Acute spinal epidural hematoma
By Athos D. Patsalides, MD; Anastasios Raptis, MD, PhD; Nicholas J. Patronas, MD
The heparin drip was discontinued, and protamine sulfate and
fresh frozen plasma were administered. Neurosurgical consultation
was obtained, and considering his medical status, it was elected to
follow the patient closely rather than proceed with neurosurgical
decompression. During the following few days, the patient's
neurological symptoms and signs gradually resolved. A follow-up
magnetic resonance (MR) scan 2 weeks later showed complete
resolution of the epidural hematoma (Figure 1B).
The incidence of spinal epidural hematomas (SEH) is 0.1 per 100,000
per year, and it affects men more often than women.1
causes of SEH fall into 3 main categories: 1) Posttraumatic,
following vertebral fractures, obstetrical birth trauma, epidural
anesthesia, lumbar puncture, spinal surgery, and stab wounds; 2) a
variety of predisposing conditions, such as anticoagulant therapy
(recognized to be the most common predisposing factor), coagulation
disorders, arteriovenous malformation, cavernous angiomas, spinal
cord neoplasm, pregnancy, Paget's disease, hypertension, and
collagen vascular disorder; and 3) spontaneous, for which no
predisposing factors can be identified. According to Beatty and
bleeding from one of the epidural arteries is
the most likely source of spontaneous SEH.
Typically, patients with SEH experience a sudden severe pain at
the level of hemorrhage, which may radiate to the
limbs.3 The radicular pain may precede the spinal pain.
A rapid development of neurological symptoms follows because of
compression of the spinal cord or the cauda equina. Motor and
sensory deficits develop, and patients may have urinary retention.
The symptoms are usually progressive and may result in permanent
neurological disability or even death due to respiratory failure if
emergent neurosurgical intervention is delayed. These clinical
features may resemble those of epidural neoplasia, transverse
myelitis, dissecting aortic aneurysm, congenital cysts,
spondylitis, epidural abscess, vertebral fractures, spinal cord
infarction, and acutely ruptured disc.4,5 In this case,
the patient's history, the clinical and imaging findings, and the
symptom evolution over time established the diagnosis of epidural
From the imaging point of view, important pathologies in the
epidural space of the spine that must be differentiated from SEH
include spinal subdural hematomas, epidural metastases, epidural
abscesses, epidural lipoma, and congenital cysts.
- Spinal subdural hematomas are rare lesions that occur when
extravasated blood accumulates in the preexisting subdural space.
Typically, they extend over a long segment of the spinal canal,
obliterating the subarachnoid space around the cord.
- Epidural metastases are usually associated with bone
destruction and are visible as homogeneous enhancement in
postcontrast MR images.
- Epidural abscesses are often associated with diskitis and/or
osteomyelitis of the spine. The discs and the affected vertebrae
show high signal intensity on T2W imaging and low signal intensity
on T1W imaging. On postcontrast scans, homogeneous enhancement is
observed in the epidural space during the initial stages of the
inflammatory process caused by phlegmon on granulation tissue.
Later, after liquefaction has taken place, fluid collections can be
discerned within the enhancing abnormality of the epidural space.
Abnormal increased enhancement is always observed in the affected
disc or vertebrae.
- Epidural lipoma is characterized by focal accumulation of fatty
tissue with high signal on T1W and low signal on fat-suppression
- Congenital cysts in the spinal canal are characterized by
loculated fluid collections with signal intensities similar to that
of cerebrospinal fluid on both T1W and T2W techniques. They present
with mass effect but show no abnormal enhancement.
With the advent of MRI, epidural hematomas are now diagnosed
more readily. The extent of these lesions in the spinal canal can
be accurately assessed, and the degree of compromise of the spinal
canal and spinal cord compression can easily be measured.
Previously reported cases of spontaneous resolution of SEH4,6-
9 document the benign natural history of this complication,
even when the hematoma extends over several vertebral segments.
Thus, early enthusiasm for surgical management of SEH has gradually
subsided, and a more conservative approach has been adopted. These
reports have shown that the parameters that favor nonsurgical
treatment include stable and nonprogressive neurological deficit of
a mild degree and absent or only minimal cord compression.
We present a patient who developed an epidural hematoma of the
cervical canal during anticoagulant therapy. The hematoma resolved
with conservative management. The authors emphasize that
nonsurgical treatment is appropriate for such patients, providing
that the neurological status is stable and nonprogressive.
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Acute spinal epidural hematoma.
February 07, 2006