SARS-CoV-2 infection and spontaneous spinal hemorrhage: a systematic review.

The neurological manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, including spontaneous spinal hemorrhage (SSH), are diverse. SSH is a detrimental neurosurgical event requiring immediate medical attention. We aimed to investigate the association between SARS-CoV-2 and SSH and delineate a rational clinical approach. The authors searched PubMed, Scopus, Web of Science, and Google Scholar for studies published up to January 25, 2023, on SSH and SARS-CoV-2 infection. For each dataset, the authors performed pooled estimates examining three outcomes of interest: (1) early post-intervention neurological status, (2) mortality, and (3) post-intervention neurological rehabilitation outcomes. After reviewing 1341 results, seven datasets were identified for the final analysis. Fifty-seven percent of patients were females. Twenty-eight percent of the patients experienced severe systemic infection. The mean interval between the SARS-CoV-2 infection and neurological presentation was 18 days. Pain and sensorimotor deficits were the most common (57%). Spinal epidural hematoma (EDH) was the most common presentation (71.4%). Three patients were treated conservatively, while 4 received neurosurgical intervention. Pain and sensorimotor deficits had the best treatment response (100%), while the sphincter had the worst response (0%). Long-term follow-up showed that 71% of patients had good recovery. SARS-CoV-2-associated SSH is a rare complication of infection, with an often insidious presentation that requires high clinical suspicion. Patients with SARS-CoV-2 infection and new neurological symptoms or disproportionate neck or back pain require a neuroaxis evaluation. Neurosurgical intervention and conservative management are both viable options to treat SSH following COVID-19. Still, a homogenous approach to the treatment paradigm of SSH cannot be obtained, but lesions with space-occupying effects are suitable for neurosurgical evacuation-decompression while more indolent lesions could be treated conservatively. These options should be tailored individually until larger studies provide a consensus.

Spontaneous cervical epidural haematoma mimicking stroke: a case report and literature review.

Spontaneous spinal epidural haematoma (SSEH) is a rare disease that requires emergency decompression or haematoma evacuation to prevent permanent neurological deficits. Hemiparesis is an extremely rare presentation of SSEH, commonly misdiagnosed as stroke. With the help of case studies and references, this paper comprehensively discusses the effective methods to distinguish SSEH from stroke and provides theoretical support and ideas for rapid and accurate identification of SSEH. Herein, we report on the case of a 51-year-old man with SSEH who presented with acute hemiparesis and posterior neck pain. Cervical computed tomography (CT) revealed cervical degeneration. A carotid CT angiogram revealed a high-density mass in the C2-C5 right posterolateral epidural region. Cervical spine magnetic resonance imaging showed SSEH. The patient was conservatively treated and discharged following a full recovery. Rapid identification of SSEH continues to present a great challenge for neurologists. A soft tissue CT scan can be used to quickly and accurately identify SSEH; however, in the absence of cranial signs, Brown-Sequard syndrome, Lhermitte's sign and Horner syndrome should be used to differentiate SSEH from stroke.

Factors predicting outcome of surgical treatment of spontaneous spinal hematomas: a retrospective cohort study in four tertiary reference centers.

BACKGROUND: Spontaneous spinal extradural hematoma (SSEH) is a rare but disabling disorder. Most of the previous assumptions regarding the factors that contribute to poor neurological recovery from SSEH are based on small case samples or conditions with similar clinical presentations but different physiopathologies. Our goal was to find the most relevant prognostic factors for neurological recovery in patients suffering SSEH treated with surgical evacuation. METHODS: From a retrospective database of 29 surgical patients with SSEH, several clinical and radiological variables were recorded. These variables were compared between patients with good and poor neurological recovery, considering good as an improvement by at least one point in the ASIA Scale. RESULTS: Among the patients included, morbidity and mortality rate was 6.9% and 3.4%, respectively, with a mean follow-up of 7.1 months. Neurological full recovery was experienced by 33% of the patients included, and 86% of individuals had an improvement in their neurological condition at last follow-up. Lesser intramedullary lesions were significantly associated with greater chances of improvement in ASIA Scale at discharge and at follow-up. Surgical decompression within the first 24 hours of onset of symptoms were correlated with better neurological outcomes at follow-up. CONCLUSIONS: MRI is a powerful tool to predict the neurological outcome in SSEH patients, and it should be considered as an another resource to better know the patients with greater chances of having neurological recovery, especially in cases where the neurological examination is not reliable at the initial exam.

Sudden Onset of Paraparesis Caused by a Hemorrhagic Thoracic Synovial Cyst.

BACKGROUND: Hemorrhage is a rare presentation of spinal synovial cysts, which are usually located in the lumbar spine. They may cause an epidural hematoma and compression of the cauda equina. Infrequently, they may be located in the thoracic spine. CASE DESCRIPTION: We present a case of sudden onset paraparesis caused by hemorrhage in a synovial cyst at a midthoracic level. Clinical, radiologic, and histologic findings are described. CONCLUSIONS: This report describes a unique case of hemorrhagic synovial cyst at the mid-thoracic spine. These lesions are rarely located in the cervico-thoracic spine but should be included in the differential diagnosis of myelopathy.

Spontaneous Spinal Epidural Hematoma with Lumbar Facet Joint Destruction Mimicking Pigmented Villonodular Synovitis.

BACKGROUND: Spontaneous spinal epidural hematoma (SSEH) is a spinal emergency that requires early diagnosis and decompression surgery. Here, we report a case of SSEH that was difficult to differentiate from pigmented villonodular synovitis (PVS) because of combined facet joint destruction and that required gross total resection, a procedure not typically indicated for SSEH. CASE DESCRIPTION: A 58-year-old woman complained of sudden-onset walk disturbance after backache without any traumatic episode. Physical examination revealed motor paralysis in the leg. Moreover, extensive destruction of the L4/5 right facet joint and an epidural mass continuing from the facet was observed. The epidural mass showed heterogeneous intensity in magnetic resonance imaging, suggesting different stages of bleeding. These hemorrhagic changes combined with the facet joint destruction suggested PVS, and preoperative and intraoperative pathologic examinations could not rule out PVS. After surgical treatment of PVS, the lesion in the articular process was resected and decompression was performed. The pathologic diagnosis was hematoma with bone necrosis in the articular process, without neoplastic finding suggesting PVS. CONCLUSIONS: SSEH could be combined with facet joint destruction composed of bone necrosis. Awareness of SSEH with facet joint destruction can facilitate early diagnosis and appropriate surgical treatment.

Chronological low field magnetic resonance appearance of canine spinal epidural hemorrhage model.

The magnetic resonance (MR) features of spinal epidural hemorrhage depending with the passage of time have a meaning in veterinary medicine. The aim of this study is to propose the characteristic MR image of spinal epidural hemorrhage using a lower field permanent magnet scanner in dogs. A total of 8 clinically normal beagle dogs, weighing about 9 kg, were allocated. After a baseline MR examination, spinal epidural hemorrhage was created. MR scanning was executed on days 1, 2, 3, 4, 5, 10, 15, 20, 25, and 30 using 0.25 Tesla low field MR. Transverse MR images were attained for image examination. T2W, T1W, fluid-attenuated inversion recovery (FLAIR), short tau inversion recovery (STIR), and T2*-GRE sequences were used. Images were compared subjectively for signal transition assessment. Spinal epidural hemorrhage models were produced positively in 8 dogs at the T12 to L2 region. Initially, the spinal cord and epidural lesions were hyper-intense on T2W and T1W images. On T2W, FLAIR and STIR images, the spinal cord lesion was steadily hyperintense. No significant and consistent hypointense signal indicating hemorrhage was seen on T2*-GRE images. This study result suggests that relatively consistent hyperinstensity on T2 and FLAIR is observed for 30 days, meanwhile T2*-GRE imaging is less useful in hemorrhage detection.

Protocatechuic acid improves functional recovery after spinal cord injury by attenuating blood-spinal cord barrier disruption and hemorrhage in rats.

After spinal cord injury (SCI), blood-spinal cord barrier (BSCB) disruption and hemorrhage lead to blood cell infiltration and progressive secondary injuries including inflammation. Inflammatory response is one of the major events resulting in apoptosis, scar formation and neuronal dysfunction after SCI. Here, we investigated whether protocatechuic acid (PCA), a natural phenolic compound, would attenuate BSCB disruption and hemorrhage, leading to functional improvement after SCI. After a moderate contusion injury at T9, PCA (50 mg/kg) was administrated via intraperitoneal injection immediately, 6 h, and 12 h after SCI, and the same dose of PCA once a day until 7 d after injury. Our data show that PCA inhibited apoptotic cell death of neurons and oligodendrocytes and improved functional recovery after injury. PCA also attenuated BSCB disruption and hemorrhage and reduced the infiltration of neutrophils and macrophages compared to vehicle control. Moreover, PCA inhibited the expression and activation of matrix metalloprotease-9, which is well known to disrupt BSCB after SCI. Furthermore, PCA treatment significantly inhibited the expression of sulfonylurea receptor 1 and transient receptor potential melastatin 4, which are known to mediate hemorrhage at an early stage after SCI. Consistent with these findings, the mRNA and protein expression of inflammatory mediators such as tumor necrosis factor alpha, interleukin 1 beta, cyclooxygenase-2, inducible nitric oxide synthase, and chemokines was significantly alleviated by PCA treatment. Thus, our results suggest that PCA improved functional recovery after SCI in part by inhibiting BSCB disruption and hemorrhage through the down-regulation of sulfonylurea receptor 1/transient receptor potential melastatin 4 and matrix metalloprotease-9.

Consecutive images of conservatively treated cervical spontaneous spinal epidural hematoma.

Spontaneous spinal epidural hematoma (SSEH) in the cervical spine is rare, and it remains unclear how this condition resolves. We aimed to elucidate the underlying pathology of SSEH conservatively treated using magnetic resonance imaging (MRI) analysis. We reviewed the clinical records of patients with SSEH treated conservatively between January 2011 and November 2016 and analyzed the patients' medical history, medication, spinal cord compression on MRI, and neurological status. Patients underwent the first MRI on admission and the second MRI at average 10.8 days (range, 3-24 days) after the first MRI. Ten patients were enrolled (five men and five women), and the average age on admission was 73 years. In all patients, the neurological status improved within 24 h and the spinal cord area had increased on the second MRI. Four patients were diagnosed with hematoma regression and six with hematoma persistence by 14 orthopedic surgeons, who were blinded to the patients' data. Hematoma regression was associated with the difference of MRI interval (hematoma regression four patients 16.3 days vs. hematoma persistence six patients 7.2 days, p = 0.01). In conclusion, our report is the largest case series of SSEH with consecutive MRI; we found that SSEH in the cervical spine required approximately 10 days for absorption on the spot, without spreading longitudinally. This information could be useful for deciding when to alter the rehabilitation program.

Engaging pain fibers after a spinal cord injury fosters hemorrhage and expands the area of secondary injury.

In humans, spinal cord injury (SCI) is often accompanied by additional tissue damage (polytrauma) that can engage pain (nociceptive) fibers. Prior work has shown that this nociceptive input can expand the area of tissue damage (secondary injury), undermine behavioral recovery, and enhance the development of chronic pain. Here, it is shown that nociceptive input given a day after a lower thoracic contusion injury in rats enhances the infiltration of red blood cells at the site of injury, producing an area of hemorrhage that expands secondary injury. Peripheral nociceptive fibers were engaged 24 h after injury by means of electrical stimulation (shock) applied at an intensity that engages unmyelinated pain (C) fibers or through the application of the irritant capsaicin. Convergent western immunoblot and cyanmethemoglobin colorimetric assays showed that both forms of stimulation increased the concentration of hemoglobin at the site of injury, with a robust effect observed 3-24 h after stimulation. Histopathology confirmed that shock treatment increased the area of hemorrhage and the infiltration of red blood cells. SCI can lead to hemorrhage by engaging the sulfonylurea receptor 1 (SUR1) transient receptor potential melastatin 4 (TRPM4) channel complex in neurovascular endothelial cells, which leads to cell death and capillary fragmentation. Histopathology confirmed that areas of hemorrhage showed capillary fragmentation. Co-immunoprecipitation of the SUR1-TRPM4 complex showed that it was up-regulated by noxious stimulation. Shock-induced hemorrhage was associated with an acute disruption in locomotor performance. These results imply that noxious stimulation impairs long-term recovery because it amplifies the breakdown of the blood spinal cord barrier (BSCB) and the infiltration of red blood cells, which expands the area of secondary injury.

Delayed-onset paralysis induced by spontaneous spinal epidural hematoma communicated with hematoma in the paraspinal muscle in a 6-month-old girl: a case report.

Spontaneous spinal epidural hematoma (SSEH) very rarely develops in infants younger than 1 year old. To our knowledge, no previous case of delayed-onset paralysis induced by SSEH communicated with hematoma in the paraspinal muscle has been reported in the literature. The authors present the case of a 6-month-old girl with a tumor mass on her back who developed a paresis of her bilateral lower limbs. On spinal magnetic resonance imaging, the epidural mass appeared to be a dumbbell type and communicated with the mass in the paraspinal muscle through T12/L1 intervertebral foramen at the right side. After excision of the mass in the paraspinal muscle, hemi-laminectomy of T10-L3 was performed. No solid lesion was also present in the spinal canal and it was found to be an epidural hematoma. No malignancy was observed on pathological examination, and vascular and nerve system tumors were negative. When a tumor mass suddenly develops on the back of an infant and motor impairment of the lower limbs develops as the mass gradually enlarges, differential diagnosis should be performed taking SSEH into consideration.

Radiologic Features and Clinical Course of Chronic Spinal Epidural Hematoma: Report of 4 Cases and Literature Review.

BACKGROUND: Spinal epidural hematoma (SEH) is a potentially devastating problem that requires rapid diagnosis and surgical intervention. A chronic course is rarely seen following SEH, and the clinical characteristics are quite different from acute cases. The epidemiology, clinical history, and radiologic findings of chronic SEH (CSEH) are not well understood, although the detection rate has increased with the widespread use of magnetic resonance imaging. The purpose of this article was to report 4 cases of surgically confirmed CSEH and clarify the radiologic features and clinical scenarios by reviewing all published cases of CSEH. CASE DESCRIPTION: All 4 patients presented with gradually worsening radicular pain in the lower extremities. Patients' mean age was 69.5 years (range, 55-85 years). Magnetic resonance imaging revealed an epidural mass in the lower lumbar spine that was heterogeneously enhanced after gadolinium administration. The rim of the mass was low intensity on T2*-weighted images. Local erosions of the adjacent cortical bone were seen with computed tomography in all cases. All patients' postoperative courses were satisfactory with complete disappearance of radicular symptoms. CONCLUSIONS: CSEH is a rare disease, and it is difficult to diagnose preoperatively on the basis of diagnostic imaging. The incidence of a low-intensity rim on T2*-weighted images and bone erosions on computed tomography may help differentiate rare CSEH from other lumbar degenerative diseases and epidural space-occupying masses.

Negative-pressure dressing management of recurrent postoperative epidural hematoma and uncontrollable intraoperative hemorrhage in posterior spine surgery: report of 4 cases.

There is a paucity of literature describing the management of recurrent symptomatic postoperative epidural hematoma or uncontrollable intraoperative hemorrhage in posterior spine surgery. Traditional management with hematoma evacuation and wound closure over suction drains may not be effective in certain cases, and it can lead to recurrence and neurological injury. The authors report 3 cases of recurrent symptomatic postoperative epidural hematoma successfully managed with novel open-wound negative-pressure dressing therapy (NPDT), as well as 1 case of uncontrollable intraoperative hemorrhage that was primarily managed with the same technique. The 3 patients who developed a postoperative epidural hematoma became symptomatic 2-17 days after the initial operation. All 3 patients underwent at least 1 hematoma evacuation and wound closure over suction drains prior to recurrence with severe neurological deficit and definitive management with NPDT. One patient was managed primarily with NPDT for uncontrollable intraoperative hemorrhage during posterior cervical laminectomy. All 4 patients had significant risk factors for postoperative epidural hematoma. NPDT for 3-9 days with delayed wound closure was successful in all patients. The 3 patients with recurrent symptomatic postoperative epidural hematoma had significant improvement in their severe neurological deficit. None of the patients developed a postoperative wound infection, and none of the patients required transfusion due to NPDT. NPDT with delayed wound closure may be an option in certain patients, when wound closure over suction drains is unlikely to prevent further neurological injury.

[Clinical Manifestations of Spinal Epidural Hematoma-Stroke Mimic and Pitfalls in Diagnosis].

Clinical manifestations of spinal epidural hematoma are presented, and the cases mimicking acute ischemic stroke have been reviewed from the literature. Many reports described the cases of spinal epidural hematoma with acute hemiparesis mimicking ischemic stroke in which intravenous thrombolytic treatment with recombinant tissue plasminogen activator was considered. A correct diagnosis of acute ischemic stroke must be made within 4.5 hours from the onset of symptoms, a relatively short window period. A spinal epidural hematoma is a potentially important stroke mimic in a wide variety of conditions that mimic a stroke. The literature review and discussion will emphasize allowing the distinction between these hemiparetic presentation of spinal epidural hematoma and acute ischemic stroke. A spinal epidural hematoma should be considered in the differential diagnosis of patients with acute onset of hemiparesis when associated with neck pain and signs of Horner's syndrome and Brown-Sequard syndrome.

Torticollis in a haemophilic infant with inhibitor: a case of spinal epidural haematoma.

Central nervous system bleeding, which can be a life-threatening complication, is seen in 2.7% of patients with haemophilia. Spinal epidural haematomas represent about one-tenth of such cases. Here, we report on a 10-month-old boy with severe haemophilia A, who presented with torticollis. Although administration of factor VIII at a dose of 50 U/kg, the patient developed flaccid paralysis of the upper extremities. Factor VIII inhibitor screen was positive. Magnetic resonance imaging of the spine revealed spinal epidural haematomas, extending from C-1 to the cauda equina. Treatment was continued with recombinant activated factor VIIa without surgery. After 1 month, complete neurological recovery was achieved and fully resolved haematomas were detected on spinal MRI. A prompt radiological evaluation of the cervical spine with MRI should be made in patients with haemophilia presenting with torticollis. In addition, in the case of life-threatening bleeding in patients with haemophilia, the possibility of an inhibitor should be kept in mind.

Worsening Cervical Epidural Hematoma After Tissue Plasminogen Activator Administration for Stroke Like Symptoms.

STUDY DESIGN: Case report. OBJECTIVE: To report an extremely rare case of stroke-mimicking, cervical spontaneous epidural hematoma (SEH) treated with tissue plasminogen activator (tPA) for hemiparesis followed by emergency cervical decompression. SUMMARY OF BACKGROUND DATA: Although hemiparesis caused by cervical SEH is a relatively uncommon symptom compared with tetraparesis, such cases were often misdiagnosed as cerebral infarction and worsened by antithrombic therapy. METHODS: A case report and literature review are presented. RESULTS: A 71-year-old male presented with sudden neck pain followed by left-sided hemiparesis, and was believed to have had a stroke. He was administered tPA as intracranial computed tomography showed no signs of hemorrhage. However, his neurological condition continued to decline, and MRI of the cervical spine revealed a large spontaneous epidural hematoma. He subsequently underwent evacuation of the epidural hematoma and C3-6 laminoplasty, and his clinical status improved after the surgery. CONCLUSION: To our knowledge, only three cases of cervical SEH with hemiparesis erroneously treated with tPA resulting in neurological decline because of the enlargement of an existing hematoma, including the current case, have been reported in the English literature. It is important for physicians, especially those who administer tPA treatment, to include cervical SEH in the differential diagnosis of stroke in patients presenting with sudden back pain followed by the onset of neurological deficits including hemiparesis. LEVEL OF EVIDENCE: 5.

[Clinical manifestations of 16 patients with spontaneous spinal epidural hematoma -stroke mimic and pitfalls for diagnosis].

Clinical manifestations of 16 patients with spontaneous spinal epidural hematoma were presented. We examined the point similar to that of stroke. During the initial visit of our hospital, the patients showed the hemiplegia in 10 cases (62.5%), Horner syndrome in 4 cases (25%), the painless onset in 1 case (6.3%). And one case showed the impairment of consciousness due to vagal reflex in severe pain onset, which was similar to those of subarachnoid hemorrhage. MRI images are useful to confirm the diagnosis. The frequent site of hematoma was the lower cervical spinal cord. The oval shaped hematomas shifted to the left or right in spinal canals, compressed spinal cords in axial image, which was a cause of hemiplegia. Many cases developed during active periods, and the hemorrhage might be relevant to oral antithrombotic agent, C hepatitis, and chronic renal failure. Rapidly progressive cases were indications for emergency surgery, but conservative therapy is also possible and was better prognosis.

Prediction of neurological recovery in spontaneous spinal epidural hematoma using apparent diffusion coefficient values.

OBJECTIVE: Magnetic resonance imaging (MRI) is useful in diagnosing spontaneous spinal epidural hematoma (SSEH). The purpose of the present study is to determine whether apparent diffusion coefficient (ADC) values could determine severity of spinal cord damage and predict functional recovery in SSEH. METHODS: The study involved four consecutive patients with SSEH (two men and two women: aged 21-76 years). Using axial slices, ADC values were determined in four separate regions of the spinal cord. These areas were classified into the following three groups based on findings in T2-weighted images: normal T2 intensity; persistent T2 abnormality; and temporary T2 abnormality. ADC values among different groups were compared. The relationship between preoperative ADC values and neurological grades were also evaluated. RESULTS: ADC values in normal T2 areas were 0.89 ± 0.10 × 10(-3) mm(2) s(-1), whereas those for the persistent T2 abnormality group were significantly lower (0.63 ± 0.14 × 10(-3)). In a patient who was Frankel A on admission and in the follow-up, the ADC value was as low as 0.41 × 10(-3). Functional recovery was also limited in the spinal cord segments with lower ADC values. In the temporary T2 abnormality group, ADC values were significantly higher (1.05 ± 0.10 × 10(-3)). CONCLUSIONS: In SSEH, if MRI demonstrated T2-hyperintensity with lower ADC values, patients may suffer from irreversible spinal cord damages. ADC values of the spinal cord can be added as a new factor that reliably indicated the severity of spinal cord damage and predicted functional recovery.