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Spontaneous intramedullary hematoma initially mimicking myocardial infarction
American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Spontaneous intramedullary hematoma initially mimicking myocardial infarction Abstract Spontaneous intramedullary hematoma (IMH) is a rare condition. The initial clinical manifestations are variable. Early symptoms of high thoracic IMH include thoracocervical pain that can be mistaken for emergent cardiopulmonary conditions such as myocardial infarction, pulmonary embolus, and aortic dissection. We report on a 34-year-old man who presented initially with chest pain and radiating pain in both shoulders. He was initially misdiagnosed as having a myocardial infarction and treated with heparin. Two hours after admission, correct diagnosis of IMH was based on the repeated neurologic examination and spine magnetic resonance imaging study. The patient underwent emergency surgical decompression and hematoma removal. We draw the misdiagnosis to the attention of the emergency physicians because early recognition of spontaneous IMH is very important for early surgical decompression to improve the prognosis. A 34-year-old man was admitted to the emergency department (ED) due to cheat pain, both shoulders pain, and nausea that occurred 30 minutes before admission during the meal. He was a 17-pack-year smoker without any special medical or trauma history. On admission, he was alert and complained of chest pain as if pressed by the sternum and tingling pain in both shoulders. Initial vital signs were as follows: blood pressure, 170/120 mm Hg; pulse rate, 110 beats/min; respiration rate, 22 breaths/min; and body temperature, 36.7°C. In the physical examination, there were no abnormal findings observed, except for tachycardia. In electrocardiography, sinus tachycardia was found, but when chest pain was severe, premature ventricular contraction (bigeminy pattern) was seen (Fig. 1). The echocardiography showed global hypokinesia and estimated ejection fraction of 35%. About 10 minutes after admission, severe headache and back pain occurred. To differentiate subarachnoid hemorrhage and aortic dissection, brain computer tomography (CT) and aortic dissection CT were obtained. The CT scans revealed normal findings. The laboratory findings revealed elevation of troponin T. The provisional diagnosis of non–STelevation myocardial infarction was made, and heparin was continuously administered. Two hours after admission, the patient complained of newly occurred tingling sensation on his right arm and motor weakness. In the neurologic examination, he had a strength score of grade IV for both lower extremities, decreased sensory with hypoesthesia (5/10), and right upper extremity motor grade IV+ with tingling. In order to examine spine lesions, spine magnetic resonance imaging (MRI) was obtained. During the MRI scan, the patient complained of severe back pain and migrating pain in both wrists and forearms. The lower extremities strength became grade 0, and sensory was decreased below the navel level (5/10). The MRI scans revealed
intramedullary hematoma (IMH) at T4/5 (Fig. 2). After MRI scan, hypoesthesia was 3/10, decreased sensation progressed up to T5 dermatome, and the strength of both upper extremities was deteriorated to grade IV. As a result, emergency decompression and hematoma removal was planned. However, the patient and caregivers neglected, and the patient was transferred to another hospital because they wanted to get a new diagnosis and treatment in an advanced hospital. Eighteen hours after the onset of symptoms, he underwent surgical decompression, and histologic examination disclosed a hematoma without evidence of neoplasm or vessel abnormality. Four weeks after the surgery, the upper extremities strength was recovered to grade V but the lower extremities strength was at grade 0, ambulation by wheelchair is possible, and he is getting rehabilitation treatment. Spinal cord disease can present in a variety of ways with acute, subacute, or chronic onset, and clinical symptoms may vary from incomplete syndromes to complete quadriplegia. Acute quadriplegia beginning with excruciating pain in the chest and back progressing over a short period to quadriplegia is highly suggestive of spinal hemorrhage, which can be epidural, subdural, subarachnoid, or intramedullary. The initial manifestation of IMH is nonspecific and is easily misdiagnosed. Early symptoms of high-level thoracic intramedullary hemorrhage include upper back pain and chest pain that can be mistaken for emergent cardiopulmonary conditions including acute myocardial infarction, pulmonary embolism, aortic dissection, and
Fig. 1. Electrocardiography revealed a bigeminy premature ventricular contraction.
0735-6757/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Choi YH, Lee DH, Spontaneous intramedullary hematoma initially mimicking myocardial infarction, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.03.002
2
Y.H. Choi, D.H. Lee. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
and the pathological findings disclosed no vascular abnormality. We considered that initial arrhythmia, low ejection fraction, and global hypokinesia were stress-induced cardiomyopathy because these findings disappeared after the operation. The initial cause of IMH in our patient was unknown, but we considered that the unnecessary anticoagulation therapy could have been the cause of hematoma expansion, with accompanying cord compression. Prognostic factors after spinal cord compression is diagnosed are strongly related to the time interval between symptom onset and surgical decompression [4]. Intramedullary hematoma has diverse presenting symptoms and should be included in the differential diagnosis when thoracocervical or chest pain and neurologic deficits are elicited from the patient. We emphasize that only early recognition, accurate diagnosis, and appropriate treatment can decrease morbidity and improved prognosis and outcome for patients with IMH. Yoon Hee Choi MD, PhD Ewha Womans University Medical Center Seoul, South Korea Department of Emergency Medicine Ewha Womans University Seoul, South Korea E-mail address: [email protected]
Fig. 2. Magnetic resonance imaging scans revealed IMH at T4/5. The white arrow indicates a hematoma.
pneumothorax [1]. In our case, the initial presentation with acute chest pain, high blood pressure, and arrhythmia misled the attending ED physician to suspect an ischemic heart disease. Nontraumatic chest pain is one of the most common complaints in the ED. The incidence of myocardial infarction with chest pain has been estimated about 10%, whereas other life-threatening conditions include pulmonary embolism, aortic dissection, spontaneous tension pneumothorax, and esophageal perforation [1]. Less emergent and common conditions including gastroesophageal reflux, costochondritis, and other musculoskeletal pain also need to be included in the differential diagnosis of chest pain [2]. This is an atypical presentation of IMH presenting primarily with chest pain, arrhythmia, back pain, and headache that exemplifies the importance of developing a broad differential diagnosis for frequent ED presentations such as chest pain, back pain, and headache with hypertension. Spontaneous IMH is the least common type of spinal cord diseases and is mostly associated with predisposing focal diseases such as tumor, arteriovenus malformation, or spinal artery aneurysm, or due to bleeding disorder [3]. In this case, the patient had no coagulopathy
Dong Hoon Lee MD, PhD Department of Emergency Medicine Chung-ang University Seoul, South Korea
http://dx.doi.org/10.1016/j.ajem.2014.03.002 References [1] Kohn MA, Kwan E, Gupta M, et al. Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain. J Emerg Med 2005;29:383–90. [2] Tsen AR, Burrows AM, Dumont TM, et al. Spinal epidural hematoma masquerading as atypical chest pain. Am J Emerg Med. 2001;29:1236.e1-3. [3] Sharma S, Sharma S. Multifocal intramedullary hemorrhage without identifiable predisposing or precipitating causes. A case report. Neuroradio J 2010;23:343–6. [4] Wang CC, Chang CH, Lin HJ, et al. Misdiagnosis of spontaneous cervical epidural haemorrhage. Eur Spine J 2009;18:210–2.
Please cite this article as: Choi YH, Lee DH, Spontaneous intramedullary hematoma initially mimicking myocardial infarction, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.03.002
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Spontaneous intramedullary hematoma initially mimicking myocardial infarction Abstract Spontaneous intramedullary hematoma (IMH) is a rare condition. The initial clinical manifestations are variable. Early symptoms of high thoracic IMH include thoracocervical pain that can be mistaken for emergent cardiopulmonary conditions such as myocardial infarction, pulmonary embolus, and aortic dissection. We report on a 34-year-old man who presented initially with chest pain and radiating pain in both shoulders. He was initially misdiagnosed as having a myocardial infarction and treated with heparin. Two hours after admission, correct diagnosis of IMH was based on the repeated neurologic examination and spine magnetic resonance imaging study. The patient underwent emergency surgical decompression and hematoma removal. We draw the misdiagnosis to the attention of the emergency physicians because early recognition of spontaneous IMH is very important for early surgical decompression to improve the prognosis. A 34-year-old man was admitted to the emergency department (ED) due to cheat pain, both shoulders pain, and nausea that occurred 30 minutes before admission during the meal. He was a 17-pack-year smoker without any special medical or trauma history. On admission, he was alert and complained of chest pain as if pressed by the sternum and tingling pain in both shoulders. Initial vital signs were as follows: blood pressure, 170/120 mm Hg; pulse rate, 110 beats/min; respiration rate, 22 breaths/min; and body temperature, 36.7°C. In the physical examination, there were no abnormal findings observed, except for tachycardia. In electrocardiography, sinus tachycardia was found, but when chest pain was severe, premature ventricular contraction (bigeminy pattern) was seen (Fig. 1). The echocardiography showed global hypokinesia and estimated ejection fraction of 35%. About 10 minutes after admission, severe headache and back pain occurred. To differentiate subarachnoid hemorrhage and aortic dissection, brain computer tomography (CT) and aortic dissection CT were obtained. The CT scans revealed normal findings. The laboratory findings revealed elevation of troponin T. The provisional diagnosis of non–STelevation myocardial infarction was made, and heparin was continuously administered. Two hours after admission, the patient complained of newly occurred tingling sensation on his right arm and motor weakness. In the neurologic examination, he had a strength score of grade IV for both lower extremities, decreased sensory with hypoesthesia (5/10), and right upper extremity motor grade IV+ with tingling. In order to examine spine lesions, spine magnetic resonance imaging (MRI) was obtained. During the MRI scan, the patient complained of severe back pain and migrating pain in both wrists and forearms. The lower extremities strength became grade 0, and sensory was decreased below the navel level (5/10). The MRI scans revealed
intramedullary hematoma (IMH) at T4/5 (Fig. 2). After MRI scan, hypoesthesia was 3/10, decreased sensation progressed up to T5 dermatome, and the strength of both upper extremities was deteriorated to grade IV. As a result, emergency decompression and hematoma removal was planned. However, the patient and caregivers neglected, and the patient was transferred to another hospital because they wanted to get a new diagnosis and treatment in an advanced hospital. Eighteen hours after the onset of symptoms, he underwent surgical decompression, and histologic examination disclosed a hematoma without evidence of neoplasm or vessel abnormality. Four weeks after the surgery, the upper extremities strength was recovered to grade V but the lower extremities strength was at grade 0, ambulation by wheelchair is possible, and he is getting rehabilitation treatment. Spinal cord disease can present in a variety of ways with acute, subacute, or chronic onset, and clinical symptoms may vary from incomplete syndromes to complete quadriplegia. Acute quadriplegia beginning with excruciating pain in the chest and back progressing over a short period to quadriplegia is highly suggestive of spinal hemorrhage, which can be epidural, subdural, subarachnoid, or intramedullary. The initial manifestation of IMH is nonspecific and is easily misdiagnosed. Early symptoms of high-level thoracic intramedullary hemorrhage include upper back pain and chest pain that can be mistaken for emergent cardiopulmonary conditions including acute myocardial infarction, pulmonary embolism, aortic dissection, and
Fig. 1. Electrocardiography revealed a bigeminy premature ventricular contraction.
0735-6757/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Choi YH, Lee DH, Spontaneous intramedullary hematoma initially mimicking myocardial infarction, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.03.002
2
Y.H. Choi, D.H. Lee. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
and the pathological findings disclosed no vascular abnormality. We considered that initial arrhythmia, low ejection fraction, and global hypokinesia were stress-induced cardiomyopathy because these findings disappeared after the operation. The initial cause of IMH in our patient was unknown, but we considered that the unnecessary anticoagulation therapy could have been the cause of hematoma expansion, with accompanying cord compression. Prognostic factors after spinal cord compression is diagnosed are strongly related to the time interval between symptom onset and surgical decompression [4]. Intramedullary hematoma has diverse presenting symptoms and should be included in the differential diagnosis when thoracocervical or chest pain and neurologic deficits are elicited from the patient. We emphasize that only early recognition, accurate diagnosis, and appropriate treatment can decrease morbidity and improved prognosis and outcome for patients with IMH. Yoon Hee Choi MD, PhD Ewha Womans University Medical Center Seoul, South Korea Department of Emergency Medicine Ewha Womans University Seoul, South Korea E-mail address: [email protected]
Fig. 2. Magnetic resonance imaging scans revealed IMH at T4/5. The white arrow indicates a hematoma.
pneumothorax [1]. In our case, the initial presentation with acute chest pain, high blood pressure, and arrhythmia misled the attending ED physician to suspect an ischemic heart disease. Nontraumatic chest pain is one of the most common complaints in the ED. The incidence of myocardial infarction with chest pain has been estimated about 10%, whereas other life-threatening conditions include pulmonary embolism, aortic dissection, spontaneous tension pneumothorax, and esophageal perforation [1]. Less emergent and common conditions including gastroesophageal reflux, costochondritis, and other musculoskeletal pain also need to be included in the differential diagnosis of chest pain [2]. This is an atypical presentation of IMH presenting primarily with chest pain, arrhythmia, back pain, and headache that exemplifies the importance of developing a broad differential diagnosis for frequent ED presentations such as chest pain, back pain, and headache with hypertension. Spontaneous IMH is the least common type of spinal cord diseases and is mostly associated with predisposing focal diseases such as tumor, arteriovenus malformation, or spinal artery aneurysm, or due to bleeding disorder [3]. In this case, the patient had no coagulopathy
Dong Hoon Lee MD, PhD Department of Emergency Medicine Chung-ang University Seoul, South Korea
http://dx.doi.org/10.1016/j.ajem.2014.03.002 References [1] Kohn MA, Kwan E, Gupta M, et al. Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain. J Emerg Med 2005;29:383–90. [2] Tsen AR, Burrows AM, Dumont TM, et al. Spinal epidural hematoma masquerading as atypical chest pain. Am J Emerg Med. 2001;29:1236.e1-3. [3] Sharma S, Sharma S. Multifocal intramedullary hemorrhage without identifiable predisposing or precipitating causes. A case report. Neuroradio J 2010;23:343–6. [4] Wang CC, Chang CH, Lin HJ, et al. Misdiagnosis of spontaneous cervical epidural haemorrhage. Eur Spine J 2009;18:210–2.
Please cite this article as: Choi YH, Lee DH, Spontaneous intramedullary hematoma initially mimicking myocardial infarction, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.03.002