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.
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
Many studies have reported spontaneous spinal epidural hematoma (SSEH). Although most cases are idiopathic, several are associated with thrombolytic therapy or anticoagulants. We report a case of SSEH coincident with acute myocardial infarction (AMI), which caused serious neurological deficits. A 56 year old man presented with chest pain accompanied with back and neck pain, which was regarded as an atypical symptom of AMI. He was treated with nitroglycerin, aspirin, low molecular weight heparin, and clopidogrel. A spinal magnetic resonance image taken after paraplegia developed 3 days after the initial symptoms revealed an epidural hematoma at the cervical and thoracolumbar spine. Despite emergent decompressive surgery, paraplegia has not improved 7 months after surgery. A SSEH should be considered when patients complain of abrupt, strong, and non-traumatic back and neck pain, particularly if they have no spinal pain history.
Acute myocardial infarction; Hematoma, epidural, spinal; Paraplegia; Thrombolytic therapy; Anticoagulants
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
Spontaneous cervical epidural hematoma (SCEDH) is a rare disease, but can cause severe neurologic impairment. We report a case of a 68-year-old female who presented with sudden onset, posterior neck pain, right shoulder pain, and progressive right hemiparesis mimicking stroke with no trauma history. Initial brain CT and diffusion MRI performed to rule out brain lesion did not show any positive findings. Laboratory examination presented only severe thrombocytopenia (45,000/mm3). Subsequent cervical MRI revealed a cervical epidural mass lesion. We confirmed that it was pure hematoma through C5 unilateral total laminectomy and C6 partial hemilaminectomy. She achieved complete neurologic recovery with active rehabilitation. Early surgical decompression for SCEDH with neurologic impairment should be recommended for better outcome.
Spontaneous cervical epidural hematoma (SCEDH); Stroke; Liver cirrhosis
Spontaneous spinal epidural hematoma (SSEH) is a rare idiopathic condition that leads to acute onset of neurological deficits, which if not recognized early can have catastrophic consequences. The definition and pathophysiology of this condition remain controversial. High index of suspicion followed by T2-weighted gradient echo sequences are particularly useful in early diagnosis. Management consists of prompt surgical decompression of the hematoma though a recent trend is toward non-surgical treatment.
A 70-year-old man presented with acute onset neck pain with a radicular component and rapidly progressive quadriparesis. Magnetic resonance imaging revealed a posteriorly located cervical extradural hematoma with cord compression that was promptly evacuated. Functional recovery to near normal function occurred within 24 hours of surgery.
SSEH in its true idiopathic form is a rare pathologic entity. Because of the high risk of poor outcome without treatment, SSEH should be a diagnostic possibility when presentation is even slightly suggestive. Prompt surgical evacuation of the hematoma leads to a favorable neurological outcome, whereas delay in treatment can be disastrous. The role of conservative management needs to be proven and should be tailored on an individual basis.
Tetraparesis; Tetraplegia; Paralysis; Myelopathy; Laminectomy; Neurologic manifestations; Progressive; Spinal cord compression; Cervical; Hematoma; Idiopathic spontaneous spinal epidural hematoma
Spontaneous chronic epidural hematomas are extremely rare and can be extremely challenging to diagnose and differentiate. The clinical findings, computed tomographic scan and magnetic resonance imaging does not always enough to complete differentiate this condition. Our purpose is to report a case of a spontaneous chronic epidural hematoma presenting as an extradural mass leading to compressive radicular symptoms with images of bony scalloping which are sparsely reported in the literature.
We describe a 61-year-old woman who was evaluated after 18-month history of pain, disestesias and mild weakness in both lower extremities with significant radicular symptoms on the right side associated to neurogenic claudication.
CT scans revealed a nodular image of soft tissue density located in the right anterolateral epidural space at the L4–L5 level demonstrating resorption of the bony margins. MRI studies revealed a round mass in the vertebral canal displacing the dural sac and scalloping the posterior wall of the L4 vertebral body. Diagnosis was established between a degenerative cyst versus an atypical neurinoma. Surgical findings demonstrated an isolated well-formed chronic hematoma.
Spontaneous chronic epidural hematomas are rare, even more when they produce scalloping of bony structures becoming a diagnostic challenge. Therefore they should be always considered as a differential diagnosis in patients with extradural chronic compressions taking into account that also chronic epidural hematomas can cause bone involvement.
Tumour; Spine, epidural; Hematoma
We describe a case of 36-year-old man who presented with a subacute headache preceded by a 1-month history of posterior neck pain without trauma history. Head and neck magnetic resonance imaging (MRI) studies disclosed bilateral supratentorial subdural and retroclival extradural hematomas associated with marked cervical epidural venous engorgement. Cerebral and spinal angiography disclosed no abnormalities except dilated cervical epidural veins. We performed serial follow-up MRI studied to monitor his condition. Patient's symptoms improved gradually. Serial radiologic studies revealed gradual resolution of pathologic findings. A 3-month follow-up MRI study of the brain and cervical spine revealed complete resolution of the retroclival extradural hematoma, disappearance of the cervical epidural venous engorgement, and partial resolution of the bilateral supratentorial subdural hematoma. Complete resolution of the bilateral supratentorial subdural hematoma was confirmed on a 5-month follow-up brain MRI. The diagnosis and possible mechanisms of this rare association are discussed.
Supratentorial subdural hematoma; Retroclival extradural hematoma; Cervical epidural venous engorgement
Spontaneous spinal epidural hematoma (SSEH) is a rare disease entity; its causative factors and the factors determining the outcome are still controversial. We reviewed our clinical experiences and analyzed the various factors related to the outcome for SSEH. We investigated 14 patients (11 men and 3 women) who underwent hematoma removal for SSEH from April 1998 to August 2004. We reviewed age, gender, hypertension, anticoagulant use and the preoperative neurological status using the Japanese Orthopaedics Association score by examining medical records, operative records, pathology reports, and radiographies, retrospectively. We were checking for factors such as the degree of cord compression owing to hematoma and the extent and location of the hematoma. Most patients included in the study were in their twenties or fifties. Four hematoma were located in the cervical region (29%), three were cervicothoracic (21%), four were thoracic (29%) and three were in the lumbar (21%) region and also 12 were located at the dorsal aspect of the spinal cord. In all cases, the neurological outcome improved after the surgical operation. There was a statistically significant difference between the incomplete and complete neurological injury for the preoperative status (P<0.05). The neurological outcome was good in those cases that had their hematoma removed within 24 h (P<0.05). The patients with incomplete neurological injury who had a surgical operation performed within 12 h had an excellent surgical outcome (P<0.01). Spontaneous spinal epidural hematoma was favorably treated by the means of a surgical operation. The favorable factors for SSEH operations were incomplete neurological injury at the time of the preoperative status and the short operative time interval.
Epidural hematoma; Cord injury; Operative time interval; Spine surgery
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.
We present a rare case of delayed onset of epidural hematoma after lumbar surgery whose only presenting symptom was vesicorectal disturbance. A 68-year-old man with degenerative spinal stenosis underwent lumbar decompression and instrumented posterolateral spine fusion. The day after his discharge following an unremarkable postoperative course, he presented to the emergency room complaining of difficulty in urination. An MRI revealed an epidural fluid collection causing compression of the thecal sac. The fluid was evacuated, revealing a postoperative hematoma. After removal of the hematoma, his symptoms disappeared immediately, and his urinary function completely recovered. Most reports have characterized postoperative epidural hematoma as occurring early after operation and accompanied with neurological deficits. But it can happen even two weeks after spinal surgery with no pain. Surgeons thus may need to follow up patients for at least a few weeks because some complications, such as epidural hematomas, could take that long to manifest themselves.
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
Spontaneous spinal epidural hematoma (SSEH) during pregnancy is rare and may result in permanent damage if not promptly treated. There were few studies discussing the etiology, presentation and treatment of SSEH during pregnancy. The authors describe a case of spontaneous cervical epidural hematoma during pregnancy, which was diagnosed by magnetic resonance imaging (MRI) and managed with surgical evacuation. A retrospective review of a case of spontaneous epidural hematoma of spine during pregnancy was performed. The clinical features, diagnoses, treatments and outcomes of all cases were analyzed. Precise diagnosis without delay and rapid surgical treatment are essential for the management of SSEH during pregnancy.
Epidural hematoma; Spine; Spontaneous; Pregnancy
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 rare in children, especially in infants, in whom only 12 cases have been reported. Because of the nonspecificity of presenting symptoms in children, the diagnosis may be delayed. We report herein a case of SSEH in a 20-month-old girl who initially presented with neck pain, and developed lower extremity motor weakness and symptoms of neurogenic bladder 2 weeks prior to admission. The magnetic resonance imaging showed an epidural mass lesion extending from C7 to T4, and the spinal cord was severely compressed by the mass. After emergency decompressive surgery the neurologic function was improved immediately. Two months after surgery, the neurological status was normal with achievement of spontaneous voiding. We suggest that surgical intervention can provide excellent prognosis in case of SSEH in infants, even if surgery delayed.
Spontaneous; Spinal epidural hematoma; Infant; Laminotomy
Traumatic brainstem hemorrhage after blunt head injury is an uncommon event. The most frequent site of hemorrhage is the midline rostral brainstem. The prognosis of these patients is poor because of its critical location. We experienced a case of traumatic brainstem hemorrhage. A 41-year-old male was presented with drowsy mentality and right hemiparesis after blunt head injury. Plain skull radiographs and brain computerized tomography scans revealed a depressed skull fracture, epidural hematoma, and hemorrhagic contusion in the right parieto-occipital region. But, these findings did not explain the right hemiparesis. T2-weighted magnetic resonance (MR) image of the cervical spine demonstrated a focal hyperintense lesion in the left pontomedullary junction. Brain diffusion-weighted and FLAIR MR images showed a focal hyperintensity in the ventral pontomedullary lesion and it was more prominent in the left side. His mentality and weakness were progressively improved with conservative treatment. We should keep in mind the possibility of brainstem hemorrhage if supratentorial lesions or spinal cord lesions that caused neurological deficits in the head injured patients are unexplainable.
Brain stem hemorrhage; Head trauma; Hemiparesis
We report on a 61-year-old female patient who developed a spontaneous spinal epidural haematoma (SSEH) after being treated by rivaroxaban, a new agent for the prevention of venous thromboembolic events in orthopaedic surgery. Although the pathogenesis of SSEH is unclear, anticoagulant therapy is a known risk factor. The patient sustained a sudden onset of severe back pain in the thoracic spine, followed by paraplegia below T8, 2 days after proximal tibial osteotomy and rivaroxaban therapy. Magnetic resonance imaging (MRI) of the whole spine demonstrated a ventral SSEH from C2 to T8. Whilst preparing for the emergency evacuation of the SSEH, the neurological symptoms recovered spontaneously 4 h after onset without surgery. After monitored bed rest for 48 h the MRI was repeated and the SSEH was no longer present. This rare condition of spinal cord compression and unusually rapid spontaneous recovery has not previously been reported following rivaroxaban therapy.
Rivaroxaban; Epidural haematoma; Compression; Spinal cord
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
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
We present a case of a 42-year-old male, an old case of deep vein thrombosis on warfarin and other drugs like quetiapine, aspirin, diclofenac sodium, fenofibrate, atorvastatin, propanolol and citalopram for concurrent illnesses, who presented with widespread mucocutaneous bleeding and epidural spinal hematoma. The epidural bleed presented clinically as a nontraumatic, rapidly improving myeloradiculopathy. Magnetic resonance imaging (MRI) of the spine revealed an epidural hematoma at D12-L1 level. The case was managed conservatively due lack of neurosurgical facilities. The patient gained full neurological recovery on conservative management alone. This case highlights the problem of drug interaction on warfarin therapy and also an unusual spontaneous recovery of spinal hematoma. Our case was anticoagulated in the recommended therapeutic INR range of 2.2 to 2.4. Most of the similar cases reported in literature were also anticoagulated in the therapeutic range. Thus intraspinal hemorrhage is a rare but dangerous complication of anticoagulant therapy. It must be suspected in any patient on anticoagulant agents who complains of local or referred spinal pain associated with neurological deficits. Drug interactions with warfarin are common. High suspicion and immediate intervention are essential to prevent complications from intraspinal hemorrhage.
Anticoagulant; spinal epidural hematoma; warfarin
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
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 one case of a 78-year-old woman who referred to our hospital because of a progressive right hemiparesis. On clinical examination a painless large soft mass in the left parietal region was observed. CT and MRI revealed an extra-axial mass in the in the left fronto-temporo-parietal region. The lesion was totally excised despite the bleeding tendency. Histology disclosed the presence of a plasmacytoma. Postoperative, the patient developed an epidural hematoma that required immediate evacuation. On further investigation active tuberculosis was detected. On follow up examination 1 year later no tumor recurrence or evidence of multiple myeloma was detected.
We present a case of a 55-year-old male with progressive neurological deficits that appeared dramatically. MRI detected a spinal epidural hematoma at the cervicothoracic junction and blood tests showed leukocytosis, mild anemia, and thrombocytosis. Spontaneous spinal epidural hematoma (SSEH) as the initial presentation of leukemia was diagnosed. Urgent posterior decompression was performed after 28 h from acute onset of backache, and the patient experienced remarkable improvement in neurological findings.
Spontaneous spinal epidural hematoma; Chronic myeloid leukemia