Simultaneous cranial and spinal subdural hematoma

A 59-year-old male presented with spinal subdural hematoma (SDH) with concomitant cranial chronic SDH manifesting as mild paraparesis and numbness in both lower extremities. Magnetic resonance (MR) imaging showed simultaneous occurrence of cranial and spinal SDHs. The patient was treated conservatively because of poor medical condition and mild neurological symptoms, and recovered well within 1 month. Serial follow-up MR imaging revealed spontaneous resolution of both lesions, with signal intensity changes suggesting the degenerative process of subacute hematoma. The spinal hematoma may have migrated from the cranial lesion. Spinal SDH is a potential sequela of chronic SDH in the cranium.     

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。     

Primary intracranial hypotension associated with chronic subdural hematoma--report of 2 cases

Low spinal fluid pressure syndrome is characterized by orthostatic headache aggravated in upright position. It is classified into two from etiological standpoint i.e. primary and secondary (most often seen after lumbar puncture). On the other hand, low spinal fluid pressure is one of the promoting factors of chronic subdural hematoma. We report 2 cases of primary low spinal fluid pressure syndrome (primary intracranial hypotension) associated with chronic subdural hematoma. Case 1 is a 47-year-old man who was admitted with disorientation following 2 week history of orthostatic headache. Spinal fluid pressure was 7mmH2O in the lateral recumbent position. CT scan revealed bilateral isodense chronic subdural hematoma. The subdural hematoma reaccumulated 17 days after the first operation. Case 2 is a 31-year-old woman who was admitted with 4 week history of progressive orthostatic headache accompanied by nausea and vomiting. Spinal fluid pressure was 0 mmH2O. CT scan and cerebral angiography showed bilateral chronic subdural hematoma. The hematoma reaccumulated 20 days after the first operation. Six cases including our two cases of primary intracranial hypotention associated with chronic subdural hematoma have been reported. When changes of characters of headache, especially mental symptoms and disturbances of consciousness occurred in patients with chronic orthostatic headache, association of chronic subdural hematoma should be suspected. In cases with chronic subdural hematoma associated with low spinal fluid pressure syndrome, the reaccumulation of hematoma tends to occur after burr hole opening and irrigation of hematoma.     

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.     

Rapid spontaneous resolution of acute subdural hematoma occurs by redistribution--Two case reports

Coronal magnetic resonance imaging provided evidence of redistribution during the rapid spontaneous resolution of acute subdural hematoma (ASDH) in two patients. A 79-year-old female was transferred to our hospital after a traffic accident. Computed tomography (CT) on admission demonstrated an ASDH in the right frontal cerebral cortex. CT 12 hours after the accident revealed spontaneous resolution of the ASDH. Coronal magnetic resonance (MR) imaging 3 days after the accident clearly detected a very thin, sharply demarcated layer diffusely covering the cerebral convexity and the middle cranial fossa. A 41-year-old female fell and sustained head trauma with the loss of consciousness. CT on admission demonstrated an ASDH in the left frontal cerebral cortex. CT 12 hours after the accident revealed spontaneous resolution of the ASDH. Coronal MR imaging 3 days after the insult clearly demonstrated the redistribution and dispersal of the hematoma. Although CT showed the disappearance of the hematoma, MR imaging demonstrated redistribution rather than disappearance of the blood in both cases. These cases indicate that spontaneous resolution of ASDH occurs by redistribution and dispersal of the hematoma.     

Spinal cord infarction after decompressive laminectomy for spontaneous spinal epidural hematoma--case report

A 68-year-old woman presented to the emergency department for evaluation of bilateral leg weakness. On admission, she had paraparesis with incomplete sensory deficit. Magnetic resonance (MR) imaging of the thoracolumbar spine revealed spontaneous spinal epidural hematoma (SSEH) compressing the spinal cord. The patient was taken to the operating room for urgent surgical decompression and evacuation of the SSEH. After the surgery, she woke up with complete paraplegia. Postoperative MR imaging showed the spinal cord was edematous, with minimal remnant hematoma. MR imaging after 1 month clearly showed anterior spinal artery thrombosis. No significant neurological improvement occurred during the 3-month follow up. Surgeons should consider the possibility of this devastating complication before aggressive and early surgical intervention in a patient with SSEH causing cord compression and neurological deficit.     

Spectrum of subdural fluid collections in spontaneous intracranial hypotension

OBJECT: Spontaneous intracranial hypotension is a noteworthy but commonly misdiagnosed cause of new daily persistent headaches. Subdural fluid collections are frequent radiographic findings, but they can be interpreted as primary rather than secondary pathological entities, and uncertainties exist regarding their optimal management. The authors therefore reviewed their experience with subdural fluid collections in 40 consecutive patients with spontaneous spinal cerebrospinal fluid (CSF) leaks and intracranial hypotension. METHODS: The mean age of the 26 female and 14 male patients was 43 years (range 13-72 years). Subdural fluid collections were present in 20 patients (50%); 12 of these patients (60%) had subdural hygromas alone, and eight (40%) had subacute to chronic subdural hematomas (SDHs) associated with significant mass effect. The subdural hygromas resolved within several days to weeks following treatment of the underlying CSF leak. Three patients with SDHs underwent evacuation of the hematoma prior to the establishment of the diagnosis of spontaneous intracranial hypotension, but the SDHs did not resolve until the underlying spinal CSF leak was treated. In the remaining five patients, the CSF leak was treated primarily and the SDHs resolved over a 1- to 3-month period without the need for evacuation. CONCLUSIONS: Subdural fluid collections are common in spontaneous intracranial hypotension, varying in appearance from thin subdural hygromas to large SDHs associated with significant mass effect. These collections can be safely managed by directing treatment at the underlying CSF leak without the need for hematoma evacuation.     

Single burr hole surgery for acute spontaneous subdural hematoma in the aged: patient reports of three cases

The method of treatment for acute spontaneous subdural hematoma in aged patients is controversial. Three cases of acute spontaneous subdural hematoma in aged patients, treated by single burr hole drainage without irrigation, were reported. The first case, an 80-year-old male was admitted with complaints of headache and stupor without any history of head trauma. CT revealed a left subdural hematoma with mixed density. Intractable facial convulsion occurred three days after admission. Single burr hole drainage was performed to remove the hematoma, and facial convulsion disappeared one week after the surgery. The second case, a 70-year-old male was admitted with complaints of consciousness disturbance without any history of head trauma. CT showed a right subdural hematoma with mixed density. The next day, he recovered consciousness and CT demonstrated shrinkage of the hematoma. However, his consciousness deteriorated again 11 days after admission, and CT revealed progression of the hematoma. We performed single burr hole drainage, and the next day, his neurological condition recovered. The third case, an 84-year-old female was admitted with complaints of consciousness disturbance without any history of head trauma. CT revealed a left subdural hematoma with mixed density. Single burr hole drainage was performed to remove the hematoma. She recovered completely and was discharged and return home 1 month after the surgery. Single burr hole drainage is less invasive than craniotomy. Our three cases indicate that this method may be one of the best methods for aged patients with acute spontaneous subdural hematoma which manifests mixed density in CT.     

Spontaneous spinal subdural hematoma with spontaneous resolution

STUDY DESIGN: Single patient case report. OBJECTIVES: To present and discuss a case of spontaneous spinal subdural hematoma that was not associated with coagulation abnormality. SETTING: Seoul National University Hospital, Seoul, Korea. METHODS: Clinical and radiological magnetic resonance imaging follow-up of the patient between August 1997 and December 1998. RESULTS: The hematoma was initially extensive, ranging from T5 to L3. However, it resolved spontaneously with the subsequent development of an adhesive arachnoid cyst. CONCLUSION: Even though urgent surgical decompression is necessary in most cases of spinal subdural hematoma, conservative management could be an option in cases with rapid resolution of the neurological deficit.     

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.     

Spinal magnetic resonance imaging of spontaneous intracranial hypotension in the early phase

A previously healthy 34-year-old woman and a previously healthy 35-year-old woman with spontaneous intracranial hypotension (SIH) presented within 1 week of the onset of symptoms. Brain magnetic resonance (MR) imaging with gadolinium demonstrated no abnormality, whereas spinal MR imaging revealed extradural fluid collection in both patients. Both patients were treated conservatively with bed rest and intravenous hydration. Their symptoms almost completely resolved. We suggest that spinal MR imaging findings of extradural fluid collection can help to establish the early diagnosis of SIH.     

Acute spontaneous subdural hematoma of arterial origin

BACKGROUND: Acute subdural hematoma is usually associated with cerebral contusion or laceration of the bridging veins following a head injury. However, several cases of acute subdural hematoma without head injury (acute spontaneous subdural hematoma) have been reported. METHODS: Among 162 cases of acute subdural hematoma admitted to our departments between 1996 and 2003, we repoort eight cases of acute spontaneous subdural hematoma. These cases fulfilled the following criteria. 1) Head injury was either trivial or absent. 2) Neither aneurysm nor arteriovenous malformation was apparent. 3) CT scan revealed neither brain contusion nor traumatic subarachnoid hemorrhage. 4) At operation, laceration of the cortical artery was observed. In this article, we describe the clinical feature (age, sex, Glasgow Coma Scale [GCS] Score on admission, past history, CT appearance, and outcome) associated with this condition. RESULTS: Patients ranged in age from 68 to 85 years (average 74.8 years), and were comprised of 3 males and 5 females. Previous medical history included cerebral infarction in 6 of the 8 patients and myocardial infarction in 1 patient. These seven patients were taking antiplatelet manifestation. GCS on admission ranged from 4 to 13. Five of the 7 patients on antiplatelet medication had secondary insults, such as hypoxia. On CT, hematoma thickness ranged from 13.2mm to 42.5mm (average 22.6mm), and midline shift ranged from 10.0mm to 24.0mm (average 16.5mm). Neurological outcome evaluated using the Glasgow Outcome Scale was as follows, good recovery n = 2, moderate disability n = 2, severe disability n = 3, persistent vegetative state n = 1. CONCLUSION: The mechanism of acute spontaneous subdural hematoma is influenced by the presence of pre-existing cerebrovascular disease and by the use of antiplatelet agents. In such cases, the possibility of cortical arterial bleeding should be taken into account, and craniotomy should be performed.     

Shaken baby syndrome manifesting as chronic subdural hematoma: importance of single photon emission computed tomography for treatment indications--case report

A boy with shaken baby syndrome first presented at age 3 months with acute subdural hematoma (SDH) and was treated by subdural tapping at a local hospital. Chronic SDH was identified at a rehabilitation center at age 19 months. The chronic SDH appeared to have developed within the preceding 16 months. His physical and mental development was already delayed. Magnetic resonance (MR) imaging revealed a 20-mm thick right chronic SDH with midline shift and small bilateral subdural effusions. The chronic SDH had compressed the right cerebral hemisphere. MR imaging also disclosed bilateral cerebral atrophy. 99mTc-ethylcysteinate dimer single photon emission computed tomography (SPECT) revealed decreased cerebral blood flow (CBF) in the non-hematoma hemisphere, although CBF is said to decrease on the chronic SDH side, especially if midline shift is present. Burr hole craniotomy with external drainage was performed, but the patient showed no change in CBF postoperatively, although the volume of hematoma decreased. The patient was clinically unchanged immediately after the operation. In this case, SPECT measurement of CBF was important in evaluating the pathophysiology of the delays in physical and mental growth. Atrophy of the bilateral hemispheres was the major mechanism in the decreased CBF, not the compression by chronic SDH. MR imaging and SPECT can determine the surgical indications for chronic SDH in patients with cortical atrophy.     

A case of the spinal subdural hematoma formation following ventriculoperitoneal shunting for von Recklinghausen's disease associated with aqueductal stenosis

Von Recklinghausen's disease associated with hydrocephalus due to non-tumoral aqueductal stenosis is rare. Furthermore the formation of subdural hematoma within the spinal canal is also a very rare complication of ventriculoperitoneal shunt. We presented a case of spinal subdural hematoma formation following ventriculoperitoneal shunting for von Recklinghausen's disease associated with aqueductal stenosis. A 10-year-old girl with von Recklinghausen's disease was referred to our hospital for gait disturbance during the previous 8 months. Magnetic resonance imaging (MRI) revealed hydrocephalus due to non-tumoral aqueductal stenosis, and ventriculoperitoneal shunt was instituted. Three months later, the patient developed lumbar pain and paraplegia. MRI revealed subdural hematoma in the lumbosacral spinal canal, and bilateral intracranial subdural hematoma were shown on computerized tomography (CT) scans. Subdural hematoma in the lumbosacral spinal canal was evacuated by laminectomy. Improvement of her neurological deficit was obtained postoperatively, and intracranial subdural hematomas disappeared spontaneously. Spinal subdural hematoma is assumed to be formed by the migratory movement of intracranial subdural hematoma under the influence of gravity. A characteristic finding of MRI is that such a subdural hematoma in the lumbosacral canal is located around the cauda equina.     

Refractory chronic subdural hematoma due to spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) is reported to cause chronic subdurai hematoma (SDH), however diagnosis of SIH in patients with SDH is not always easy. We report a case of chronic SDH refractory to repeated drainage, which was attributed to SIH. A forty-five-year-old man who had been suffering from orthostatic headache for one month was admitted to our hospital presenting with unconsciousness and hemiparesis. CT on admission revealed a chronic subdural hematoma, which was successfully treated once with subdural drainage. However, the patient fell into unconscious again with recurrence of the hematoma within several days. After two more sessions of drainage, SIH due to cerebrospinal fluid leakage was diagnosed with spinal magnetic resonance imaging (MRI) and radionuclide cisternography. Spinal MRI demonstrated abnormal fluid accumulation in the thoracic epidural space, and the radionuclide cisternogram showed early excretion of tracer into urine as well as absence of intracranial tracer filling. After treatment with epidural blood patching, the hematoma rapidly disappeared and he was discharged without symptoms. In the treatment of chronic SDH, especially in young to middle aged patient without preceding trauma or hematological disorders, physicians should pay attention to underlying SIH to avoid multiple surgery. MRI of the spine as well as radionuclide cisternography is useful in evaluation of this condition.     

Acute nontraumatic spinal subdural hematomas in three patients.

STUDY DESIGN: The clinical data, magnetic resonance imaging, intraoperative findings, and functional outcome were reviewed for three patients under anticoagulant therapy who experienced acute nontraumatic spinal subdural hematoma. OBJECTIVES: To draw attention to this rare complication of anticoagulant therapy and to assess the magnetic resonance findings and clinical outcome of patients with spinal subdural hematoma after surgical evacuation. SUMMARY OF BACKGROUND DATA: Among intraspinal hematomas, spinal subdural hematomas are by far the least common. Magnetic resonance findings have been demonstrated in only a few cases of spinal subdural hematomas. The timing of the operation and the anatomic location of the hematoma essentially determine the functional outcome. METHODS: Three case reports of spinal subdural hematomas in patients receiving anticoagulant therapy are presented. Particular interest was given to the clinical and magnetic resonance data, the intraoperative findings, and the functional outcome. RESULTS: The three patients each had a complete preoperative neurologic deficit. Sagittal T1- and T2-weighted magnetic resonance images of the spine proved to have high sensitivity for defining the type of bleeding and delineating the craniocaudal extension of the hematoma. Surgical evacuation was performed within 26 hours after the onset of symptoms. Intraoperative findings showed the hematoma to be confined between the dura and the arachnoid in two patients, and to be associated with rupture into the subarachnoid space in one patient. Postoperative recovery was incomplete in two patients, and did not improve in the remaining patient. CONCLUSIONS: Spinal subdural hematoma must be considered in patients under anticoagulant therapy with spontaneous signs of acute spinal cord or cauda equina compression. Magnetic resonance imaging with sagittal T1- and T2-weighted images were adequate and reliable for diagnosis of spinal subdural hematoma. On the basis of previous studies and the authors' intraoperative findings, spinal subdural hematomas could be viewed as spinal dural border hematomas. The level of preoperative neurologic deficit seemed to be critical for recovery despite prompt surgical evacuation.     

Spinal epidural hematoma following epidural anesthesia versus spontaneous spinal subdural hematoma. Two case reports

Two cases of lumbar hemorrhage with subsequent persistent neurologic sequelae are presented and their possible causes are discussed in the context of a literature review: one patient with spontaneous spinal subdural hematoma with no trauma or lumbar puncture and one with spinal epidural hematoma associated with preceding epidural catheterization for postoperative pain relief. The subdural hematoma was associated with a thrombocytopenia of about 90,000/microliters due to intraoperative blood loss. This might have been contributory to the formation or expansion of the hematoma, but it is not convincing since a platelet count of this amount should not lead to spontaneous bleeding. Both patients received low-dose heparin, but since coagulation tests were normal, prolonged bleeding does not appear to be a likely cause, although it cannot be excluded. In conclusion, the reasons for both hematoma remain unclear. With regard to the epidural hematoma and low-dose heparinization, the possible coincidence of spontaneous lumbar hematoma and lumbar regional block should be taken into consideration.     

Lumbar spinal subdural hematoma following craniotomy--case report.

A 52-year-old female complained of lumbago and weakness in the lower extremities 6 days after craniotomy for clipping an aneurysm. Neurological examination revealed symptoms consistent with lumbosacral cauda equina compression. The symptoms affecting the lower extremities spontaneously disappeared within 3 days. Magnetic resonance (MR) imaging 10 days after the operation demonstrated a lumbar spinal subdural hematoma (SSH). She had no risk factor for bleeding at this site, the symptoms appeared after she began to walk, and MR imaging suggested the SSH was subacute. Therefore, the SSH was probably due to downward movement of blood from the cranial subdural space under the influence of gravity. SSH as a complication of cranial surgery is rare, but should be considered if a patient develops symptoms consistent with a lumbar SSH after craniotomy.     

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.     

Subdural hyperintense band on diffusion-weighted imaging of chronic subdural hematoma indicates bleeding from the outer membrane

The diffusion-weighted magnetic resonance (MR) imaging characteristics of chronic subdural hematoma and the correlation between hematoma liquidity and apparent diffusion coefficient (ADC) were investigated in 26 consecutive patients, 16 males and 10 females aged 42 to 92 years (mean +/- SD 73.3 +/- 13.1 years), with 31 chronic subdural hematomas. The chronic subdural hematomas were divided into homogeneous, separate, and trabecular types based on diffusion-weighted MR imaging findings. Almost all hematomas were low intensity on diffusion-weighted imaging, and the mean ADC value was 1.81 +/- 0.79 x 10(-3) mm2/sec. The high intensity areas in the subdural hematomas consisted of several types: high intensity line along the dura mater (subdural hyperintense band), high intensity along the intrahematoma septum, and laminar shape along the inner membrane. The subdural hyperintense bands accounted for almost all high intensity areas in the subdural hematomas. The mean ADC value of the high intensity areas was 0.76 +/- 0.24 x 10(-3) mm2/sec, close to that of the normal brain. The subdural hyperintense bands were considered to be intracellular and/or extracellular methemoglobin based on the T1- and T2-weighted imaging and intraoperative findings. The subdural hyperintense band is an important finding indicating relatively fresh bleeding from the outer membrane. Diffusion-weighted imaging shows liquid subdural hematoma as low intensity, and measurement of the ADC values can differentiate between liquid and solid components of the chronic subdural hematoma.