postoperative SEH, we propose: to tailor the surgical exposure individually based on preoperative findings of the SEH; and to begin the surgical exposure with a limited laminectomy focused on the symptomatic levels that may allow an efficient evacuation of the SEH instead of a systematic extensive laminectomy based on imaging.
Epidural; Hematoma; Spine; Surgery; Management; Emergency; Postoperative
Thrombolysis for acute ischemic stroke has remained controversial. The Canadian Alteplase for Stroke Effectiveness Study, a national prospective cohort study, was conducted to assess the effectiveness of alteplase therapy for ischemic stroke in actual practice.
The study was mandated by the federal government as a condition of licensure of alteplase for the treatment of stroke in Canada. A registry was established to collect data over 2.5 years for stroke patients receiving such treatment from Feb. 17, 1999, through June 30, 2001. All centres capable of administering thrombolysis therapy according to Canadian guidelines were eligible to submit patient data to the registry. Data collection was prospective, and follow-up was completed at 90 days after stroke. Copies of head CT scans obtained at baseline and at 24–48 hours after the start of treatment were submitted to a central panel for review.
A total of 1135 patients were enrolled at 60 centres in all major hospitals across Canada. The registry collected data for an estimated 84% of all treated ischemic stroke patients in the country. An excellent clinical outcome was observed in 37% of the patients. Symptomatic intracranial hemorrhage occurred in only 4.6% of the patients (95% confidence interval [CI] 3.4%–6.0%); however, 75% of these patients died in hospital. An additional 1.3% (95% CI 0.7%–2.2%) of patients had hemiorolingual angioedema.
The outcomes of stroke patients undergoing thrombolysis in Canada are commensurate with the results of clinical trials. The rate of symptomatic intracranial hemorrhage was low. Stroke thrombolysis is a safe and effective therapy in actual practice.
Symptomatic spontaneous spinal epidural hematoma(SSEH) is an uncommon cause of cord compression that commonly is considered as an indication for emergent surgical decompression. We aimed to investigate a patient with a SSEH that completely resolved clinically and radiographically, without surgical treatment. The patient presented three days after the sudden onset of back pain, numbness, and weakness. Magnetic Resonance Imaging (MRI) revealed a posterior thoracolumbar epidural hematoma extending from the level of T10 to L2 with significant cord compression. Decompression was recommended but he refused surgery and was managed conservatively. One month later, weakness totally recovered and hematoma was absent on MRI.
Spinal epidural hematoma; Cord compression; Conservative therapy
Symptomatic spontaneous spinal epidural hematoma(SSEH) is an uncommon cause of cord compression that commonly is considered an indication for emergent surgical decompression. We aimed to investigate a patient with a SSEH that completely resolved clinically and radiographically, without surgical treatment. The patient presented three days after the sudden onset of back pain, numbness, and weakness. Magnetic Resonance Imaging (MRI) revealed a posterior thoracolumbar epidural hematoma extending from the level of T10 to L2 with significant cord compression. Decompression was recommended but he refused surgery and was managed conservatively. One month later weakness totally recovered and hematoma was absent on MRI.
Spinal epidural hematoma; Cord compression; Conservative therapy
Intracranial subdural hematoma following spinal anesthesia is an infrequent occurrence in the obstetric population. Nevertheless, it is a potentially life-threatening complication. In the majority of the cases, the first clinical symptom associated with intracranial subdural bleeding is severe headache, but the clinical course may have different presentations. In this report, we describe the case of a 38-year-old woman with an acute intracranial subdural hematoma shortly after spinal anesthesia for cesarean section. Early recognition of symptoms of neurologic impairment led to an emergency craniotomy for hematoma evacuation with good recovery of neurologic functions. The possibility of subdural hematoma should be considered in any patient complaining of severe persistent headache following regional anesthesia, unrelieved by conservative measures. Only early diagnosis and an appropriate treatment may avoid death or irreversible neurologic damage.
Reversal of early ischemic injury on diffusion-weighted MRI (DWI) occurs rarely. In a stroke patient who abruptly developed stupor and left hemiparesis, DWI scanned 78 min after onset demonstrated a large ischemic injury in the right hemisphere with a DWI-ASPECTS (Albert Stroke Program Early Computed Tomography Score) of 5 points, although baseline brain CT was perfectly normal. MR angiography (MRA) showed an occlusion of the right middle cerebral artery trunk, and the patient received intravenous thrombolysis 105 min after onset. A second MRA 30 h later showed complete vessel recanalization, and DWI demonstrated a perfect reversal of the initial large ischemic injury, associated with very small thrombus-fragmented cortical surface infarctions. Outcome at 3 months was a modified Rankin Scale score of 0, and the fluid-attenuated inversion recovery image showed only a small final infarction at the cortical surface. Hyper-acute DWI-defined large ischemic injury may very rarely represent a nearly perfect reversible area, and it may be a therapeutic target.
Diffusion-weighted MRI; Ischemic stroke; Reversal; Thrombolysis
This case details the possible relationship between a reported mild concussion and an acute subdural hematoma in a football athlete. Concussion grading scales and return-to-play guidelines are also discussed.
An otherwise healthy athlete suffered a re- ported mild concussion, and continued symptoms led to the diagnosis of postconcussion syndrome. The patient returned to football 25 days after the injury and sustained a second head injury 10 days later. He became unconscious and presented with decerebrate posturing, a fixed and dilated left pupil, shallow breathing, right-sided paralysis, and bilateral Babinski signs.
Possible pathologies included subdural hematoma, epidural hematoma, cerebrovascular accident, cerebral edema, and intracerebral hemorrhage.
Computerized tomography indicated fluid overlying the left hemisphere and temporal fossa. Two burr holes released acute and clotted subdural blood. After 19 days, the patient was discharged without neurologic deficit.
Traditionally, acute subdural hematomas are thought to result from single traumatic incidents. However, individuals may be more susceptible to such pathology after recent head trauma.
Recent mild head injury may increase the risk for catastrophic pathology. This case emphasizes the importance of using concussion grading scales and adhering to return-to-play guidelines, as well as the use of additional diagnostic techniques after mild head Injury.
head injury; mild brain injury; second-impact syndrome
Therapeutic guidelines of intravenous thrombolysis with tissue plasminogen activator (tPA) for hyperacute ischemic stroke are very strict. Because of potential higher risk of bleeding complications, the presence of unruptured cerebral aneurysm is a contraindication for systemic thrombolysis with tPA. According to the standard CT criteria, a 66-year-old woman who suddenly developed aphasia and hemiparesis received intravenous tPA within 3 h after ischemic stroke. Magnetic resonance angiography during tPA infusion was performed and the presence of a small unruptured cerebral aneurysm was suspected at the anterior communicating artery. Delayed cerebral angiography confirmed an aneurysm with a size of 7 mm. The patient did not experience any adverse complications associated with the aneurysm. Clinical experiences of this kind of accidental off-label thrombolysis may contribute to modify the current rigid tPA guidelines for stroke.
Aneurysm; Stroke; Thrombolysis; Tissue plasminogen activator