自发性硬脊膜外血肿的诊断和治疗策略

目的探讨自发性硬脊膜外血肿的临床特征、治疗及影响预后的因素。方法对16例自发性硬脊膜外血肿患者的临床特征、手术治疗时机以及手术后神经功能恢复情况进行回顾总结,并结合文献分析影响预后的因素。所有自发性硬脊膜外血肿患者均行MRI检查。结果16例患者的硬脊膜外血肿分别位于下颈段（2例）、颈胸段（6例）、胸段（7例）及胸腰段（1例）。MRI检查T1WI表现为等信号或略高信号,T2WI以高信号为主,其中可见混杂低信号。12例施行手术治疗的患者中10例预后良好;4例保守治疗者中3例神经功能完全恢复。结论脊髓MRI检查是诊断自发性硬脊膜外血肿的首选方法,早期诊断和外科手术治疗是恢复神经功能、提高疗效的关键。手术疗效主要与自发性硬脊膜外血肿患者手术前的神经功能缺损程度和手术间隔时间有关;症状较轻者在密切观察下可予以保守治疗,其神经功能的恢复主要取决于神经功能缺损程度。目的探讨自发性硬脊膜外血肿的临床特征、治疗及影响预后的因素。方法对16例自发性硬脊膜外血肿患者的临床特征、手术治疗时机以及手术后神经功能恢复情况进行回顾总结,并结合文献分析影响预后的因素。所有自发性硬脊膜外血肿患者均行MRI检查。结果16例患者的硬脊膜外血肿分别位于下颈段（2例）、颈胸段（6例）、胸段（7例）及胸腰段（1例）。MRI检查T1WI表现为等信号或略高信号,T2WI以高信号为主,其中可见混杂低信号。12例施行手术治疗的患者中10例预后良好;4例保守治疗者中3例神经功能完全恢复。结论脊髓MRI检查是诊断自发性硬脊膜外血肿的首选方法,早期诊断和外科手术治疗是恢复神经功能、提高疗效的关键。手术疗效主要与自发性硬脊膜外血肿患者手术前的神经功能缺损程度和手术间隔时间有关;症状较轻者在密切观察下可予以保守治疗,其神经功能的恢复主要取决于神经功能缺损程度。     

Spontaneous spinal epidural hematoma during pregnancy

BACKGROUND: Spontaneous spinal epidural hematoma is a rare phenomenon that has no distinct etiology. Spontaneous spinal epidural hematoma (SSEH) during pregnancy is extremely rare. We present what we believe to be the fifth reported case of spontaneous spinal epidural hematoma associated with pregnancy in the English literature. METHODS: A 31-year-old female presented with acute onset of paraplegia at 32 weeks of pregnancy. The patient had a T2 sensory level and complete paralysis of all lower extremity motor groups. Magnetic resonance imaging of the thoracic spine showed an acute epidural hematoma posterior to the thoracic spinal cord between the second and fourth thoracic vertebrae. RESULTS: The patient was taken to the operating room were her child was delivered by caesarean section. She then underwent a posterior laminectomy and evacuation of a spinal epidural hematoma. Follow-up selective spinal angiography was negative for any vascular malformation. The patient gradually recovered lower extremity function and was independently ambulating at six month follow-up. Voluntary bowel and bladder function returned within four months but twice daily intermittent catheterization remained necessary for excessive post-void residual urine. CONCLUSIONS: Spontaneous spinal epidural hematoma in pregnancy is a rare phenomenon. It is postulated that elevated venous pressure associated with pregnancy may be a contributing factor. In the reported cases of SSEH in pregnancy most patients presented with acute symptoms, thoracic location and profound neurological deficits but, with prompt surgical treatment, generally had good long term recovery.     

Spinal angiolipoma in a pregnant woman presenting with acute epidural hemorrhage

A 26-year-old woman in week 31 of pregnancy presented to the emergency room with acute onset of paraplegia. Her medical history was unremarkable. Neurological examination revealed complete paraplegia, total sensory loss below the T7 dermatome, and significant vesicorectal dysfunction. MRI revealed an intraspinal mass from T3 to T4, which was hyperintense on both T1-weighted and T2-weighted images. Blood examination found no abnormality. She underwent emergent hemilaminectomy and removal of the hematoma. Intraoperatively, unusually ectatic venous vessels were found adhered to the lower surface of the epidural clot. No concurrent vascular malformations were identified and the dura mater was intact. The histological diagnosis was angiolipoma. Postoperatively her neurological deficits showed remarkable improvement, and she gave birth to a healthy baby. Spinal angiolipoma in a pregnant woman may be complicated with acute epidural hemorrhage. Emergent surgical evacuation can be performed safely with a good functional prognosis.     

Is spontaneous spinal epidural hematoma in elderly patients an emergency surgical case?

Spontaneous spinal epidural hematoma (SSEH) is a rare condition requiring urgent diagnosis and treatment. Patients with SSEH typically present with acute onset of severe back pain and rapidly develop signs of compression of the spinal cord. The authors present a case with spontaneous resolution of SSEH which is extremely rare. We discuss a man who presented to our clinic with mild paraparesis at the seventh day of his symptoms. He had a history of poorly controlled hypertension and hypercholestrolemia requiring an antihyperlipidemic agent and anticoagulation. His upper level of hypoesthesia was at the third thoracic segment. Cervicothoracic SSEH was diagnosed by magnetic resonance imaging. Since there was a gradual recovery of the neurological deficits beginning 12 hours after the onset of symptoms, surgery was obviated and strict bed rest, serial neurological examinations, and pain controls with opiates were instituted. The neurological deficits showed complete recovery on the 25th day of the clinical course. SSEH is rare and immediate surgical decompression is suggested. Rapid neurological deterioration followed by early and progressive neurological recovery, confirmed by radiological resolution of the lesion, may indicate nonoperative treatment.     

Spontaneous Spinal Epidural Hematoma in an Infant : A Case Report and Review of the Literature

Spontaneous spinal epidural hematoma (SSEH) is rare in children, especially in infants, in whom only 12 cases have been reported. Because of the nonspecificity of presenting symptoms in children, the diagnosis may be delayed. We report herein a case of SSEH in a 20-month-old girl who initially presented with neck pain, and developed lower extremity motor weakness and symptoms of neurogenic bladder 2 weeks prior to admission. The magnetic resonance imaging showed an epidural mass lesion extending from C7 to T4, and the spinal cord was severely compressed by the mass. After emergency decompressive surgery the neurologic function was improved immediately. Two months after surgery, the neurological status was normal with achievement of spontaneous voiding. We suggest that surgical intervention can provide excellent prognosis in case of SSEH in infants, even if surgery delayed.     

Spontaneous spinal epidural hematoma: a case report and review of the literatures

Purpose: To emphasize the importance of early recognition and emergent surgery for spontaneous spinal epidural hematoma (SSEH). Case Report: A 61-year-old female presented with sudden onset of severe neck and back pain after finishing worshiping Buddha followed by quadriparesis, sensory deficits below C4 level and sphincter dysfunction. MR imaging demonstrated acute extensive epidural hematoma of cervico-thoracic spinal segments (C2-T7). Idiopathic SSEH was diagnosed and emergent decompressive laminectomy with hematoma evacuation was performed within 12 hours of symptoms onset. Good functional and neurological outcomes were obtained. Conclusion: SSEH is a rare but disabling or even fatal entity. Early diagnosis and prompt surgery improve the neurological and functional outcome but still remain a clinical challenge. Relevant physicians should pay attention to the typical symptoms of the rare entity and SSEH should be one of differential diagnoses.     

Spontaneous spinal epidural hematoma secondary to extradural arteriovenous malformation in a child: a case-based update

Introduction

The aim of this study was to report a rare pediatric case of spontaneous spinal epidural hematoma (SSEH) mimicking Guillain-Barré syndrome (GBS), secondary to an epidural arteriovenous malformation (AVM). Furthermore, a case-based update and insight into the entity is attempted.

Methods

An 8-year-old male presented with progressing severe lower limb weakness and no traumatic history. Presentation was mimicking GBS with ascending symptoms. Magnetic resonance (MR) scan revealed a dorsal epidural mass, extending from C6–C7 to T2, compressing the spinal cord. Emergency laminoplasties and surgical evacuation of the hematoma were performed. An up-to-date review of reported SSEH cases in children was conducted, with emphasis on underlying vascular malformations (epidural AVMs in particular). Pathogenesis, predisposing factors, imaging, diagnosis, treatment and outcome are discussed.

Results

The hematoma was successfully evacuated. A vascular membrane on the dura was peeled off and sent for histopathology. There was no evidence of intradural vascular penetration. The patient improved postoperatively and was able to walk with support 7 months later. Histology revealed closely packed thin-walled angiomatous structures with wide lumens (filled with red blood cells) with walls composed of collagen and smooth muscle fibers, findings consistent with AVM.

Conclusions

Non-traumatic SSEH is rare in the pediatric population. Although vascular malformations are suspected, they are extremely rarely identified histopathologically. This case represents one of the very few reports of pediatric SSEH caused by a histologically proven, purely epidural AVM. High index of clinical suspicion and low threshold for MR can lead to timely diagnosis and prompt treatment with good functional outcome.     

Relapsed spontaneous spinal epidural hematoma associated with aspirin and clopidogrel

An acute spontaneous spinal epidural hematoma (SSEH) is a rare spinal pathology. A 57-year-old man who had hypertension and had been on dual antiplatelet therapy with aspirin and clopidogrel for primary prevention presented with the sudden onset of mid back pain and monoplegia of the left lower extremity. Magnetic resonance imaging revealed an epidural hematoma, and the patient underwent emergency hemilaminectomy for evacuation. However, the symptoms worsened, and complete paraplegia developed. A second procedure to remove the recurrent hematoma was performed. No vascular malformation or other possible cause for SSEH was found other than the aspirin and clopidogrel medication. This case report describes relapsed SSEH caused by the combination of aspirin and clopidogrel medication and urges caution in prescribing dual antiplatelet agents.     

Acute hemiparesis: A rare presentation of spontaneous spinal epidural hematoma mimicking acute stroke

Acute hemiparesis is an extremely rare presentation of spontaneous spinal epidural hematoma, which may be misdiagnosed as acute ischemic stroke and improperly treated with an intravenous thrombolytic agent. Here, we report a case of a 54-year-old woman who presented with acute neck pain and right-sided weakness. She was initially suspected of having ischemic stroke and therefore treated with an intravenous thrombolytic agent. However, she developed progressive tetraparesis, and subsequent magnetic resonance images confirmed cervical spontaneous spinal epidural hematoma.

Stroke is a leading cause of mortality and morbidity in Taiwan.1 Acute hemiparesis is one of the most indicative manifestations of acute stroke. Administration of recombinant tissue plasminogen activator (rtPA), a thrombolytic agent, within 3 to 4.5 hours of symptom onset is the standard treatment for acute ischemic stroke.2 However, various diseases such as slipped cervical discs, epilepsy, and spinal epidural hematoma may present along with acute hemiparesis, mimicking acute stroke, and thus be inappropriately treated with rtPA.3 Spontaneous spinal epidural hematoma (SSEH) is a rare condition of unknown etiology and requires urgent surgical intervention.3-5 The characteristic manifestation of SSEH is sudden-onset neck pain following by motor paralysis or tetraparesis.4 However, SSEH presenting with acute hemiparesis has been rarely reported in the literature. Therefore, we reported a case of SSEH with acute hemiparesis wrongly treated with rtPA in the emergency department (ED).     

Cerebral infarction in the caudate nucleus associated with acute epidural hematoma and diffuse brain injury in a child after severe head injury

Case report A 6-year-old boy was admitted to our hospital 20 min after receiving a direct impact to his head in an automobile accident. He was semi-comatose on admission and computed tomography showed acute epidural hematoma in the right supratentorial region. Three hours later, his consciousness deteriorated due to the enlargement of the hematoma. Surgical removal of hematoma relieved his consciousness disturbance. Post-operative magnetic resonance imaging revealed spotty high-intensity lesions in the corpus callosum on T2-weighted images, and a solitary high-intensity lesion in the left caudate nucleus extending to the medial globus pallidum on T2-weighted and diffusion-weighted images. Magnetic resonance angiography showed no abnormality in the main arteries. These results suggested cerebral infarction in the vascular territory supplied by the recurrent artery of Heubner in association with diffuse brain injury. Post-operative course was uneventful and he was discharged without neurological deficit.Conclusions Post-traumatic cerebral infarction in the caudate nucleus is extremely rare, and its association with diffuse brain injury and epidural hematoma is apparently unique.     

Spinal epidural abscess as the cause of torticollis--diagnosis by magnetic resonance imaging

Spinal epidural abscesses are rare, accounting for only 0.2-1.2 of every 10,000 hospital admissions. Because they often present with non-specific symptoms, they are frequently misdiagnosed. We present a case in which superconduction MRI was used to make the diagnosis and to follow the clinical course of a spinal epidural abscess. In December 1988, a 33-year-old male developed spiking fever and the sudden onset of torticollis. He had had a cerebral palsy from birth, with chronic tetraparesis and mental retardation. Isolation of staphylococcus aureus in urine and blood cultures confirmed the diagnosis of pyelonephritis and septicemia. A high fever persisted despite antibiotic therapy commenced immediately. A technetium 99 m scan showed a localized uptake of isotope in the cervical spine. An MRI examination performed in the following day under sedation showed a mass with the same signal intensity as muscle on T1-weighted images. It was located behind the vertebral bodies C1-Th1 compressing the spinal cord. In addition, a lesion with a decreased signal was also evident in the C5-C6 vertebral bodies. Because of torticollis, the patient was unable to keep his head still for a sufficient period of time, to obtain T2-weighted imaging. The MRI findings indicated the presence of a spinal epidural abscess and osteomyelitis. A second MRI done one month after admission showed a reduction in the size of the epidural mass, but further diminishing of the signal intensity of the vertebral lesion. One month later, the patient underwent the surgical removal of the pus and inflammatory soft tissue, and anterior fusion. The torticollis resolved following the operation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Spontaneous epidural hematoma recurred three times

Spontaneous spinal epidural hematoma (SSEH) is a rare space-occupying disease. The pathogenesis of SSEH is unclear, but anticoagulant therapy, arteriovenous malformation, coagulopathy, tumors and infection are risk factors. Ventral SSEH is even more rare, as the ventral sac is fixed firmly to the posterior longitudinal ligament. The authors report a very rare case, a 16-year-old previously healthy female who had repeated relapse of cervico-thoracic SSEH. This occurred three times in the ventral epidural space with subsequent syringomyelia, without structural abnormality and coagulopathy. The patient underwent conservative care twice, and two operations. The diagnosis was made by magnetic resonance imaging. In rapidly progressing SSEH, the clinician should make the diagnosis as early as possible to enable spinal decompression surgery.     

自发性硬脊膜外血肿

目的探讨自发性硬脊膜外血肿的出血原因、临床表现、MRI特征、诊断及治疗。方法本组7例自发性硬脊膜外血肿患者均行MRI检查。均采用后正中入路,行椎管探查、硬脊膜外血肿清除术并椎板减压术,4例术中见硬脊膜外血管畸形,分别在显微镜下予以结扎或电凝并切除病变。结果本组无1例死亡。随访0.5~2.5年,患者均预后良好,按脊髓损伤的Frankel分级,D级4例,E级3例。无复发。结论MRI检查能清楚显示血肿的部位、范围及脊髓受损情况,是诊断本病的最佳方法,及时的脊髓减压手术是改善自发性硬脊膜外血肿患者预后的关键。     

Tophaceous gout of the lumbar spine mimicking infectious spondylodiscitis and epidural abscess: MR imaging findings.

We report a case of surgically proven tophaceous gout of the lumbar spine at the L5-S1 level that mimicked infectious spondylodiscitis and epidural abscess on magnetic resonance (MR) images in a 65-year-old woman. The spinal tophi were hypointense on T1-weighted images; focally and strongly hyperintense on T2-weighted images; and heterogeneously, marginally enhancing on contrast-enhanced T1-weighted images. The aim of this report is to emphasize the importance of considering this disease entity in the differential diagnosis of an epidural mass in a patient with chronic back pain.     

Glioblastoma Mimicking Herpes Simplex Encephalitis

We report a case of 70-year-old man with glioblastoma presenting as acute encephalitic illness. The patient exhibited sudden onset of cognitive impairment and headache for 2 days. Initial brain MRI showed left temporal lobe hyperintensity, and cerebrospinal fluid cytology revealed a mild pleocytosis. The patient had initially improved after medical treatment with a presumptive diagnosis of herpes simplex encephalitis (HSE). After 8 months, the patient complained of recurrent seizures. A follow-up brain MRI revealed marked increases in size and surrounding perilesional edema in the left temporal lesion on T2-weighted images and a new contrast-enhancing lesion on gadolinium-enhanced T1-weighted images. Stereotactic brain biopsy revealed a glioblastoma. The atypical encephalitic presentation of glioblastoma should be considered if definitive evidence for the diagnosis of HSE cannot be obtained.     

Contrast enhanced fast fluid-attenuated inversion-recovery MR imaging for diagnosing cerebral venous angioma: report of two cases]

It has been reported that contrast-enhanced fluid-attenuated inversion-recovery (FLAIR) sequences were useful for detecting superficial abnormalities, such as meningeal disease, because they do not demonstrate contrast enhancement of cortical vessels with slow flow as do T1-weighted images. We reported the usefulness of contrast-enhanced FLAIR images to differentiate cerebral venous angioma from tumor in two patients. Case 1 was a 71-year-old man developed cortical hemorrhage. Post contrast-enhanced T1-weighted images showed an enhanced lesion around the hematoma, whereas contrast-enhanced FLAIR images showed no enhancement of the lesion, thus he was diagnosed as cortical hemorrhage from cerebral venous angioma. Case 2 was a 72-year-old woman, who was examined MR images because of the jugular foramen neurinoma. There was a T2-high-intensity lesion in the right frontal lobe, and post contrast-enhanced T1-weighted images showed an enhanced lesion in and around the T2-high-intensity lesion. Post-contrast FLAIR images showed no enhancement, and she was diagnosed as cerebral venous angioma. Contrast-enhanced fast FLAIR sequences was useful in differentiation between venous angiomas and tumors. Identification of these lesions was due to the flow-void phenomenon in vessels with slow-flowing blood such as venous angioma, which could not be differentiated from tumors on T1-weighted images.     

自发性椎管内硬脊膜外血肿的诊断和治疗

目的总结自发性椎管内硬脊膜外血肿（SSEH）诊断和治疗的经验。方法回顾性分析10例SSEH患者的临床资料,其中手术治疗7例（术前Frankel分级B级4例,C级2例,D级1例）,保守治疗3例（术前Frankel分级E级）。结果 7例术后未出现并发症,术后复查MRI显示血肿清除;术后病理组织学结果示,4例为单纯血凝块,1例血凝块伴炎性细胞浸润,1例符合血管瘤出血,1例血凝块含较多血管伴血管壁肌层发育不良。所有患者随访1∽40个月,手术治疗7例中5例Frankel分级恢复至E级,2例恢复至D级;3例保守治疗患者复查MRI示血肿均吸收,Frankel分级维持E级。结论 SSEH起病急,进展快;治疗以手术椎板减压＋清除血肿为主要方法,部分患者可考虑选择保守治疗。     

Conservative treatment of spontaneous spinal epidural hematoma associated with oral anticoagulant therapy in a child

Objective Spontaneous spinal epidural hematoma (SSEH) is rare in the pediatric population. This case report reviews the indications and strategies for nonoperative management in selected patients. Methods An eight-year-old boy presented with back pain. There was no antecedent trauma, but the patient was anticoagulated for a mechanical heart valve. MRI revealed an epidural mass from T12 to L2 consistent with SSEH. The absence of focal neurologic deficits, combined with the high stroke risk with anticoagulation reversal, prompted a nonoperative approach. Clinical symptoms resolved over several weeks while maintaining therapeutic anticoagulation. Follow-up MRI demonstrated resolution of the hematoma. Conclusion SSEH can present in the setting of poorly controlled therapeutic anticoagulation in the pediatric population. This case supports the premise that patients who present with SSEH without focal neurologic deficit can be successfully managed while maintaining therapeutic levels of anticoagulation. Close follow-up with frequent neurologic examinations, imaging and monitoring of the prothrombin time is mandatory.     

Lumbar Spinal Extradural Angiolipoma: Case Report and Review of the Literature

Angiolipomas in the lumbar spinal region are extremely rare. The present report describes the identification of such a tumor and its removal, and discusses the tumor characteristics and prognosis. A 74-year-old woman was presented with a 5-month history of lower back pain. Severe radiculopathy was experienced in the left leg for 5 days prior to the presentation, and there were no neurological deficits. Magnetic resonance (MR) images showed an approximately 3.5 cm heterogeneously enhanced and elongated mass at the left L5-S1 level. A portion of the mass appeared with high signal intensity on T2-weighted MR images, with low signal intensity on T1-weighted images, and with high signal intensity on T1 fat suppression enhancement images. Resection of the tumor was approached via an L5 and S1 laminectomy. A fibrous sticky yellowish hypervascular tumor was identified. Histological study revealed the tumor as an angiolipoma. Symptoms were relieved after tumor excision, and there were no neurological sequelae. Although extremely rare, lumbar epidural angiolipoma should be considered in the differential diagnosis of lumbar spinal epidural lesions. The prognosis after surgical management of this lesion is favorable.     

Magnetic Resonance Imaging of the Thalamus following Cryothalamotomy for Parkinson's Disease and Dystonia

Magnetic resonance imaging (MRI) was performed on 3 patients after cryothalamotomy, one of whom had bilateral cryothalamotomies. The time between surgery and MRI ranged from 23 days to 6.5 months. Images made 3 to 4 weeks after surgery showed a lesion of high signal intensity on both T1-weighted and T2-weighted images, and an additional central area of low signal intensity on T1-weighted images. Images obtained at 2, 4, and 6.5 months after surgery showed smaller lesions with low signal intensity on T1-weighted and T2-weighted images, a pattern consistent with resolving hematoma after cryothalamotomy.