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Spontaneous Cervical Epidural Hematoma Masquerading as an Abscess on Magnetic Resonance Imaging Scan
SPONTANEOUS CERVICAL EPIDURAL HEMATOMA MASQUERADING AS AN ABSCESS ON MAGNETIC RESONANCE IMAGING SCAN Ali Nourbakhsh, MD,a Gregory Chaljub, MD, b and Kim J. Garges, MDa
ABSTRACT Objective: The aims of the study are to describe a case of spontaneous spinal epidural hematoma (SSEH) without any predisposing factors and magnetic resonance imaging (MRI) features of epidural abscess and to highlight the importance of high clinical suspicion. Clinical Features: A 75-year-old male presented to the emergency department after a severe neck pain. He progressively showed sensory and upper motor signs on the left side of the body. The MRI scans were suggestive of cervical epidural abscess with peripheral enhancement of the lesion. Interventions and Outcomes: He underwent a multiple level (C3-T1) laminectomy when he was found to have an SSEH. There has been no history of trauma or other predisposing factor, and presence of arteriovenous malformation was ruled out by MR angiography. Conclusions: The MRI features of SSEH may be misleading and mimic other spinal lesions such as abscess. Presence of tapering superior and inferior margins, spotty Gadolinium enhancement in the mass, along with abrupt clinical onset of pain and neurologic deficit, should raise the suspicion toward epidural hematoma. Enhancement in the hyperacute stage of the hematoma itself might indicate continued bleeding and, in the case of deteriorating neurologic status, will necessitate decompression. (J Manipulative Physiol Ther 2009;32:391-395) Key Indexing Terms: Hematoma; Epidural; Spinal; Neck Abscess
pontaneous spinal epidural hematoma (SSEH) is a rare disease entity requiring urgent diagnosis.1 Its incidence is estimated to be 0.1 per 100 000 patients annually; most patients are beyond the age of 50 years.1,2 A variety of contributing factors have been described in the literature, including coagulopathy, anticoagulation, vascular anomaly, disk herniation, Paget disease of the bone, use of the Valsalva maneuver, and hypertension.3 Most of the lesions are found in the thoracolumbar area in adults.4 A case of SSEH in the cervical spine without any causative factor is described. Diagnostic magnetic resonance imaging (MRI) was suggestive of an epidural abscess; definitive diagnosis of SSEH was made during surgery. The purposes of this study
S
a
Associate Professor of Orthopedics, Division of Spine Surgery, Department of Orthopedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Tex. b Department of Radiology, The University of Texas Medical Branch, Galveston, Tex. Submit requests for reprints to: Kim Garges, MD, NASA Spine Institute, 18100 St John Dr, Nassau Bay, TX 77058 (e-mail: [email protected]). Paper submitted May 20, 2008; in revised form March 22, 2009; accepted April 6, 2009. 0161-4754/$36.00 Copyright © 2009 by National University of Health Sciences. doi:10.1016/j.jmpt.2009.04.007
are to describe a case of SSEH without any predisposing factors and MRI features of epidural abscess and to highlight the importance of high clinical suspicion.
CASE REPORT This study was reviewed by the institutional review board of the authors' institution. Although the requirement to obtain authorization for use and disclosure of personal health information was waived by the institutional review board, the patient consented to allowing his medical information regarding this case to be used for the purposes of this study and its subsequent publication. A 75-year-old male presented to our emergency department with sudden severe pain in the distal portion of his posterior cervical spine, extending into both shoulders without any history of trauma, strenuous exercise, or use of anticoagulant medication. At first, he had been transported to a community hospital emergency department, where he was found to be afebrile; laboratory analysis revealed a prothrombin time of 10.6 (normal), an international normalized ratio of 0.9 (normal), a partial thromboplastin time of 26 (normal), and a white blood cell (WBC) count of 6700 (cells/ mL) (normal). Because of the progressive weakness, a gadolinium MRI scan of the cervical spine was obtained. The results of this scan were interpreted as a probable epidural 391
392
Nourbakhsh, Chaljub, and Garges Spontaneous Epidural Hematoma
Fig 1. Sagittal T1-weighted MRI scan of the cervical spine, showing a posterior lesion extending from C3 to T2 (asterisks). Showing the tapering ends of the lesion (black arrow).
abscess, extending posterior and lateral along the left spinal canal from C4 to T1, causing severe spinal cord compression. He was placed on bed rest, intravenous antibiotics, and intravenous dexamethasone. Neurologic evaluation showed the patient to be awake, alert, and oriented without any fever. He had full strength of all upper and lower extremity muscle groups on the right side. Motor strength throughout the left upper extremity was 0/5, except in the biceps, where it was 2/5. Examination of the left lower extremity revealed minimal contraction of the quadriceps, minimal plantar flexion strength (2/5), and no function of any other muscle group (0/5). Sensation was decreased throughout the left lower extremity. Patellar and ankle reflexes were absent bilaterally, there were 2 beats of clonus in the left ankle, and there was a positive Babinski sign. Sensation in the remaining
Journal of Manipulative and Physiological Therapeutics June 2009
Fig 2. T2-weighted MRI scan of the cervical spine. Sagittal plane, showing the presence of hypodense signal due to hemosiderin (white arrow).
limbs was normal. Anal tone and squeeze were normal. He felt radiating pain to both arms during neck extension. The patient had no Hoffman's signs. White cell count was 6.4; erythrocyte sedimentation rate (ESR) was 6; prothrombin time was 12.1; partial thromboplastin time was 24; international normalized ratio was 1.0; and C-reactive protein was less than 0.4. Blood and urine cultures were negative for bacterial growth. A repeat gadolinium MRI scan was obtained at our hospital, which was interpreted by the neuroradiologist as an epidural abscess from C3 to T2, causing severe spinal cord compression (Figs 1-3) The plan was to proceed with cervical decompression and evacuation of the probable abscess. Because the patient refused the operation at first, approximately 50 hours after symptoms first appeared, nondestabilizing laminectomies and decompression of the spinal cord from C3 to T1 were performed without
Journal of Manipulative and Physiological Therapeutics Volume 32, Number 5
Nourbakhsh, Chaljub, and Garges Spontaneous Epidural Hematoma
complications. A dense organized hematoma was evacuated from the left side of the spinal canal. There were no signs of infection. Cultures revealed no growth, and pathologic study only revealed hematoma. He had an uneventful postoperation recovery. At 2 weeks after surgery, the patient's left upper and lower extremity strength had improved in all motor groups to greater than antigravity strength (4/5), and sensation was intact. He continued to improve, and at 3 months, weakness had completely resolved, and sensation was intact. An MRI of the cervical spine with contrast and an MR angiography of the neck vessels were performed to rule out the presence of arteriovenous malformation, which did not show any vascular tangles.
DISCUSSION Spinal epidural masses may be caused by infection (tuberculosis or acute epidural abscess), hematoma, or malignancies (such as meningioma, sarcoma, hemangioma, or tumors of the nervous system). Spinal epidural hematoma is usually seen in middle-aged patients. Cervical SSEH is a rare cause of acute devastating neurologic symptoms. Spine pain is a prodromal symptom that may precede neurologic deterioration.5 The characteristic symptom is sudden dorsal pain, with radicular radiation in more than 50% of the cases. Intense local pain in the spine is followed by progressive neurologic deficits, usually within minutes or hours, which may progress to complete paralysis.6 The causes of SSEH include disruption of epidural arteries,7 transmission of intraabdominal or thoracic pressure to the epidural plexus,6 and an extradural spinal vascular anomaly.8 Groen and Ponssen9 analyzed 199 cases of SSEH from the literature. He concluded that the posterior internal vertebral venous plexus plays an important part in the etiology of the SSEH. The MRI findings are useful in establishing the diagnosis of epidural hematoma and are considered to be the technique of choice for diagnosis by several authors.3,8 The hematomas in the series by Sklar et al5 (17 cases) on acute spinal epidural hematoma showed variable signal intensity, being isointense to slightly hyperintense on T1-weighted images and hyperintense with areas of hypointensity on T2-weighted images. Isointensity to spinal cord on T1-weighted imaging may persist for 5 days.3 The signal intensity of a spinal epidural hematoma (SEH) varies over time. During the subacute stage, such as 30 hours after symptom onset, the hematoma usually has a heterogeneous
Fig 3. A and B, The MRI scan of the cervical spine after gadolinium injection. Sagittal image showing (A) the peripheral enhancement (white arrows), and axial image (B) showing a posterior lesion with peripheral enhancement (black arrow).
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Nourbakhsh, Chaljub, and Garges Spontaneous Epidural Hematoma
hyperintensity on both T1- and T2-weighted images. The increased heterogeneity of the hematomas results from degradation products of hemoglobin.8,10 In our case, T2 imaging showed the hypointense stripped dura in the rim of the lesion (Fig 2), which showed prominent enhancement after intravenous injection of gadolinium-diethylene triamine penta-acetic acid, probably due to hyperemia and enhancement of the thickened meninges adjacent to the hematoma (Fig 3).11 Besides that, T2 view demonstrated hyperintensity of the lesion with areas of hypointensity, presumably due to the presence of deoxyhemoglobin. Fukui et al3 reported a case of SSEH with minimal contrast enhancement on the MRI scan. Most SEHs are located dorsal to the dural sac because of the firm adherence of the dural sac to the posterior longitudinal ligament in the ventral aspect of the spinal canal.9,10 It rarely surrounds the dural sac or spinal cord but compresses it from one side.12 Sagittal MR imaging usually shows, in the dorsal epidural space, the biconvex hematoma with well-defined contours and tapering superior and inferior margins. On the axial section, an SEH appears as a concave or convex mass.10,12 An epidural abscess is seen as a lesion inside the spinal canal and outside the spinal cord, hyperintense on T2weighted, and slightly hypointense on T1-weighted MR images. They are usually located ventrally and involve disk and adjacent vertebral bodies. These lesions may extend throughout multiple levels and are continuous with the infected disk spaces. Necrotic areas often appear on MR images as ring or marginal enhancement.12,13 One can see the difficulty in distinguishing between a spinal epidural hematoma and spinal epidural abscess using MRI alone, as highlighted by the current case. There was a bright signal on T2 in the spinal cord that was most probably due to compression. Rise of WBC has been reported in 60% to 89% of cases diagnosed with epidural hematoma.14-16 The study by Hadjipavlou15 showed that laboratory studies such as leukocyte count and ESR apparently were not sensitive tests in the diagnosis of spondylodiskitis because they were elevated in 42.6% and 81.3% of the patients. In light of the different treatment options and modalities for epidural abscess and hematoma, MRI results should be considered along with the results of laboratory tests and the clinical presentation when making a diagnosis. In our case, the absence of fever, of normal inflammatory markers, and the sudden onset of symptoms were more suggestive of a SSEH, in contrast to the MRI findings, which were compatible with epidural abscess. In the setting of deteriorating neurologic status as in our case, emergent surgical decompression should be performed. In the recent literature, a number of cases of SSEH with spontaneous recovery have been reported. 17-19 Conservative management of the SSEH may be appropriate if early and substantial neurologic recovery is noticed.19 Conservative management is often successful,
Journal of Manipulative and Physiological Therapeutics June 2009
but it can also put such patients at risk for developing spinal cord damage that may not be reversed by an evacuation of the hematoma.10 On the other hand, the cornerstone for the treatment of spinal epidural abscess is decompression and sampling contents.15 Clinical symptoms, along with MRI scan and infection profile, should lead the surgeon toward the best treatment option because MRI scan can rarely be misleading. Enhancement in the hyperacute stage of the hematoma itself might indicate continuing bleeding,10,12 which will necessitate decompression, especially in the setting of deteriorating neurologic status. The level of preoperative neurologic deficit, severity of the neurologic deficit, and operative interval have been described as the most critical factors affecting recovery.2 Although rare, spinal epidural hematoma should be considered as one of the differential diagnosis in the setting of abrupt, severe neck pain followed by neurologic symptoms, even in the absence of predisposing factors such as trauma or anticoagulation therapy. It is noteworthy that MRI features are sometimes misleading in the diagnosis of SSEH and may mimic other spinal lesions such as abscess. The presence of tapering superior and inferior margins, of spotty gadolinium enhancement in the mass, and also of peripheral enhancement, along with abrupt clinical onset of pain and neurologic deficit, should raise the suspicion toward epidural hematoma. The absence of vertebral osteomyelitis or extension of the lesion to the intervertebral disk along with normal WBC and ESR may help differentiate it from epidural abscess.
CONCLUSION Spontaneous epidural hematoma of the spine can show changes that are similar to epidural abscess on MRI scan. Thus, along with the use of imaging, diagnosis of these 2 entities should be based on the results of several studies, including blood and cerebrospinal fluid analysis and blood culture.
Practical Applications • The MRI features of SSEH may be misleading and mimic other spinal lesions such as abscess. • Peripheral enhancement and heterogeneous intensity after gadolinium injection can be some of the features of SSEH on MRI. • A high index of clinical suspicion is necessary to accurately diagnose an epidural hematoma in a patient with no medical history of predisposing factors.
Journal of Manipulative and Physiological Therapeutics Volume 32, Number 5
REFERENCES 1. Holtås S, Heiling M, Lönntoft M. Spontaneous spinal epidural hematoma. Findings at MR imaging and clinical correlation. Radiology 1996;199:409-33. 2. Groen RJ, van Alphen HA. Operative treatment of spontaneous spinal epidural hematomas: a study of the factors determining postoperative outcome. Neurosurgery 1997;39:494-504. 3. Fukui MB, Swarnkar AS, Williams RL. Acute spontaneous spinal epidural hematomas. AJNR Am J Neuroradiol 1999;20: 1365-72. 4. Lee JS, Yu CY, Huang KC, et al. Spontaneous spinal epidural hematoma in a 4-month-old infant. Spinal Cord 2006:1-5. 5. Sklar EML, Post JMD, Falcone S. MRI of acute spinal epidural hematomas. J Comput Assist Tomogr 1999;23:238-43. 6. Ainslie JP. Paraplegia due to spontaneous extradural or subdural hemorrhage. Br J Surg 1958;45:565-7. 7. Beatty RM, Winston KR. Spontaneous cervical epidural hematoma. A consideration of etiology. J Neurosurg 1984;61: 143-8. 8. D'Angelo V, Bizzozero L, Talamonti G, et al. Value of magnetic resonance imaging in spontaneous extradural spinal hematoma due to vascular malformation: case report. Surg Neurol 1990;34:343-4. 9. Groen RJ, Ponssen H. The spontaneous spinal epidural hematoma. A study of the etiology. J Neurol Sci 1990;98:121-38. 10. Nawashiro H, Higo R. Contrast enhancement of a hyperacute spontaneous spinal epidural hematoma. AJNR Am J Neuroradiol 2001;22:1445.
Nourbakhsh, Chaljub, and Garges Spontaneous Epidural Hematoma
11. Crisi G, Sorgato P, Colombo A, et al. Gadolinium-DTPAenhanced MR imaging in the diagnosis of spinal epidural haematoma. Report of a case. Neuroradiology 1990;32: 64-6. 12. Chang FC, Lirng JF, Chen SS, Luo CB, Guo WY, Teng MM, Chang CY. Contrast enhancement patterns of acute spinal epidural hematomas: a report of two cases. AJNR Am J Neuroradiol 2003;24:366-9. 13. Shin JJ, Kuh SU, Cho YE. Surgical management of spontaneous spinal epidural hematoma. Eur Spine J 2006;15: 998-1004. 14. Rigamonti D, Liem L, Sampath P, et al. Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol 1999;52:189-96 [discussion 197]. 15. Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ. Hematogenous pyogenic spinal infections and their surgical management. Spine 2000;25:1668-79. 16. Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000;23:175-204 [discussion 205]. 17. Clarke DB, Bertrand G, Tampieri D. Spontaneous spinal epidural hematoma causing paraplegia: resolution and recovery without surgical decompression. Neurosurgery 1992;30: 108-11. 18. Silber SH. Complete nonsurgical resolution of a spontaneous spinal epidural hematoma. Am J Emerg Med 1996; 14:391-3. 19. Schröder J, Palkovic S, Wassmann H. Spontaneous spinal epidural haematoma: a therapeutical challenge? Report of an unusual case. Emerg Med J 2005;22:387-8.
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ABSTRACT Objective: The aims of the study are to describe a case of spontaneous spinal epidural hematoma (SSEH) without any predisposing factors and magnetic resonance imaging (MRI) features of epidural abscess and to highlight the importance of high clinical suspicion. Clinical Features: A 75-year-old male presented to the emergency department after a severe neck pain. He progressively showed sensory and upper motor signs on the left side of the body. The MRI scans were suggestive of cervical epidural abscess with peripheral enhancement of the lesion. Interventions and Outcomes: He underwent a multiple level (C3-T1) laminectomy when he was found to have an SSEH. There has been no history of trauma or other predisposing factor, and presence of arteriovenous malformation was ruled out by MR angiography. Conclusions: The MRI features of SSEH may be misleading and mimic other spinal lesions such as abscess. Presence of tapering superior and inferior margins, spotty Gadolinium enhancement in the mass, along with abrupt clinical onset of pain and neurologic deficit, should raise the suspicion toward epidural hematoma. Enhancement in the hyperacute stage of the hematoma itself might indicate continued bleeding and, in the case of deteriorating neurologic status, will necessitate decompression. (J Manipulative Physiol Ther 2009;32:391-395) Key Indexing Terms: Hematoma; Epidural; Spinal; Neck Abscess
pontaneous spinal epidural hematoma (SSEH) is a rare disease entity requiring urgent diagnosis.1 Its incidence is estimated to be 0.1 per 100 000 patients annually; most patients are beyond the age of 50 years.1,2 A variety of contributing factors have been described in the literature, including coagulopathy, anticoagulation, vascular anomaly, disk herniation, Paget disease of the bone, use of the Valsalva maneuver, and hypertension.3 Most of the lesions are found in the thoracolumbar area in adults.4 A case of SSEH in the cervical spine without any causative factor is described. Diagnostic magnetic resonance imaging (MRI) was suggestive of an epidural abscess; definitive diagnosis of SSEH was made during surgery. The purposes of this study
S
a
Associate Professor of Orthopedics, Division of Spine Surgery, Department of Orthopedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Tex. b Department of Radiology, The University of Texas Medical Branch, Galveston, Tex. Submit requests for reprints to: Kim Garges, MD, NASA Spine Institute, 18100 St John Dr, Nassau Bay, TX 77058 (e-mail: [email protected]). Paper submitted May 20, 2008; in revised form March 22, 2009; accepted April 6, 2009. 0161-4754/$36.00 Copyright © 2009 by National University of Health Sciences. doi:10.1016/j.jmpt.2009.04.007
are to describe a case of SSEH without any predisposing factors and MRI features of epidural abscess and to highlight the importance of high clinical suspicion.
CASE REPORT This study was reviewed by the institutional review board of the authors' institution. Although the requirement to obtain authorization for use and disclosure of personal health information was waived by the institutional review board, the patient consented to allowing his medical information regarding this case to be used for the purposes of this study and its subsequent publication. A 75-year-old male presented to our emergency department with sudden severe pain in the distal portion of his posterior cervical spine, extending into both shoulders without any history of trauma, strenuous exercise, or use of anticoagulant medication. At first, he had been transported to a community hospital emergency department, where he was found to be afebrile; laboratory analysis revealed a prothrombin time of 10.6 (normal), an international normalized ratio of 0.9 (normal), a partial thromboplastin time of 26 (normal), and a white blood cell (WBC) count of 6700 (cells/ mL) (normal). Because of the progressive weakness, a gadolinium MRI scan of the cervical spine was obtained. The results of this scan were interpreted as a probable epidural 391
392
Nourbakhsh, Chaljub, and Garges Spontaneous Epidural Hematoma
Fig 1. Sagittal T1-weighted MRI scan of the cervical spine, showing a posterior lesion extending from C3 to T2 (asterisks). Showing the tapering ends of the lesion (black arrow).
abscess, extending posterior and lateral along the left spinal canal from C4 to T1, causing severe spinal cord compression. He was placed on bed rest, intravenous antibiotics, and intravenous dexamethasone. Neurologic evaluation showed the patient to be awake, alert, and oriented without any fever. He had full strength of all upper and lower extremity muscle groups on the right side. Motor strength throughout the left upper extremity was 0/5, except in the biceps, where it was 2/5. Examination of the left lower extremity revealed minimal contraction of the quadriceps, minimal plantar flexion strength (2/5), and no function of any other muscle group (0/5). Sensation was decreased throughout the left lower extremity. Patellar and ankle reflexes were absent bilaterally, there were 2 beats of clonus in the left ankle, and there was a positive Babinski sign. Sensation in the remaining
Journal of Manipulative and Physiological Therapeutics June 2009
Fig 2. T2-weighted MRI scan of the cervical spine. Sagittal plane, showing the presence of hypodense signal due to hemosiderin (white arrow).
limbs was normal. Anal tone and squeeze were normal. He felt radiating pain to both arms during neck extension. The patient had no Hoffman's signs. White cell count was 6.4; erythrocyte sedimentation rate (ESR) was 6; prothrombin time was 12.1; partial thromboplastin time was 24; international normalized ratio was 1.0; and C-reactive protein was less than 0.4. Blood and urine cultures were negative for bacterial growth. A repeat gadolinium MRI scan was obtained at our hospital, which was interpreted by the neuroradiologist as an epidural abscess from C3 to T2, causing severe spinal cord compression (Figs 1-3) The plan was to proceed with cervical decompression and evacuation of the probable abscess. Because the patient refused the operation at first, approximately 50 hours after symptoms first appeared, nondestabilizing laminectomies and decompression of the spinal cord from C3 to T1 were performed without
Journal of Manipulative and Physiological Therapeutics Volume 32, Number 5
Nourbakhsh, Chaljub, and Garges Spontaneous Epidural Hematoma
complications. A dense organized hematoma was evacuated from the left side of the spinal canal. There were no signs of infection. Cultures revealed no growth, and pathologic study only revealed hematoma. He had an uneventful postoperation recovery. At 2 weeks after surgery, the patient's left upper and lower extremity strength had improved in all motor groups to greater than antigravity strength (4/5), and sensation was intact. He continued to improve, and at 3 months, weakness had completely resolved, and sensation was intact. An MRI of the cervical spine with contrast and an MR angiography of the neck vessels were performed to rule out the presence of arteriovenous malformation, which did not show any vascular tangles.
DISCUSSION Spinal epidural masses may be caused by infection (tuberculosis or acute epidural abscess), hematoma, or malignancies (such as meningioma, sarcoma, hemangioma, or tumors of the nervous system). Spinal epidural hematoma is usually seen in middle-aged patients. Cervical SSEH is a rare cause of acute devastating neurologic symptoms. Spine pain is a prodromal symptom that may precede neurologic deterioration.5 The characteristic symptom is sudden dorsal pain, with radicular radiation in more than 50% of the cases. Intense local pain in the spine is followed by progressive neurologic deficits, usually within minutes or hours, which may progress to complete paralysis.6 The causes of SSEH include disruption of epidural arteries,7 transmission of intraabdominal or thoracic pressure to the epidural plexus,6 and an extradural spinal vascular anomaly.8 Groen and Ponssen9 analyzed 199 cases of SSEH from the literature. He concluded that the posterior internal vertebral venous plexus plays an important part in the etiology of the SSEH. The MRI findings are useful in establishing the diagnosis of epidural hematoma and are considered to be the technique of choice for diagnosis by several authors.3,8 The hematomas in the series by Sklar et al5 (17 cases) on acute spinal epidural hematoma showed variable signal intensity, being isointense to slightly hyperintense on T1-weighted images and hyperintense with areas of hypointensity on T2-weighted images. Isointensity to spinal cord on T1-weighted imaging may persist for 5 days.3 The signal intensity of a spinal epidural hematoma (SEH) varies over time. During the subacute stage, such as 30 hours after symptom onset, the hematoma usually has a heterogeneous
Fig 3. A and B, The MRI scan of the cervical spine after gadolinium injection. Sagittal image showing (A) the peripheral enhancement (white arrows), and axial image (B) showing a posterior lesion with peripheral enhancement (black arrow).
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Nourbakhsh, Chaljub, and Garges Spontaneous Epidural Hematoma
hyperintensity on both T1- and T2-weighted images. The increased heterogeneity of the hematomas results from degradation products of hemoglobin.8,10 In our case, T2 imaging showed the hypointense stripped dura in the rim of the lesion (Fig 2), which showed prominent enhancement after intravenous injection of gadolinium-diethylene triamine penta-acetic acid, probably due to hyperemia and enhancement of the thickened meninges adjacent to the hematoma (Fig 3).11 Besides that, T2 view demonstrated hyperintensity of the lesion with areas of hypointensity, presumably due to the presence of deoxyhemoglobin. Fukui et al3 reported a case of SSEH with minimal contrast enhancement on the MRI scan. Most SEHs are located dorsal to the dural sac because of the firm adherence of the dural sac to the posterior longitudinal ligament in the ventral aspect of the spinal canal.9,10 It rarely surrounds the dural sac or spinal cord but compresses it from one side.12 Sagittal MR imaging usually shows, in the dorsal epidural space, the biconvex hematoma with well-defined contours and tapering superior and inferior margins. On the axial section, an SEH appears as a concave or convex mass.10,12 An epidural abscess is seen as a lesion inside the spinal canal and outside the spinal cord, hyperintense on T2weighted, and slightly hypointense on T1-weighted MR images. They are usually located ventrally and involve disk and adjacent vertebral bodies. These lesions may extend throughout multiple levels and are continuous with the infected disk spaces. Necrotic areas often appear on MR images as ring or marginal enhancement.12,13 One can see the difficulty in distinguishing between a spinal epidural hematoma and spinal epidural abscess using MRI alone, as highlighted by the current case. There was a bright signal on T2 in the spinal cord that was most probably due to compression. Rise of WBC has been reported in 60% to 89% of cases diagnosed with epidural hematoma.14-16 The study by Hadjipavlou15 showed that laboratory studies such as leukocyte count and ESR apparently were not sensitive tests in the diagnosis of spondylodiskitis because they were elevated in 42.6% and 81.3% of the patients. In light of the different treatment options and modalities for epidural abscess and hematoma, MRI results should be considered along with the results of laboratory tests and the clinical presentation when making a diagnosis. In our case, the absence of fever, of normal inflammatory markers, and the sudden onset of symptoms were more suggestive of a SSEH, in contrast to the MRI findings, which were compatible with epidural abscess. In the setting of deteriorating neurologic status as in our case, emergent surgical decompression should be performed. In the recent literature, a number of cases of SSEH with spontaneous recovery have been reported. 17-19 Conservative management of the SSEH may be appropriate if early and substantial neurologic recovery is noticed.19 Conservative management is often successful,
Journal of Manipulative and Physiological Therapeutics June 2009
but it can also put such patients at risk for developing spinal cord damage that may not be reversed by an evacuation of the hematoma.10 On the other hand, the cornerstone for the treatment of spinal epidural abscess is decompression and sampling contents.15 Clinical symptoms, along with MRI scan and infection profile, should lead the surgeon toward the best treatment option because MRI scan can rarely be misleading. Enhancement in the hyperacute stage of the hematoma itself might indicate continuing bleeding,10,12 which will necessitate decompression, especially in the setting of deteriorating neurologic status. The level of preoperative neurologic deficit, severity of the neurologic deficit, and operative interval have been described as the most critical factors affecting recovery.2 Although rare, spinal epidural hematoma should be considered as one of the differential diagnosis in the setting of abrupt, severe neck pain followed by neurologic symptoms, even in the absence of predisposing factors such as trauma or anticoagulation therapy. It is noteworthy that MRI features are sometimes misleading in the diagnosis of SSEH and may mimic other spinal lesions such as abscess. The presence of tapering superior and inferior margins, of spotty gadolinium enhancement in the mass, and also of peripheral enhancement, along with abrupt clinical onset of pain and neurologic deficit, should raise the suspicion toward epidural hematoma. The absence of vertebral osteomyelitis or extension of the lesion to the intervertebral disk along with normal WBC and ESR may help differentiate it from epidural abscess.
CONCLUSION Spontaneous epidural hematoma of the spine can show changes that are similar to epidural abscess on MRI scan. Thus, along with the use of imaging, diagnosis of these 2 entities should be based on the results of several studies, including blood and cerebrospinal fluid analysis and blood culture.
Practical Applications • The MRI features of SSEH may be misleading and mimic other spinal lesions such as abscess. • Peripheral enhancement and heterogeneous intensity after gadolinium injection can be some of the features of SSEH on MRI. • A high index of clinical suspicion is necessary to accurately diagnose an epidural hematoma in a patient with no medical history of predisposing factors.
Journal of Manipulative and Physiological Therapeutics Volume 32, Number 5
REFERENCES 1. Holtås S, Heiling M, Lönntoft M. Spontaneous spinal epidural hematoma. Findings at MR imaging and clinical correlation. Radiology 1996;199:409-33. 2. Groen RJ, van Alphen HA. Operative treatment of spontaneous spinal epidural hematomas: a study of the factors determining postoperative outcome. Neurosurgery 1997;39:494-504. 3. Fukui MB, Swarnkar AS, Williams RL. Acute spontaneous spinal epidural hematomas. AJNR Am J Neuroradiol 1999;20: 1365-72. 4. Lee JS, Yu CY, Huang KC, et al. Spontaneous spinal epidural hematoma in a 4-month-old infant. Spinal Cord 2006:1-5. 5. Sklar EML, Post JMD, Falcone S. MRI of acute spinal epidural hematomas. J Comput Assist Tomogr 1999;23:238-43. 6. Ainslie JP. Paraplegia due to spontaneous extradural or subdural hemorrhage. Br J Surg 1958;45:565-7. 7. Beatty RM, Winston KR. Spontaneous cervical epidural hematoma. A consideration of etiology. J Neurosurg 1984;61: 143-8. 8. D'Angelo V, Bizzozero L, Talamonti G, et al. Value of magnetic resonance imaging in spontaneous extradural spinal hematoma due to vascular malformation: case report. Surg Neurol 1990;34:343-4. 9. Groen RJ, Ponssen H. The spontaneous spinal epidural hematoma. A study of the etiology. J Neurol Sci 1990;98:121-38. 10. Nawashiro H, Higo R. Contrast enhancement of a hyperacute spontaneous spinal epidural hematoma. AJNR Am J Neuroradiol 2001;22:1445.
Nourbakhsh, Chaljub, and Garges Spontaneous Epidural Hematoma
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