SPINAL SUBDURAL HEMATOMA ASSOCIATED WITH LUMBAR PUNCTURE - A CASE REPORT.

Spinal subdural hematoma caused by lumbar puncture is a rare state of acute blood clot in spinal subdural space, and in some cases, it can be the cause of local compression and consecutive neurological symptoms. We present a 36-year-old female patient who was hospitalized due to persistent headache despite pharmacological therapy. Therefore, we performed lumbar puncture in order to measure intracranial pressure and evaluate cerebrospinal fluid. After lumbar puncture, the patient was complaining of pain in the lumbar region. Emergency magnetic resonance imaging (MRI) of the lumbosacral (LS) region was performed to show acute subdural hematoma of up to 7.3 mm in the dorsal part of the spinal canal at the level of L1 vertebra to the inferior endplate of L4 vertebra. Repeat LS MRI after 3 hours showed unchanged finding. The patient reported gradual regression of pain in the LS region over the next few days, therefore conservative treatment was applied. Patients with a previously known blood clotting disorder and patients on anticoagulation therapy have worse outcome as compared with patients without such disorders. During treatment, it is necessary to monitor patient clinical state and consider the need of surgical treatment.

Lumbar Subdural Hematoma Detected After Surgical Treatment of Chronic Intracranial Subdural Hematoma.

BACKGROUND: Spinal subdural hematoma (SSDH), which can cause lower back pain, leg pain, and leg weakness, is rare and will usually be associated with a bleeding tendency, trauma, spinal vascular malformation, intraspinal tumor, or iatrogenic invasion. Only a few cases of SSDH after intracranial chronic subdural hematoma (CSDH) have been reported. We report a case of lumbar SSDH in the absence of predisposing factors after reoperation for recurrent intracranial CSDH, which improved with conservative treatment. CASE DESCRIPTION: Approximately 1 month after falling, a 63-year-old woman was experiencing left hemiparesis and impaired orientation that was diagnosed as right intracranial CSDH using computed tomography. Surgical treatment of the CSDH led to immediate improvement of her symptoms. On postoperative day 29, the right CSDH had recurred with left hemiparesis, and successful reoperation relieved the symptoms within a few hours postoperatively. However, 1 day after the second operation, very small acute subdural hematomas in regions along the left tentorium cerebelli and left falx cerebri were found on computed tomography. On day 31, she complained of sitting-induced bilateral radiating lower limb pain. Magnetic resonance imaging on day 34 showed an acute SSDH at the L4-L5 level and a sacral perineural cyst filled with hematoma, although her radiating pain was showing improvement. She was treated conservatively and was discharged without symptoms on day 44. CONCLUSIONS: Although SSDH is rare, it is important for neurosurgeons and physicians to consider the possibility of a SSDH when lower limb pain or paresis occurs after procedures that will result in rapid intracranial pressure alterations such as drainage of an intracranial CSDH.

Idiopathic cervical spinal subdural haematoma: a case report and literature review.

This report describes a case of idiopathic cervical spinal subdural haematoma (SSDH) in which the haematoma was spontaneously absorbed without any treatment. A 68-year-old male patient presented with persistent neck pain and no obvious cause. Magnetic resonance imaging (MRI) revealed a space-occupying lesion at the C4-T1 levels. The lesion was initially misdiagnosed as a tumour. An operation was arranged to remove the tumour, but a preoperative computed tomography scan showed no obvious abnormal soft tissue density in the cervical spinal canal. Repeat enhanced MRI showed degeneration of the cervical vertebrae, but no obvious abnormal soft tissue density and no obvious enhanced signals in the cervical spinal canal. Spontaneous resolution of an idiopathic cervical SSDH was considered. Idiopathic cervical SSDH without obvious neurological symptoms are difficult to diagnose, so suspected cases should be carefully monitored. If the neurological symptoms grow progressively more debilitating with time, emergency surgery might need to be considered. To avoid unnecessary surgery, conservative management should be an option for patients with minimal neurological deficits and re-examination with MRI could be the best way to observe the dynamic changes taking place in the idiopathic cervical SSDH.

Delayed Posttraumatic Subacute Lumbar Subarachnoid Hematoma: Case Report and Review of the Literature.

BACKGROUND: Traumatic spinal subarachnoid hematoma, associated or not with a concurrent subdural hematoma, has rarely been described. The evolution of such hematomas is heterogeneous. This study aims at defining the most accurate management, which is currently not standardized. CASE DESCRIPTION: A 20-year-old man, victim of a high-kinetic road accident 5 days before and with several nonneurologic nonsurgical vertebral fractures, experienced a sudden dorsolumbar pain radiating to his lower limbs. A rapidly progressive asymmetric paraparesis with loss of reflexes was noticed, associated with bilateral global hypoesthesia of the lower limbs and with acute urinary retention, whereas the anal tonicity was preserved (American Spinal Injury Association C). Magnetic resonance imaging scan revealed a conus medullaris compression at the level of the L1-L2 vertebrae by an intradural expansive mass. Immediate surgical decompression revealed a strictly subarachnoid hematoma. Venous bleeding was seen at the level of the conus medullaris and controlled. Pathologic examination of the clot excluded an underlying tumor or vascular abnormality. The complete coagulation profile was normal. CONCLUSION: Six weeks after surgery, the neurologic examination revealed only a slight tactile hypoesthesia of the left thigh. With only 4 reported cases, purely subarachnoid spinal hematomas remain widely rarer than epidural hematomas. The reported case possesses a certain number of peculiarities: young age, pure subarachnoid location, lumbar location, occurrence after a car accident, subacute onset, and excellent neurologic recovery. In our opinion, a symptomatic subarachnoid spinal hematoma should be surgically evacuated at the early phase so neurologic recovery can be expected.

Acute non-traumatic idiopathic spinal subdural hematoma: radiographic findings and surgical results with a literature review.

PURPOSE: Intraspinal hematoma is a serious condition, and early diagnosis is necessary to permit emergency treatment. Among such hematomas, non-traumatic spinal subdural hematoma is a rare occurrence. We have experienced three patients with surgically proven subdural spinal hematoma, and here we report these cases with a review of their clinical and imaging characteristics. METHODS: All three cases were idiopathic with no history of disease, no coagulopathy, and no trauma. All had acute onset that brought about paralysis of the lower limbs with severe pain. Early surgery was performed, based on a relatively early diagnosis using thoracolumbar MRI and CT. RESULTS: Since the epidural fat is not affected by bleeding, the normal structure remains and the boundary between hematoma and fat is a significant feature in MRI and CT. Partial Gd enhancement in MRI and ring enhancement in contrast CT were also apparent. Two of the cases had subarachnoid hematomas. CONCLUSIONS: Preoperative diagnosis of spinal subarachnoid hematoma is difficult because there are no specific radiological findings and confirmation can only occur intraoperatively. In particular, one case had a massive hematoma causing canal stenosis, and it was difficult to distinguish between intradural and extradural hematoma. In all cases of subarachnoid or subdural hematoma, decompression was performed within 24 h after onset, and consequently, the patients had relatively good outcomes.

Spontaneous Spinal Subdural Hematoma.

OBJECTIVE: Spinal subdural hematomas (SSDHs) are rare. Causes are (1) posttraumatic, (2) iatrogenic (following surgery or lumbar puncture), (3) spontaneous including underlying malformations or coagulation deficits. With a systematic review of literature we want to shed light on the last group: symptomatology, etiology, treatment and outcome will we discussed. METHODS: Systematic review of literature on PubMed for cases of acute nontraumatic noniatrogenic SSDHs in adults (≥18 y of age). A total of 122 cases were reviewed including 2 cases from our hospital. RESULTS: There was a slight preponderance of female patients with spontaneous SSDHs and the mean age was 60 years. Spontaneous SSDHs were mostly located in the thoracic region (40%). Motor symptoms were most frequent (89%), followed by pain. Sensory deficits were present in 64%, of which 81% had a sensory level. In 6% radiculating pain, without any focal neurological deficits, was the presenting symptom. SSDHs were mainly caused by a coagulopathy (48%), predominantly due to the use of coumarins (34%). Other causes were underlying (vascular) malformations and vasculitis. Forty-three percent the SSDHs was idiopathic. 72% of patients underwent a decompressive laminectomy. 59% had a favorable outcome and 34% had a poor outcome. CONCLUSIONS: Spontaneous SSDHs were predominantly located in the thoracic spine, presenting with paraparesis/paraplegia, sensory level and pain. Over 40% was caused by a coagulation defect, most frequently due to coumarins. Six percent of patients presented with radiculating pain without any focal neurological deficits.

Intracranial subdural hematomas with elevated rivaroxaban concentration and subsequently detected spinal subdural hematoma: A case report.

A 79-year-old lean man with a height of 157cm and weight of 42kg (body mass index, 17.2kg/m(2)) receiving rivaroxaban developed an intracranial subdural hematoma and was treated conservatively. Because he had a reduced creatinine clearance of 44mL/min, his dosage of rivaroxaban was reduced from 15 to 10mg daily according to official Japanese prescribing information. However, he developed bilateral intracranial subdural hematomas 2weeks later. Plasma rivaroxaban concentration on anti-factor Xa chromogenic assay was elevated at 301ng/mL, suggesting excessive accumulation. He underwent burr hole drainage and resumed anticoagulation with warfarin. Subsequently, he developed a lumbosacral hematoma. He was treated conservatively and discharged without neurological sequelae. The main cause of the increased concentration of rivaroxaban was believed to be his older age and low body weight. The etiology of the spinal hematoma was suspected to be the migration of intracranial hematoma to the spinal subdural space.

Spinal Spot Sign.

INTRODUCTION: A marker predictive of hematoma expansion in the central nervous system could aid the selection of patients for hemostatic or surgical treatment. CASE REPORT: Here, we present a 83-year-old patient with acute spinal subdural hematoma with paraparesis progressing to paraplegia. A contrast extravasation within the intraspinal hematoma was visualized on spinal MR indicating active bleeding (spinal spot sign). A second acquisition of contrast-enhanced MR images showed progression of contrast extravasation helping to different active bleeding from spinal arteriovenous malformations/fistula. CONCLUSIONS: A "spinal spot sign" may be important for treatment decisions, notably in patients with incomplete neurological deficits at the time of imaging.

A calvarial acute subdural hematoma migrating into the spinal canal in a young male.

It is not common for an acute subdural hematoma (SDH) in the supratentorial region to show rapid resolution or migration during the clinical course. In this report, we present a rare case where the SDH in the supratentorial region was observed to rapidly migrate into the lumbar spinal canal, leading to severe radiculopathy. A 20-year-old male patient was admitted to the emergency department with severe headache after head trauma. The patient's overall condition was good, whereas his Glasgow Coma Scale score was 15 and blood pressure was normal. He had vomited 3 times after the onset of pain. No stiff neck was found, and the computed tomography showed an ASDH over the outer layer of the right hemisphere, causing a 7- to 8-mm shift. During the follow-up, the headache regressed and eventually resolved after 12 hours; however, another severe pain occurred in the lumbar region and in both legs. The pain worsened over time, progressing to sciatica in both legs. Acute SDH associated with a minor head trauma may migrate from the supratentorial compartment into the spinal canal by the help of elastic cerebral tissues in young adults and children.

Traumatic Subarachnoid Hemorrhage Originating from Mid-Cervical Arterial Injury.

BACKGROUND: Subarachnoid hemorrhage (SAH) occasionally originates from extracranial arteries, and SAH caused by cervical trauma is even rarer. CASE REPORT: A 17-year-old male patient was admitted to our emergency department aftera bike accident; he was drowsy and showed left hemiparesis. Initial computed tomography (CT) of the brain showed SAH into the cervicomedullary cistern. A 4-hour follow-up brain CT revealed heavy bleeding into the basal cistern. Because CT angiography did not show any vascular injury, we performed imaging studies of the cervical spine. Magnetic resonance imaging revealed a blood clot located ventral to the C4-C5 level of the spinal cord without any flow void. The patient's condition deteriorated over time, and he was accordingly referred for surgery. Intraoperatively, a thick subarachnoid hematoma ventral to the spinal cord was observed. The hematoma was removed and hemostasis by bipolar cauterization was performed for bleeding from a small branch of the anterior spinal artery. Postoperatively, the weakness of the lower extremity improved considerably. CONCLUSION: In young adult patients with SAH of unexplained origin, we suggest that the cervical region be considered as the bleeding focus; in such cases, surgical evacuation of bleeding can save some patients.

Spontaneous thoracic ventral spinal subdural hematoma mimicking a tumoral lesion: a case report.

INTRODUCTION: Spinal subdural hematoma is rare and can cause serious neurological symptoms. Sometimes, idiopathic spinal subdural hematoma can spontaneously occur without any identifiable underlying etiologies. In this report, we present such an uncommon case of paraplegia caused by idiopathic spinal subdural hematoma that was successfully managed by laminectomy. CASE PRESENTATION: A 45-year-old Chinese woman presented with sudden onset of progressive asthenia and numbness in both lower extremities, accompanied by difficulty in micturition. An initial non-contrast spinal magnetic resonance imaging at a local hospital suggested a spinal subdural tumoral hematoma at the T9 level. She was referred to our hospital and an emergency laminectomy from T8 to T10 was performed 22 hours after onset of her initial symptoms. However, nothing but a hematoma was identified during the operation, and a final diagnosis of spontaneous acute spinal subdural hematoma was concluded. She had partial return of sensations and voluntary movement after the operation. CONCLUSIONS: On imaging findings, spinal subdural hematoma could manifest as focal and independent from the dura matter, and, therefore, it should be included in the differential diagnosis of medullary compressive lesions.

Prospective assessment of concomitant lumbar and chronic subdural hematoma: is migration from the intracranial space involved in their manifestation?

OBJECT: Spinal subdural hematomas (SDHs) are rare and some are concomitant with intracranial SDH. Their pathogenesis and etiology remain to be elucidated although their migration from the intracranial space has been suggested. The authors postulated that if migration plays a major role, patients with intracranial SDH may harbor asymptomatic lumbar SDH. The authors performed a prospective study on the incidence of spinal SDH in patients with intracranial SDH to determine whether migration is a key factor in their concomitance. METHODS: The authors evaluated lumbar MR images obtained in 168 patients (125 males, 43 females, mean age 75.6 years) with intracranial chronic SDH to identify cases of concomitant lumbar SDH. In all cases, the lumbar MRI studies were performed within the 1st week after surgical irrigation of the intracranial SDH. RESULTS: Of the 168 patients, 2 (1.2%) harbored a concomitant lumbar SDH; both had a history of trauma to both the head and the hip and/or lumbar area. One was an 83-year-old man with prostate cancer and myelodysplastic syndrome who suffered trauma to his head and lumbar area in a fall from his bed. The other was a 70-year-old man who had hit his head and lumbar area in a fall. Neither patient manifested neurological deficits and their hematomas disappeared under observation. None of the patients with concomitant lumbar SDH had sustained head trauma only, indicating that trauma to the hip or lumbar region is significantly related to the concomitance of SDH (p < 0.05). CONCLUSIONS: As the incidence of concomitant lumbar and intracranial chronic SDH is rare and both patients in this study had sustained a direct impact to the head and hips, the authors suggest that the major mechanism underlying their concomitant SDH was double trauma. Another possible explanation is hemorrhagic diathesis and low CSF syndrome.

Acute spinal subdural hematoma with hemiplegia after acupuncture: a case report and review of the literature.

BACKGROUND CONTEXT: Subdural spinal hematoma (SDH) is a very rare entity; however, it can lead to serious complications resulting from injuries to the spinal cord and roots. Although acupuncture has been a popular method for the management of pain control, we encountered the first case of SDH after acupuncture. PURPOSE: The purpose of this case report was to present the first case of subdural hematoma after acupuncture and the reasons for the risks of blind cervical acupuncture. STUDY DESIGN: A case report and review of the previous literature are presented. METHODS: A 69-year-old man complained of progressive weakness in the right upper and lower extremities 2 hours after acupuncture on the cervical spine and back. The diagnosis was delayed because of unilateral weakness, and the symptom was initially misinterpreted as a transient ischemic attack because of no sensory change and pain and normal findings of two brain magnetic resonance imaging (MRI). RESULTS: Cervical MRI 36 hours after onset revealed acute hematoma from the C3-C5 level; hematoma showed an isointensity on T1-weighted image (WI) with the preservation of epidural fat and a hypointensity on T2WI. A decompressive surgery was scheduled to perform within 2 days after the cervical MRI scan because of a previous anticoagulation therapy, but the patient refused it. Finally, 9 days after the onset, surgical decompression and removal of hematoma were performed. Three months postoperatively, the patient had fully recovered demonstrating fine hand movement and good ability to walk up and down the stairs. CONCLUSIONS: Our study indicates that it is essential to perform cervical MRI when a patient does not show an improvement in the neurologic deficit and has a negative brain MRI after acupuncture. In addition, blind acupuncture if not correctly practiced may be harmful to the cervical structures.

Spinal subdural hematoma as a complication of spinal surgery: can it happen without dural tear?

Post spinal surgery subdural hematoma is a rare entity. This is a report of a case of acute post-operative spinal subdural hematoma, without any dural injury. The case was managed expectantly and went on to complete resolution of the hematoma and full clinical recovery.

Spinal subdural hematoma mimicking epidural lipomatosis.

We report a case of spinal subdural hematoma in the lumbar spine of a 75-year-old woman. Magnetic resonance imaging showed lesions of homogeneous high intensity in the spinal canal on both T1- and T2-weighted images, findings closely resembling those for epidural lipomatosis. Identification of 2-layered signal intensity surrounding the cauda equina on axial images is the key for accurate diagnosis.

Simultaneous cranial subarachnoid hemorrhage and spinal subdural hematoma.

We report a rare case of simultaneous cranial subarachnoid and spinal subdural hematoma (SDH) in a 42-year-old man who was on Warfarin therapy after cardiac bypass surgery. Computed tomography at presentation revealed a cranial subarachnoid hemorrhage, and spinal Magnetic Resonance Imaging (MRI) showed a spinal SDH extending from the T6 to L5 segments. He had paraparesis due to spinal cord compression. The patient was managed conservatively due to his poor general condition and was infused with intravenous steroid therapy, but he experienced sudden cardiac arrest 5 hours later after being admitted to the hospital. This case is of interest because of its first presentation of spinal subdural hematoma and cranial subarachnoid hemorrhage simultaneously and it is also the second longest vertebral segmental spread in the literature.

Subdural hematoma after an epidural blood patch.

We report the case of a 37-year-old postpartum patient who developed a contained subacute spinal subdural hematoma causing mass effect on the cauda equina and severe spinal stenosis after undergoing an epidural blood patch for postdural puncture headache. Recovery occurred following administration of oral steroids.