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.
We report a series of epidural hematomas which cause neurologic deterioration after spinal surgery, and have taken risk factors and prognostic factors into consideration. We retrospectively reviewed the database of 3720 cases of spine operation in a single institute over 7 years (1998 April-2005 July). Nine patients who demonstrated neurologic deterioration after surgery and required surgical decompression were identified. Factors postulated to increase the postoperative epidural hematoma and to improve neurologic outcome were investigated. The incidence of postoperative epidural hematoma was 0.24%. Operation sites were cervical 3 cases, thoracic 2 cases, and lumbar 4 cases. Their original diagnoses were tumor 3 cases, cervical stenosis 2 cases, lumbar stenosis 3 cases and herniated lumbar disc 1case. The symptoms of epidural hematomas were neurologic deterioration and pain. After decompression, clinical outcome revealed complete recovery in 3 cases (33.3%), incomplete recovery in 5 cases (55.6%) and no change in 1 case (11.1%). Factors increasing the risk of postoperative epidural hematoma were coagulopathy from medical illness or anticoagulation therapy (4 cases, 44.4%) and highly vascularized tumor (3 cases, 33.3%). The time interval to evacuation of complete recovery group (29.3 hours) was shorter than incomplete recovery group (66.3 hours). Patients with coagulopathy and highly vascularized tumor were more vulnerable to spinal epidural hematoma. The postoperative outcome was related to the preoperative neurological deficit and the time interval to the decompression.
Clinical outcome; risk factor; postoperative; spinal epidural hematoma; spine surgery
Spontaneous spinal epidural hematoma (SSEH) is an uncommon neurological emergency which can present with the features ranging from simple back pain with radiculopathy to complete paraplegia or quadriplegia depending on the site and severity of the compression. Spinal hemorrhage associated with anti-platelet drugs is rarely seen. We report a case of SSEH in a 68-year-old hypertensive male who was on a low dose clopidogrel for secondary stroke prophylaxis and presented with bilateral lower limb paralysis, preceeded by severe back bain. A spinal magnetic resonance imaging scan was performed which revealed a posterior epidural hematoma of the thoraco-lumbar spine. To the best of our knowledge, not more than four cases of clopidogrel related spinal epidural hematoma have been reported. Emergent decompressive laminectomy was done within 4 hours of the presentation with excellent clinical outcome. Clinicians should, therefore, consider the remote risk of SSEH in hypertensive patients who are on anti-platelet drugs as early decompressive laminectomy and evacuation of the hematoma minimizes the permanent neurological damage.
Clopidogrel; decompressive laminectomy; hypertension; spontaneous spinal epidural hematoma
Spontaneous spinal epidural hematoma (SSEH) is a rare spinal cord compression disorder. Thunderclap headache mimicking subarachnoid hemorrhage as an initial manifestation of this disorder has been scarcely reported. Moreover, the neurological outcome of conservative treatment is satisfactory only in some clinical settings. The unusual presentation and mechanisms for spontaneous recovery of SSEH are discussed.
To report a case of SSEH that presented with acute severe headache that mimicked subarachnoid hemorrhage. After a period of neurological deficit, spontaneous improvement was seen, which progressed to full recovery without neurosurgical intervention.
A 62-year-old man presented with acute occipital headache and neck stiffness for which subarachnoid hemorrhage was initially suspected. An emergency computed tomographic brain scan and cerebrospinal fluid analysis excluded subarachnoid hemorrhage. Later, he developed acute paraparesis, hypoesthesia up to the fourth thoracic dermatomal level (T4) as well as bowel and bladder dysfunction. The magnetic resonance imaging eventually revealed spinal epidural hematoma, located anterior to C7 through T4 spinal level. He had no previous history of spinal injury, systemic, and hematological disorders. The neurological recovery began 20 hours after the onset and continued until complete recovery, 4 months after the onset without neurosurgical intervention.
SSEH could sometimes imitate subarachnoid hemorrhages when it located in the cervical region. Spontaneous recovery of SSEH without surgical intervention might be possible in cases with continuing neurological recovery, although the recovery began much later in the clinical course.
Headache; Spontaneous spinal epidural hematoma; Subarachnoid hemorrhage; Paraparesis
We intend to report the largest series of spinal epidural cavernomas (SEC), discuss their clinical features, imaging characteristics, surgical findings, outcome analysis and compare them with similar reports in the literature.
Among the cases of spinal tumors treated surgically by the authors, there have been nine cases of SEC’s. All the data were collected prospectively and the cases have been followed after surgery up to the time of this analysis.
There were six female and three male patients with the ages ranging between 13 and 74 years. The lesions were located in the thoracic spine (4 cases), lumbar spine (4 cases) and one at the sacral level. Clinical presentations included acute spinal pain and paraparesis in two, low back pain and radiculopathy in five, and slowly progressive myelopathy in the other two cases. The lesion was iso-intense with the spinal cord in T1W images and hyperintense in T2W images and showed strong homogeneous enhancement after contrast medium injection in most of our cases. In the presence of hemorrhage inside the lesion, it was hyperintense in both T1W and T2W MR sequences as in our case 6. In the single case presenting with acute hemorrhage, epidural hematoma was the only finding, our case 1. Complete surgical removal was achieved in all our cases, and confirmed by postoperative MRI.
SEC is hard to be differentiated from other epidural spinal lesions before intervention but should be considered in the list of differential diagnosis regarding its favorable outcome.
Cavernous angioma; Magnetic resonance imaging; Spinal epidural cavernoma; Spinal epidural lesion
Spinal epidural haemorrhage may present as back pain associated with radicular symptoms and can be a catastrophic clinical scenario with progression to paraplegia or even sudden death. Being a rare entity, it needs a high index of clinical suspicion to diagnose it. Fractures have been documented as a cause of hematorrachis but such hematomas only extend to one or two vertebral segments. Large epidural hematomas are usually associated with conditions like bleeding diathesis, arterio-venous malformations, plasma cell myeloma, and non-Hodgkin’s lymphoma. Surgical management with immediate evacuation of the hematoma is the usual line of management in patients with neurological deficits. Though rare, monitored and careful conservative management can lead to recovery of neurological symptoms and resolution of the hematoma. We report a case of a very large post traumatic epidural hematorrchis extending to 11 vertebral segments from D3 to L1 vertebral bodies, who had a gradual spontaneous recovery.
Compression fracture; Epidural hematoma; Hematorrachis
Spontaneous cervical SDH with no underlying pathology is a very unusual condition. To the best of the authors' knowledge, only two cases have been previously reported. A 48-year-old female patient was admitted to our emergency room due to severe neck pain following standing up position with rapid onset of hemiparesis. MRI revealed a dorsolateral subdural hematoma from C3-C5 with cord compression. An emergency laminectomy was planned, but motor weakness gradually improved during surgical preparation. The patient showed substantial clinical improvement and complete recovery was confirmed after 7 days of conservative management without surgical treatment. To determine a differential diagnosis distinct from other conditions such as cervical epidural hematoma, a lumbar spinal puncture was performed. Follow-up MRI performed 10 days after admission revealed complete resolution of the hematoma. We report an extremely rare case of spontaneous cervical spinal subdural hematoma (SDH), present a review of relevant literature, and discuss the etiology, pathogenesis, and prognosis of this case.
Cervical; Spontaneous; Subdural hematoma
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
Spinal epidural angiolipoma is a rare benign tumor containing vascular and mature adipose elements. A slow progressive clinical course was mostly presented and rarely a fluctuating course during pregnancy. The authors report the original case of spontaneous spinal epidural bleeding resulting from thoracic epidural angiolipoma who presented with hyperacute onset of paraplegia, simulating an extradural hematoma. The patient was admitted with sudden non-traumatic hyperacute paraplegia during a prolonged walk. Neurologic examination showed sensory loss below T6 and bladder disturbances. Spinal MRI revealed a non-enhanced heterogeneous thoracic epidural lesion, extending from T2 to T3. A bilateral T2–T4 laminectomy was performed to achieve resection of a lipomatous tumor containing area of spontaneous hemorrhage. The postoperative course was uneventful with complete neurologic recovery. Histologic examination revealed the tumor as an angiolipoma. Because the prognosis after rapid surgical management of this lesion is favorable, the diagnosis of spinal angiolipoma with bleeding should be considered in the differential diagnosis of hyperacute spinal cord compression.
Angiolipoma; Epidural spinal tumor; Spinal cord compression; Spinal epidural hematoma
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.
Analgesia; Epidural; Hematoma; Postoperative complications; Spinal
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
An 80-year-old white male suffered a stroke, fell to the floor, and suffered acute right hemiparesis and facial palsy. After an intravenous alteplase infusion 2.5 h later, the patient first complained of numbness in his right arm, then neck pain, followed by left leg numbness and slowly progressing paraparesis. MRI of the spine demonstrated an acute spinal dorsal epidural hematoma extending from the C6 to the T6 level; 12 h later, he underwent hematoma evacuation and laminectomy. Three months after surgery, the patient was paraplegic with moderate sensory loss below mamillary level. Acute ischemic stroke is often associated with a sudden fall, which, after thrombolysis, may result in unusual hemorrhagic complications.
Cerebral infarction; Thrombolysis; Spinal epidural hematoma
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.
Pyogenic spondylodiscitis represents a potentially life-threatening condition. Due to the low incidence, evidence-based surgical recommendations in the literature are equivocal, and the treatment modalities remain controversial.
A 59 year-old patient presented with a history of thoracic spondylodiscitis resistant to antibiotic treatment for 6 weeks, progressive severe back pain, and a new onset of bilateral lower extremity weakness. Clinically, the patient showed a deteriorating spastic paraparesis of her lower extremities. An emergent MRI revealed a kyphotic wedge compression fracture at T7/T8 with significant spinal cord compression, paravertebral and epidural abscess, and signs of myelopathy. The patient underwent surgical debridement with stabilization of the anterior column from T6–T9 using an expandable titanium cage, autologous bone graft, and an anterolateral locking plate. The patient recovered well under adjunctive antibiotic treatment. She presented again to the emergency department 6 months later, secondary to a repeat fall, with acute paraplegia of the lower extremities and radiographic evidence of failure of fixation of the anterior T-spine. She underwent antero-posterior revision fixation with hardware removal, correction of kyphotic malunion, evacuation of a recurrent epidural abscess, decompression of the spinal canal, and 360° fusion from T2–T11. Despite the successful salvage procedure, the patient deteriorated in the postoperative phase, when she developed multiple complications including pneumonia, acute respiratory distress syndrome, bacterial meningitis, abdominal compartment syndrome, followed by septic shock with multiple organ failure and a lethal outcome within two weeks after revision surgery.
This catastrophic example of a lethal outcome secondary to failure of anterior column fixation for pyogenic thoracic spondylodiscitis underlines the notion that surgical strategies for the infected spine must be aimed at achieving absolute stability by a 360° fusion. This aggressive – albeit controversial – concept allows for an adequate infection control by adjunctive antibiotics and reduces the imminent risk of a secondary loss of fixation due to compromises in initial fixation techniques.
Spinal epidural hematoma (SEH) causing acute myelopathy is rare. The usual clinical presentation of a SEH is sudden severe neck or back pain that progresses toward paraparesis or quadriparesis, depending on the level of the lesion. Recent studies have shown that early decompressive surgery is very important for patient's recovery. We experienced five patients of cervico-thoracic epidural hematomas associated with neurologic deficits that were treated successfully with surgical intervention.
Intraspinal; Epidural; Hematoma; Laminectomy
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
Idiopathic hypertrophic spinal pachymeningitis (IHSP) is a rare inflammatory disease characterized by hypertrophic inflammation of the dura mater and various clinical courses that are from myelopathy. Although many associated diseases have been suggested, the etiology of IHSP is not well understood. The ideal treatment is controversial. In the first case, a 55-year-old woman presented back pain, progressive paraparesis, both leg numbness, and voiding difficulty. Initial magnetic resonance imaging (MRI) demonstrated an anterior epidural mass lesion involving from C6 to mid-thoracic spine area with low signal intensity on T1 and T2 weighted images. We performed decompressive laminectomy and lesional biopsy. After operation, she was subsequently treated with steroid and could walk unaided. In the second case, a 45-year-old woman presented with fever and quadriplegia after a spine fusion operation due to lumbar spinal stenosis and degenerative herniated lumbar disc. Initial MRI showed anterior and posterior epidural mass lesion from foramen magnum to C4 level. She underwent decompressive laminectomy and durotomy followed by steroid therapy. However, her conditions deteriorated gradually and medical complications occurred. In our cases, etiology was not found despite through investigations. Initial MRI showed dural thickening with mixed signal intensity on T1- and T2-weighted images. Pathologic examination revealed chronic nonspecific inflammation in both patients. Although one patient developed several complications, the other showed slow improvement of neurological symptoms with decompressive surgery and steroid therapy. In case of chronic compressive myelopathy due to the dural hypertrophic change, decompressive surgery such as laminectomy or laminoplasty may be helpful as well as postoperative steroid therapy.
Idiopathic hypertrophic spinal pachymeningitis; Spinal cord compression; Chronic nonspecific inflammation; Dural thickening
Aim. Spontaneous cervical epidural hematoma (SCEH) is defined as an epidural hematoma that does not have an etiological explanation. The most common site for SCEH is cervicothoracic area. Early diagnosis and treatment are important for prognosis and good results. In this paper, we aimed to present a case who complains of sudden weakness on right extremities imitating cerebral stroke and that neuroimaging reveals spontaneous cervical epidural hematoma. Case. A 72-year-old woman was admitted to our hospital with acute neck pain and loss of strength on right extremities. On neurological examination, the patient had right hemiparesis. PT, aPTT, and INR results were 50.5, 42.8, and 4.8, respectively. Cranial MRI was in normal limits. Spinal MRI revealed a lesion that extends from C4 to C7 located on the right side and compatible with epidural hematoma. The patient was operated after normalization of INR values. Conclusion. Even though SCEH is a rare condition, it can cause severe morbidity and mortality. Early diagnosis and treatment are quiet important for prognosis. SCEH can easily be mistaken for stroke as with other pathologies and this diagnosis should come to mind especially in patients who have diathesis of bleeding.
Study Design Case report.
Objective We present the first reported case of spontaneous spinal epidural hematoma secondary to calcium pyrophosphate crystal deposition disease (pseudogout) in a 75-year-old woman.
Methods A retrospective review of the patient's case notes was undertaken and the limited literature on this subject reviewed.
Results This patient presented with sudden-onset lower limb paresis, sensory loss, urinary retention, and back pain. Magnetic resonance imaging showed an epidural hematoma, which was evacuated. Histologic specimens of the clot showed calcium pyrophosphate dihydrate crystal deposits (pseudogout).
Conclusion The importance of histopathologic review of surgical specimens is highlighted when considering the differential diagnosis of apparently spontaneous spinal epidural hematoma.
calcium pyrophosphate; spinal; epidural; hematoma
A review of the literature was conducted to study the pathomechanics by which Paget's Disease of bone (PD) alters the spinal structures that result in distinct spinal pathologic entities such as pagetic spinal arthritis, spinal stenosis, and other pathologies, and to assess the best treatment options and available drugs. The spine is the second most commonly affected site with PD. About one-third of patients with spinal involvement exhibit symptoms of clinical stenosis. In only 12–24% of patients with PD of the spine is back pain attributed solely to PD, while in the majority of patients back pain is either arthritic in nature or a combination of a pagetic process and coexisting arthritis. Neural element dysfunction may be attributed to compressive myelopathy by pagetic bone overgrowth, pagetic intraspinal soft tissue overgrowth, ossification of epidural fat, platybasia, spontaneous bleeding, sarcomatous degeneration and vertebral fracture or subluxation. Neural dysfunction can also result from spinal ischemia, when blood is diverted by the so-called ''arterial steal syndrome''. Because the effectiveness of pharmacologic treatment for pagetic spinal stenosis has been clearly demonstrated, surgical decompression should only be instituted after failure of antipagetic medical treatment. Surgery is indicated as a primary treatment when neural compression is secondary to pathologic fractures, dislocations, spontaneous epidural hematoma, syringomyelia, platybasia, or sarcomatous transformation. Since, in the majority of cases with pagetic spinal involvement, there are also coexisting osteoarthritic changes, antipagetic medical treatment alone may be disappointing. Therefore, one must be careful before attributing low back pain to PD alone. Five classes of drugs are available for the treatment of PD: bisphosphonates, calcitonins, mithramycin (plicamycin), gallium nitrate, and ipriflavone. Bisphosphonates are the most popular, and several forms have been investigated, but only the following forms have been approved for clinical use: disodium etidronate, clodronate, aledronate, risedronate, neridronate, pamidronate, tiludronate, ibadronate, aminohydroxylbutylidene bisphosphonate, olpadronate, and zoledronate. Several of these forms are still under investigation.
Paget's Disease Back pain Spinal stenosis Myelopathy Complications Medical treatment Surgery Review
Spontaneous spinal epidural hematoma is an uncommon cause of cord compression in children, especially in infants. An 8-month-old infant was admitted to our hospital for a 40-day history of paraparesis in the lower extremities. This rapidly progressed to paraparesis with an inability to move the lower extremities. MRI of the cervicothoracic spine revealed an epidural mass with compression of the spinal cord. The infant underwent C7-T3 total laminectomies. The pathology and postoperative MRI confirmed spinal epidural hematoma from a vascular malformation. We present the case to highlight the significance of recognizing this chronic spontaneous spinal epidural hematoma and discuss the diagnosis, treatment options and prognosis.
The spontaneous spinal epidural hematoma (SSEH) is a rare clinical entity. Patients typically present with sudden onset back pain followed by neurological deficits.
Diagnosis of SSEH is usually made with MRI and standard treatment is surgical evacuation. In 1996, Groen published the most comprehensive review on the SSEH in which he analyzed 333 cases. We review 104 cases of SSEH presented in the English literature since the last major review and add three of our own cases, for a total of 107 cases.
Our patients presented with back pain and neurologic deficits. Two made excellent functional recovery with prompt surgical decompression while one continued to have significant deficits despite evacuation. Better postoperative outcome was associated with less initial neurological dysfunction, shorter time to operation from symptom onset and male patients.
We discuss the etiology of SSEH and report current trends in diagnosis, treatment, and outcome.
Spinal epidural hematoma; Back pain; Neurological deficits; MRI
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
Background. Primary spinal dural lymphomas (PSDL) are tumors with characteristic histopathology of a lymphoma, which are completely in the spinal epidural space without any other systemic involvement. Extranodal primary lymphoma involving nervous system prefers thalamus/basal ganglia, periventricular region, cerebellum, eyes, meninges/dura, and cranial nerves or spinal cord. Rare spinal localization with acute spinal cord compression is worth attention. Case Presentation. A 48-year-old male presented with a several-month-long history of upper back pain. Lately, he had numbness and weakness at both lower extremities and was unable to walk for one week. A spinal MRI showed a thoracic lesion with cord compression at T2–T4 levels. The patient underwent surgical decompression, with his final histopathology showing diffuse large B-cell lymphoma. Systemic work-up was negative for nodal disease. Following surgery, he received radiotherapy combined with chemotherapy. He experienced a good outcome after four years. Conclusion. The upper thoracic cord is a rare location for primary spinal lesions/metastases, both of which prefer the lower thoracic and upper lumbar regions. In cases of progressive paraparesis, there should be immediate surgical intervention in the case of denovo disease, followed by combined radiotherapy and chemotherapy procedures.