Acute spinal subdural hematoma: A case report of spontaneous recovery from paraplegia.

RATIONALE: Spontaneous spinal subdural hematoma (SSDH) is a rare disease that can cause severe permanent neurological dysfunction. Here we present a case of spontaneous SSDH, in which a series of magnetic resonance images (MRIs) taken through the course of the disease facilitated understanding of the resolution process of the hematoma and the diagnosis of SSDH. PATIENT CONCERNS: A 59-year-old male presented with sudden severe back pain and rapid onset of paraplegia. This symptom had continued developing while he was transferred to the emergency department. Initial physical examination showed flaccid paralysis of both lower limbs with areflexia and loss of all sensation below T6 bilaterally. MRI images showed an anterior subdural hematoma from C7 to T7 with spinal cord compression. DIAGNOSIS: Based on MRI findings, the diagnosis was SSDH. INTERVENTIONS: We chose conservative treatment of 1-week bed rest and intensive rehabilitation for the patient due to the presence of sacral sparing and the slight motor recovery at 24 hours after the onset. OUTCOMES: Frequent MRI images demonstrated that the spinal cord compression was surprisingly mitigated only 2 days and mostly absorbed 4 days after the onset. The patient's motor function was recovered completely and he was discharged after 8 weeks of hospitalization. LESSONS: Our chronological MRI findings provide crucial information for diagnosing SSDH and also suggest that spinal surgeons should consider the potential option of a conservative approach for treating SSDH. Although prompt selection of a therapeutic strategy for SSDH could be challenging, the surgeons could observe the course of the patient's neurological status for a few days to detect signs of spontaneous recovery.

Spontaneous Spinal Subdural Hematoma after Percutaneous Mechanical Thrombectomy Combined with Catheter-Directed Thrombolysis for Deep Venous Thrombosis: A Case Report.

BACKGROUND: Percutaneous mechanical thrombectomy combined with catheter-directed thrombolysis is one of the most important methods for deep venous thrombosis treatment. Spontaneous spinal subdural hematoma is a remarkably rare complication in the thrombolysis process with catastrophic consequences, as shown in this case report. METHODS: Percutaneous mechanical thrombectomy, percutaneous angioplasty, and catheter-directed thrombolysis were performed for the patient. Postoperatively, the patient was diagnosed with spontaneous spinal subdural hematoma and received a series of medical treatments and surgical interventions. RESULTS: The patient was still paraplegic and incontinent at the postoperative 7-month follow-up. CONCLUSIONS: Neurologic symptoms must be monitored carefully both during and after the thrombolysis procedure. The onset of spinal neurologic deficits in any patient must raise the suspicion that a spinal subdural hematoma has occurred. Surgical decompression beyond 24 hr may cause permanent neurological damage.

Aneurysmal Subarachnoid Hemorrhage with Spinal Subdural Hematoma: A Case Report and Systematic Review of the Literature.

OBJECTIVE: Spinal subdural hematoma (S-SDH) rarely occurs after aneurysmal subarachnoid hemorrhage (SAH). Little information is known regarding the management and prognosis of patients with both S-SDH and SAH. Here, we present an illustrative case and provide a systematic review of S-SDH in the setting of SAH. METHODS: A systematic literature review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines revealed 11 previous cases of concurrent intracranial SAH and spinal SDH, which are presented with our new reported case. RESULTS: Intracranial sources of spontaneous SAH included 8 aneurysms, 1 pseudoaneurysm, and 3 angiogram-negative cases. Hunt Hess grades ranged from 1 to 4, mean time between SAH and S-SDH was 5.8 days, and S-SDH presented most frequently in the lumbar spine. Eight patients showed significant to complete clinical recovery, 2 had continued plegia of the lower extremities, and 2 expired. Modified Rankin scores (mRS) ranged from 0 to 6, with mRS >2 for 4 of 12 patients. Patients with a poor clinical outcome (mRS >2) had an initially negative cerebral angiogram, earlier presentation with less time between SAH and S-SDH (0.8 vs. 7.6 days), use of antithrombotic medication, no diversion of cerebrospinal fluid, and cervical or thoracic S-SDH. CONCLUSION: S-SDH is uncommon in the setting of aneurysmal SAH; better outcomes are associated with lumbar location, delayed presentation, cerebrospinal fluid diversion, and lack of antithrombotic use. Conservative treatment may be sufficient in patients with delayed S-SDH and lack of significant neurologic deficits. More reported cases will allow greater understanding of this clinical entity.

Clival SubduralHematoma after Drainage of Concomitant Intracranial and Spinal Cord Subdural Hematomas ­ Rare Case Report

Concomitant traumatic spinal cord and intracranial subdural hematomas associated with a retroclival hematoma are very uncommon. Their pathophysiology is not totally elucidated, but one hypothesis is the migration of the hematoma from the head to the spine. In the present case report, the authors describe the case of a 51-year-old man presenting with headache, nauseas and back pain after a head trauma who presented with intracranial and spinal cord subdural hematomas. Drainage was performed but, 1 week later, a retroclival subdural hematoma was diagnosed. The present paper discusses the pathophysiology, the clinical presentation, as well as the complications of concomitant traumatic spinal cord and intracranial subdural hematomas associated with a retroclival hematoma, and reviews this condition.

Spontaneous lumbar spinal subdural hematoma: a case report.

Spinal subdural hematoma (SSDH) is an uncommon disease causing acute onset of spinal disorder. Several causes of SSDH have been reported, but reports of spontaneous occurrence of SSDH are limited.

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.

Acute spinal subdural hematoma after vigorous back massage: a case report and review of literature.

STUDY DESIGN: A case report and review of literature. OBJECTIVE: We report on a patient with traumatic spinal subdural hematoma after vigorous back massage while on vacation. SUMMARY OF BACKGROUND DATA: Traumatic spinal subdural hematoma is extremely rare, and to our knowledge, this is the first case reported after violent back massage. We emphasize a high index of suspicion for early recognition and treatment for a good neurological recovery. METHODS: A 41-year-old male was brought to our hospital with severe back pain, motor and sensory impairments of the bilateral lower extremities, and urinary dysfunction after vigorous back massage. Magnetic resonance images revealed an acute spinal subdural hematoma in the thoracolumbar region. After careful monitoring of his neurological status, the patient was successfully managed with conservative treatment. RESULTS: After 2 weeks of hospitalization, complete motor power recovery was achieved with only minor sensory deficit. At a follow-up of more than 12 months, the patient has no residual neurological deficits. CONCLUSION: Spinal subdural hematoma secondary to physical trauma is quite rare. This case brings new information that traumatic spinal subdural hematoma can be caused by violent massage. LEVEL OF EVIDENCE: N/A.

Non-traumatic spontaneous spinal subdural haematoma.

We are presenting a case of non-traumatic spontaneous spinal subdural hematoma in a patient on warfarin and fluoxetine. This diagnosis should be considered early in patients who are on warfarin or fluoxetine or both presenting with acute neurological abnormalities of the limbs, and early decompression could result in good neurological outcome.

A rare, high cervical traumatic spinal subdural hematoma.

Spinal subdural hematomas (SSDH) are rare lesions occurring in association with a wide variety of conditions, including anticoagulation, coagulation disorders, spinal anesthesia, lumbar puncture, spinal tumors and vascular malformations. SSDH resulting from trauma are the exception. We present a 62-year-old woman with a rare post-traumatic focal SSDH at C1 with bulbomedullary compression, treated successfully with surgery. A review of the literature revealed 26 patients with traumatic SSDH. The aim of this report is to describe the clinical presentation, imaging characteristics and management of traumatic SSDH. The controversial pathogenesis is also discussed.

Anticoagulant and antithrombotic drugs in pregnancy: what are the anesthetic implications for labor and cesarean delivery?

Neuraxial anesthetic techniques are commonly used during the peripartum period to provide effective pain relief for labor and anesthesia during cesarean delivery. Major neurologic complications are rare after neuraxial anesthesia; however, spinal hematoma is associated with catastrophic neurologic outcomes (including lower-limb paralysis). Anticoagulant and antithrombotic drugs can increase the risk of spinal hematoma after neuraxial anesthesia, and better understanding of the pharmacokinetics and pharmacodynamics of anticoagulants has led to greater appreciation for withholding anticoagulation before and after neuraxial anesthesia. A number of national anesthetic societies have produced guidelines for performing neuraxial anesthesia in patients receiving anticoagulation. However, there is limited information about anesthetic implications of anticoagulation during the peripartum period. This article will review the risks of spinal hematoma after neuraxial anesthesia in pregnant patients; current guidelines for neuraxial anesthesia for anticoagulated patients; and relevant pharmacological data of specific anticoagulant and antithrombotic drugs in pregnancy.

Traumatic subdural hematoma of the thoraco-lumbar junction of spinal cord.

BACKGROUND: Spinal subdural hematoma (SSDH) is an exceedingly uncommon and potentially neurologically devastating condition. Recognition of blood products in magnetic resonance imaging is a very important clue for the diagnosis of SSDH. It is generally agreed that prompt surgical evacuation should be performed before irreversible damage to the spinal cord occurs. However, conservative treatment still plays a role in the management of SSDH. OBJECTIVES: To describe the clinical presentation, characteristic MRI findings, and treatment of traumatic SSDH. METHODS: A case of traumatic SSDH at the thoraco-lumbar junction. RESULTS: Magnetic resonance imaging findings of high signal intensity lesion in both T1 and T2 sequences suggest the possibility of subdural hematoma although it may be mistaken for tumorlike cystic lesion of the cord. Although there is a place for conservative treatment of subdural hematoma, we believe that rapid surgical drainage of the subdural hematoma will be associated with the best prognosis especially in the cervical, thoracic, and thoraco-lumbar junctions of the spinal cord. CONCLUSIONS: Rapid surgical drainage of traumatic SSDH affecting the thoraco-lumbar junction of the cord will be associated in most of the cases with rapid neurologic recovery.

Acute clival and spinal subdural hematoma with spontaneous resolution: clinical and radiographic correlation in support of a proposed pathophysiological mechanism. Case report.

Infratentorial and spinal subdural hematomas (SDHs) from traumatic injury in the pediatric population occur with such rarity that they can present the clinician with a challenge in diagnosis and management. When such hematomas are correctly identified, clinicians must decide whether to evacuate the lesion or manage it expectantly. The authors discuss the case of a 4-year-old child who presented with a clival and spinal SDH after a fall from a fourth-story window. The clinical and radiographic findings support a possible mechanism of evolution of these lesions. There is little evidence to guide management of clival and spinal SDHs. This case supports the evaluation for a spinal SDH when a clival hematoma is diagnosed. In the setting of a good neurological examination, expectant management can be an appropriate method of treatment. Additionally, this case lends insight into the pathophysiology of spinal SDHs. Unlike its intracranial counterpart, the spinal subdural space lacks bridging veins. The mechanism of formation of spinal SDHs after trauma has been heretofore relatively unclear. The images in this case support the hypothesis that redistribution of the clival SDH to dependent areas in the spinal subdural space is a significant mechanism in the evolution of these lesions.

Functional outcome after surgical treatment of spontaneous and nonspontaneous spinal subdural hematomas.

OBJECT: Because of the rarity of spinal subdural hematomas (SDHs), the literature offers scarce estimates of the outcome and predictive factors in patients suffering from these lesions. In addition, single-institution surgical series are still lacking. Therefore, the authors retrospectively evaluated the early and long-term functional outcomes measured in eight patients with spontaneous and nonspontaneous spinal SDHs in whom the clot had been evacuated. METHODS: The patients' charts were evaluated for origin of the lesion, risk factors, and neurological deficits at symptom onset and at 28 days after extirpation of the spinal SDH. Long-term clinical outcome (Barthel Index [BI]) was evaluated by administering a telephone questionnaire to the patient or a relative. Only one patient with a spontaneous spinal SDH was identified. Four patients were undergoing anticoagulant therapy, and three patients had undergone a previous anesthetic/diagnostic spinal procedure. Twenty-eight days postoperatively, neurological deficits improved in six of eight patients; however, in two of the six patients, the improvement did not allow the patients to become independent again. In two patients, surgery did not affect the complete sensorimotor deficits. In the long-term survivors (median 45 months) a median BI of 55 was achieved. The latency between symptom onset and surgery did not correlate with functional outcome in this series. The preoperative neurological condition and location of the hematoma correlated positively with early and long-term functional outcome. CONCLUSIONS: To the best of their knowledge, the present study is the largest single-institutional study of patients with surgically treated spinal SDHs. Despite some postoperative improvement of sensorimotor deficits in most patients, the prognosis is poor because 50% of the patients remain dependent. Their outcome was determined by the preoperative sensorimotor function and spinal level of the spinal SDH.

Ruptured aneurysm of the posterior spinal artery of the conus medullaris.

A case of a posterior spinal artery aneurysm of the conus medullaris is presented. The patient presented with severe lower back pain with radiation into the right leg. Spinal angiography was consistent with a partially thrombosed arteriovenous malformation (AVM) or an aneurysm. At operation a partially thrombosed aneurysm of the posterior spinal artery was found at the level of conus medullaris, which, after review of the literature, is the first case treated with total microsurgical excision.