自发性脊髓硬膜外和硬膜下血肿

目的 探讨自发性脊髓硬膜外血肿（SSEH)及硬膜下血肿(SSSH)的病因、临床特点、诊治方法及预后相关因素。方法 自1995～2002年收治的4例SSEH及2例SSSH患者．均在静息或轻微活动后发病，发病前均无感染或服药史，其中1例63岁患者诉有高血压病史．1例65岁患者入院检查后发现患有Ⅱ型精尿病．余均否认患有其他疾病。所有患者均表现为突发性的颈、肩、胸、背部疼痛，数分钟到数小时内出现肢体运动、感觉障碍、大小便障碍及潴留，5例患者有抻经根放射痛症状．有3例行腰穿，压力无明显增高．均行手术治疗．手术距发病时间10～16d．平均12.5d，手术均在局麻下进行．4例SSEH患者行患部全椎板切除血肿清除术．2例SSSH患者行全椎板切除并硬静膜切开血肿清除，硬脊膜修补术。结果 均经MR检查、手术及病理证实。MRI显示椎管后方或后外方占位性病变，T1加权能特征性地反映血肿随时间发生的信号变化而最有价值．T22加权可很好地判断血肿的位置，患者预后与术前的神经功能状态及发病至手术的时间密切相关，本组患者随访6～18个月，平均10个月．6例患者除大、小便功能有不同程度的改善外．5例患者肢体的运动、感觉功能无明显恢复，1例SSSH患者感觉消失平面下降，右上肢肌力较前增强，结论 自发性脊髓硬膜外及硬膜下血肿是一种少见病，MRI是其首选的检查方法，应当注意的是早期诊断并及时手术是治疗SSEH和SSSH．防止永久性神经功能障碍的关健。     

Spontaneous spinal epidural hematoma in a pregnant patient

Spontaneous spinal epidural hematoma is a rare occurrence during pregnancy with only five cases described in the literature since 1900. Even in the general population, the frequency of spontaneous spinal epidural hematoma is extremely low and the etiology unclear. Several theories exist for the cause of spontaneous spinal epidural hematoma, however, none has gained uniform acceptance. A case of spontaneous spinal epidural hematoma during pregnancy in a 27-year-old, gravida 2, para 1, female at term with 36 hours duration of both paresthesia and progressive weakness of the lower extremities is presented. In addition, all previous known cases are summarized, including outcome. We hypothesize that the cause of spontaneous spinal epidural hematoma is multifactorial, and pregnancy-induced structural changes in arterial walls and hemodynamic changes may play a role. In addition, we postulate that the origin of the bleeding is arterial, rather then venous. Lastly, the symptoms, diagnosis, and management of spontaneous spinal epidural hematoma during pregnancy are discussed.     

Acute epidural hematoma following evacuation of chronic subdural hematoma with continuous closed system drainage]

The authors report a case of acute epidural hematoma occurring after evacuation of chronic subdural hematoma with continuous closed system drainage. Laboratory data of the patient including bleeding time were within normal limits. The cause of the postoperative intracranial hematoma was the rapid surgical decompression of the initial lesion, and we considered that it could be prevented if chronic subdural hematoma was treated using closed system drainage and slow decompression. But acute epidural hematoma occurred after this operative procedure and it was accelerated by evacuation of the chronic subdural hematoma through the drain. An emergent craniotomy and removal of the hematoma was performed, so the patient was discharged from hospital with satisfactory neurological recovery. A careful check of the evacuated hematoma volume is very important, and CT scanning should be immediately performed if postoperative hematoma is suspected.     

Epidural hematoma after spinal anesthesia in a patient with undiagnosed epidural lymphoma

The incidence of hemorrhagic complications after neuroaxial anesthesia is very infrequent. We report a case of a woman developing epidural bleeding 3 wk after performing an uneventful spinal anesthesia at the lumbar level L3-4 for removal of a wire loop in her left knee. No hemostasis altering medication had been taken before and after spinal puncture. The hematoma presenting at the lumbar level L2-3 had to be removed via laminectomy. Pathological examination of the hematoma revealed a highly vascularized centroblastic non-Hodgkin's lymphoma that was not diagnosed before surgery. The patient did not develop any neurological deficits. IMPLICATIONS: We report a case of a women developing epidural bleeding 3 wk after performing an uneventful spinal anesthesia for removal of a wire loop in her left knee. Pathological examination of the neurosurgically removed hematoma revealed a highly vascularized epidural centroblastic non-Hodgkin lymphoma.     

Spinal subdural hematoma: case report and review of the literature.

A case of lumbar spinal subdural hematoma in a patient who had been on anticoagulant therapy is reported. Thus far 19 cases of spinal subdural hematoma have been reported in the literature, the majority in patients with a bleeding diathesis and after a lumbar puncture. Our case is the third reported to be in association with anticoagulant therapy. The hematoma was lumbosacral, in contrast to the usual location in the dorsal-lumbar area. A possible mechanism for the production of spinal subdural hematoma after a lumbar puncture is discussed. An early decompressive laminectomy and evacuation of the hematoma is the recommended treatment to obtain the best possible recovery of neurological function. (Neurosurgery, 5: 614--616, 1979).     

Chronic spontaneous spinal epidural hematoma simulating a lumbar stenosis

Summary A case of a patient with a clinical picture of lumbar spine stenosis actually caused by a chronic, spontaneous, spinal epidural hematoma is reported. There was no history of major or minor trauma to the lumbar spine. The correct preoperative diagnosis was made by magnetic resonance imaging. The possible etiology and clinical and radiological findings and treatment of this rare entity are discussed.     

Extensive postoperative epidural hematoma after full anticoagulation: case report and review of the literature

BACKGROUND/OBJECTIVE: A 67-year-old man with degenerative lumbar spinal stenosis and a medical history significant for coronary artery disease underwent routine lumbar surgical decompression. The objective of this study was to report a case of postoperative epidural hematoma associated with the use of emergent anticoagulation, including the dangers associated with spinal decompression and early postoperative anticoagulation. METHODS: Case report. FINDINGS: After anticoagulation therapy for postoperative myocardial ischemia, the patient developed paresis with ascending abdominal paraesthesias. Immediate decompression of the surgical wound was carried out at the bedside. Magnetic resonance imaging revealed a massive spinal epidural hematoma extending from the middle of the cervical spine to the sacrum. Emergent cervical, thoracic, and revision lumbar laminectomy without fusion was performed to decompress the spinal canal and evacuate the hematoma. RESULTS: Motor and sensory function returned to normal by 14 days postoperatively, but bowel and bladder function continued to be impaired. Postoperative radiographs showed that coronal and sagittal spinal alignment did not change significantly after extensive laminectomy. CONCLUSIONS: Full anticoagulation should be avoided in the early postoperative period. In cases requiring early vigorous anticoagulation, patients should be closely monitored for changes in neurologic status. Combined cervical, thoracic, and lumbar laminectomy, without instrumentation or fusion, is an acceptable treatment option.     

Spontaneous recovery from a spinal epidural hematoma with atypical presentation in a nonagenarian

PURPOSE: Spinal epidural hematoma following epidural anesthesia is extraordinarily rare in association with low-dose sc heparin, and the prognosis for neurologic recovery without rapid surgical decompression poor. We report a case of spinal epidural hematoma in a nonagenarian who received low-dose sc unfractionated heparin postoperatively in accordance with standard guidelines, presented with no back pain, and made full neurologic recovery without surgical intervention. CLINICAL FEATURES: A 90-yr-old female with gastric adenocarcinoma presented for subtotal gastrectomy. Her past medical history and physical examination were largely unremarkable and she had no bleeding diathesis. She took no medications other than preoperative ranitidine, and had a normal coagulation profile. A thoracic epidural catheter was placed uneventfully before induction of general anesthesia. Postoperatively, low-dose sc unfractionated heparin was started 12 hr after the epidural catheter insertion. On postoperative day two, the patient developed flaccid lower extremity paralysis and paresthesia without back pain. Her coagulation profile remained normal. Subsequent magnetic resonance imaging showed a large epidural hematoma extending from T3 to T11. With conservative treatment and no surgery, the patient slowly made full neurologic recovery and was discharged home on postoperative day 56. CONCLUSION: Complete neurologic recovery from flaccid paralysis following spinal epidural hematoma occurred without surgical decompression in a nonagenarian. Low-dose sc heparin may be a greater risk factor for spinal epidural hematoma than previously assumed, and the absence of back pain does not rule out this diagnosis.     

自发性脊柱硬膜外血肿的非典型MRI表现与鉴别诊断

目的 提高对自发性脊柱硬膜外血肿非典型MRI表现的认识.方法 对2000年至2008年来院的10例自发性脊柱硬膜外血肿非典型MRI表现进行分析,男7例,女3例;年龄12--64岁,平均32.1岁.所有病例均无明显的外伤史.常规行矢状位T1WI、T2WI,横轴位TwI,8例行增强扫描.结果 血肿呈梭形、椭圆形,位于脊髓的侧后方或后方的硬膜外腔.血肿发生于颈段5例,胸段3例,胸腰段2例.病灶与脊髓之间有一低信号线状影相隔,尤以T2WI显示最佳.血肿范围多在2～4个椎体,总量约5～10 ml,均值为(6.9±1.8)ml.在T1WI图像上,6例表现为等信号,4例表现为高信号;在T2WI图像上,6例表现为混杂高信号,4例表现为混杂低信号.5例血肿壁边缘轻度强化.6例血肿MRI信号比较典型.4例血肿MRI信号不典型.活动性出血以及血肿因时间而演变是血肿征象不典型的原因.本组4例误诊的原因:(1)活动性出血所致血肿征象不典型;(2)血肿位于狭窄的腔隙内;(3)临床上无外伤史.结论 根据血肿演变的规律,结合起病时间及可能存在活动性出血对血肿MRI信号进行分析,有利于对非典型血肿的诊断和鉴别诊断.     

Spontaneous epidural hematoma due to cervico-thoracic angiolipoma

Epidural angiolipomas are uncommon benign tumors of the spine. Their clinical presentation is usually a progressive spinal cord compression. We report the case of a 22-year-old patient who presented with an acute paraparesis and a spontaneous epidural hematoma, which revealed a epidural angiolipoma which extended from C7 to T3. The patient underwent a C7–T3 laminectomy, in emergency, with evacuation of the hematoma and extradural complete resection of a fibrous epidural tumor bleeding. The postoperative course was favorable with regression of neurological symptoms. Epidural angiolipomas can be revealed by spontaneous intratumoral hemorrhage without traumatism. The standard treatment is total removal by surgery.     

Lumbar spinal epidural hematoma after chiropractic manipulation: A case report

Lumbar epidural hematoma is a very rare condition and can cause permanent neurological deficit needing urgent investigation and prompt intervention. We present here a case of lumbar epidural hematoma after chiropractic manipulation therapy for low back pain without any obvious predisposing factor. A fairly healthy and lively 72-year-old woman was admitted to our hospital because of grade 4 paresis after chiropractic manipulation therapy. She had no history of anticoagulation therapy. Magnetic resonance imaging (MRI) showed a spinal epidural hematoma with dural sac compression at the level of L3–L4. Rapid decompression of the spinal channel was performed. On follow-up 4 weeks after surgery, the patient was fully ambulatory and complained only of slight pain at the surgical site. MRI is the most useful method for diagnosing spinal epidural hematoma, the appropriate treatment for patients with neurological deficits being surgical decompression. Practitioners of chiropractic manipulation therapy should be aware of spinal epidural hematoma as a possible complication and should exercise caution in subgroups of patients on antithrombotic medication. Spinal epidural hematoma is a potentially reversible cause of neurological deterioration if diagnosed early and treated promptly.     

Spinal epidural hematoma

Three cases of spinal epidural hematoma are reported, one lumbar, another cervical, and the third thoracic. All were dorsolaterally localized, the first and the third were dependent on anticoagulant therapy, and the second was spontaneous. In addition to the symptoms of sudden onset, acute spinal pain, flaccid paralysis, and loss of sphincter control, the second case had the exceptional picture of a cervical anterior spinal cord syndrome with preoperative transient improvement, followed by the development of Brown-Séquard syndrome with subsequent deterioration. This case was diagnosed by means of computed tomography. The postoperative course has been satisfactory in all patients, with complete recovery in two.     

Spontaneous cervical epidural hematoma. Apropos of a case

We report one case of spinal epidural hematoma located in the cervical area, so-called spontaneous because this unknown etiology, extended over C3-C6, diagnosed by Computed Tomography, with complete recovery after surgical treatment accomplished 36 hours after the onset of symptoms. The clinical picture is characterized by sudden onset of severe cervical or interscapular pain, associated with radicular radiation into the upper extremities, followed by development of progressive signs of spinal cord compression with varying degree of motor and sensory paralysis. We emphasized the importance of an early diagnosis, easily possible with Computed Tomography. The CT findings are similar to intracranial acute epidural hematoma: showing a characteristic hyperdense lenticular collection, typically localized in the dorsolateral spinal epidural space. Computed Tomography appears to be the procedure of choice for preoperative diagnosis and for postoperative control. The surgical indication is absolute.     

Spontaneous acute thoracic epidural hematoma causing paraplegia in a patient with severe preeclampsia in early labor

This is a case of acute spontaneous thoracic epidural hematoma in a laboring patient at term who presented with severe preeclampsia and acute spinal cord compression, paraplegia, and sensory loss below T8. In early labor, at home, the patient experienced sudden lumbar back pain that progressed to mid-scapular pain leading to paraplegia and T8 sensory loss within one hour of onset of pain. Her symptoms were caused by a spontaneous thoracic epidural hematoma. Upon arrival at the first hospital, the correct presumptive diagnosis was made in the emergency room, magnesium sulfate was administered, and the patient was transferred to our medical center. Her hypertension was not treated despite severe preeclampsia in order to maintain spinal cord perfusion pressure. Following cesarean section under general anesthesia, thoracic laminectomy was performed and an epidural hematoma compressing the spinal cord to 2-3 mm was evacuated 13 h after the onset of symptoms. After approximately three months of paraplegia, five months with quad-walker and cane use, the patient can now walk with a cane or other minimal support but has remaining bowel and bladder problems. The conflicting anesthetic management objectives of severe preeclampsia and acute paraplegia secondary to spinal epidural hematoma required compromise in the management of her preeclampsia in order to preserve spinal cord perfusion.     

Spontaneous regression of paraplegia caused by spontaneous cervico-thoracic epidural hematoma

Spontaneous spinal epidural hematoma is a rare condition that usually requires surgical treatment in emergency. We report the unusual and well-documented case of a spontaneous spinal epidural hematoma, extending from C6 to T2, occurring in a 56-year old man and causing paraplegia. Without surgery, the paraplegia spontaneously and completely recovered within the first 24 hours. Serial MRI studies demonstrated the remitting course of the spinal epidural hematoma. Emergency surgical evacuation should still be the standard treatment for patients with disabling and/or persistent neurologic deficit. A conservative approach under close neurologic observation may be recommended for patients with no or mild deficits, for patients who show early and continuous clinical improvement within the first 24 hours and for patients with small and/or non-compressive spinal epidural hematoma. Reported cases of spontaneous remission are very rare.     

Acute epidural hematoma developing during twist-drill craniostomy: a complication of percutaneous subdural tapping for the treatment of chronic subdural hematoma

BACKGROUND

This case illustrates that although percutaneous subdural tapping for patients with chronic subdural hematoma (CSDH) is successful and minimally invasive, it can be complicated by acute epidural hematoma.

CASE PRESENTATION

A 62-year-old woman presented with headache two months after minor head trauma. Computed tomography (CT) scanning revealed CSDH with mixed density on the right side. Prior to percutaneous subdural tapping, twist-drill craniostomy was performed at the parietal tuber. When the drill-needle reached the dura mater, the patient began to complain of headache, which was followed by altered consciousness. CT scanning disclosed acute epidural hematoma abutting the CSDH; both hematomas were evacuated by emergency craniotomy. At surgery, no definite bleeding source was identified apart from oozing on the dura mater.

CONCLUSION

Hemorrhagic complications after percutaneous subdural tapping are rare. The formation of acute epidural hematoma during twist-drill craniostomy has not been reported in the literature. This complication can occur when the blunt tip of the drill-needle remains on the dura mater without penetrating into the subdural hematoma cavity.     

Chronic spontaneous spinal epidural hematoma – a rare cause of cervical myelopathy

Spontaneous spinal epidural hematoma (SSEH) is a rare entity. SSEH occurring anterior to the spinal cord in the cervical region with spontaneous improvement is even more rare. One such rare case is reported. A 19-year-old male presented with a 2-month history of neck pain and weakness of the upper and lower limbs without sensory deficit. Magnetic resonance imaging (MRI) showed features of anteriorly located cervical epidural hematoma. As the patient had started improving by the time he sought neurosurgical consultation, he was treated conservatively, and he improved over a period of 2 months. This case illustrates that, though rare, chronic spontaneous spinal epidural hematoma should be entertained in the differential diagnosis of cervical cord compression. Spontaneous resolution of spinal epidural hematomas is known to occur, and in properly selected cases, surgical intervention may not always be necessary.     

Thoracic epidural hematoma after spinal manipulation therapy

Posttraumatic spinal epidural hematoma is an unusual pathology. The authors report the case of a 64-year-old woman who experienced thoracic epidural hematoma during a session of spinal manipulation therapy (SMT). In the literature, such an event has been reported previously only twice. This case represents the first spinal epidural hematoma occurring after a chiropractic manipulation in the lumbar region. Surgical evacuation of the spinal hematoma resulted in complete recovery in the patient. Complications of SMT are reviewed, and the etiology and features of spinal epidural hematoma are discussed.     

Combined epidural and intracerebral hematomas after evacuation of bilateral chronic subdural hematoma

Bleeding after surgery for chronic subdural hematoma far from the operative site is a rare phenomenon with possibly serious consequences. We report a case of combined epidural and intracerebral hemorrhage immediately after evacuation of bilateral chronic subdural hematoma. The epidural hematoma was evacuated by emergency craniotomy, but the deep parenchymal hematoma was treated conservatively. The patient recovered progressively with a good outcome. Approximately 30 cases of chronic subdural hematomas complicated by intracerebral hematoma were previously reported, but only seven cases of epidural hematoma. These complications could be avoided if slow, gradual decompression is used during surgery. Clinicians should suspect its occurrence without delay when a postoperative neurological deterioration is demonstrated. Possible mechanisms are discussed.     

Large subcutaneous hematoma complicating epidural block

We present a case of a large subcutaneous hematoma in the lumbar region that occurred after epidural block was performed for the relief of labor pain. Epidural analgesia was begun in a young and healthy primigravida. Eight hours later, she needed an emergency cesarean section. Before anesthesia, blood was observed flowing freely around the site of the catheter insertion. General anesthesia was administered. Postoperative computed tomography showed a large subcutaneous hematoma in the lumbar region. Her postpartum course was complicated by an unexplained fever, which responded to antibiotic therapy and warranted prolonged hospitalization. Coagulation and bleeding studies were normal. We conclude subcutaneous hematoma after epidural block can cause significant morbidity and should be added to the list of neuroaxial block complications.