Spontaneous spinal subarachnoid hematoma—Case report

ELSEVIER

Spine

SPONTANEOUS HEMATOMA-CASE

SPINAL SUBARACHNOID REPORT

Ichiro Sunada, M.D., Yoshinori Akano, M.D., Yusuke Kidosaki, M.D., Nobuyuki Shimokawa, M.D., and Shigeru Yamamoto, M.D. Department of Neurosurgery, Baba Memorial Hospital and Osaka City University, Osaka, Japan

Sunada I, Akano Y, Kidosaki Y, Shimokawa N, Yamamoto S. Spontaneous spinal subarachnoid hematoma-case report. Surg Nemo1 1995;44:133-136. BACKGROUND

Spinal subarachnoid hemorrhage is unusual, and rarely results in spinal subarachnoid hematoma because the cerebrospinal fluid tends to dilute the blood and prevent the formation of clots. We describe a patient with spinal subarachnoid hematoma of unusual spontaneous origin.

because hematoma may cause spinal cord damage. Both the hematoma and the source of hemorrhage malformation, spinal cord (e.g., arteriovenous tumor, or aneurysm) can frequently be treated surgically. We describe a patient with spinal subarachnoid hematoma of unusual spontaneous origin.

CASE

A 66-year-old female presented with sudden onset of intense back pain with paraplegia. Magnetic resonance imaging demonstrated a mass lesion between T2 and T6, compressing the spinal cord anteriorly. Emergency osteoplastic laminotomy exposed a hematoma in the subarachnoid space from T2 to T6, but no source of the hemorrhage was found. The patient was able to walk by herself about 20 days after the operation. CONCLUSION

The outcome is significantly influenced by the duration between onset and operation, preoperative neurologic status, and rapidity of symptom progression. Therefore, we emphasize the importance of early diagnosis, and rapid and complete operative removal of spinal subarachnoid hematoma in order to achieve the best outcome. KEY

WORDS

Magnetic resonance imaging, spinal subarachnoid toma, spontaneous.

hema-

S

pinal subarachnoid hemorrhage @AH) is unusual, accounting for less than 1% of all cases of SAH [28], and rarely results in spinal subarachnoid hematoma because the cerebrospinal fluid (CSF) tends to dilute the blood and prevent the

formation of clots. The clinical symptoms are generally similar to those of intracranial SAH [ 191. This disease should be diagnosed as soon as possible, Address reprint requests to: Ichiro Sunada M.D., Department of Neurosurgery, Baba Memorial Hospital, 4-244, Funao-Higashi, Hamadera, Sakai, 592, Japan. Received December 5, 1994; accepted March 22, 1995. 0 1995 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010

CASEREPORT A 66year-old woman suffered sudden onset of occipital headache on October 9, 1992. Two hours after onset, intense

back pain suddenly

developed.

She was transferred to a hospital where some evaluations were performed, but no lesion was identified. One hour after onset of back pain, she developed paraplegia and loss of sensation in both legs extending cephalad to the thoracoabdominal junction, and difficulty in voiding urine. There was no history of prior headache, back pain, trauma, or usage of anticoagulant drugs. She was transferred to our hospital for further evaluation and treatment. On admission the patient was alert and had flaccid paraplegia with complete sensory loss below the T7 dermatome and urinary retention. Magnetic resonance imaging (MRl) (1.5 Tesla) demonstrated a mass lesion between T2 and T6 (Figure 1). The lesion was located dorsal to the spinal cord and compressed the spinal cord anteriorly Figure 2). The lesion was isointense to the spinal cord on the T,-weighted MRI and hyperintense on the T,-weighted image. The MRI findings suggested the lesion was a hematoma, but could not indicate whether this lesion was located in the epidural, subdural, or subarachnoid space. The MRl also showed no vascular anomaly possibly responsible for the hemorrhage. We decided to remove the spinal hematoma as soon as possible. An osteoplastic laminotomy from T2 to T7 was 00903019/95/$9.50 SSDI 0090-3019(95)00166-2

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MRI (sagittd view) demonstrated a mass lesion between T2 and T6 (lee; T,-weighted image, right-, T,-weighted image).

performed 10 hours after the onset of paraplegia. There was no lesion in the epidural space. Opening the dura mater, which was tense and not pulsatile, we exposed a hematoma in the subarachnoid space from T2 to T6 (Figure 3). The hematoma was apparently fresh, and the amount was greatest on the T5 level. The clot was easily and completely removed after opening the arachnoid membrane. The spinal cord was strongly compressed. A relatively large vessel was found on the surface of the spinal cord at the T5 level, but this vessel appeared to be normal. There was no other remarkable finding on the surface of spinal cord or arachnoidal adhesion. Both the arachnoid membrane and dura mater were

B

HdnBfoma

The operative view. (A) A hematoma existed in the H subarachnoid space. (B) Graphic representation of the situation described in (A).

closed separately, and the bone was fixed anatomically. Pulsation of the dura mater had recovered by the end of the operation. The patient’s paraplegia and urinary retention gradually improved, and she was able to walk by herself approximately 20 days after the operation. Spinal angiography was performed 25 days after the operation, but no cranial lesion and no origin for the hematoma could be found.

DISCUSSION

MRf (T,-weighted, axial view). The lesion was loqspinal cated dorsal to the spinal cord and compressed the cord anteriorly.

The paroxysmal onset of severe back pain is the characteristic symptom of spinal SAH [ 191. Sudden pain usually occurs at the level of the lesion, and may radiate into one or both legs, the flanks, or occasionally into the abdomen, therefore mimicking a visceral catastrophe [28]. There is frequently a history of episodes of back pain, suggesting intermittent hemorrhage [ 61. Neurologic findings referable to the spinal cord are frequently absent, but sudden paraparesis, urinary retention, and leg numbness may occur at the onset [19]. Cerebral symptoms after spinal SAH may be conspicuous

Spinal Subarachnoid Hematoma

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Surg Neurol 1995;44:133-136

135

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PREOPERATIVE DIAGNOSTIC TOOL

DURATION BETWEEN ONSET AND OPERATION

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and confuse the diagnosis.

The severity of the intracranial symptoms is probably related to whether blood reaches the cerebral hemisphere. More cephalad sources of bleeding are more likely to result in blood reaching the brain. Eighty percent of patients with spinal W-l had intracranial symptoms; headache in 70%, and mental status changes in 22% [6]. Moreover, headache and other cranial symptoms may be the first manifestations of spinal W-l and are occasionally as severe as those caused by intracranial W-l, although headache improves rapidly after spinal SAH [20]. The most common cause of spinal W-l appears to be an arteriovenous malformation (AVM) of the spinal cord. Spinal AVMs are usually located in the thoracolumbar region and are more common in men than women [6]. Approximately 10% of spinal AVMs result in spinal W-l as their presenting symptom [24]. Spinal aneurysms may also cause spinal SAH and occur at a number of locations, most commonly the anterior spinal artery [26]. Spinal tumors, especially in the region of the cauda equina and conus medullaris, have been causes of spinal W-l, and ependymoma is the most common cause [9]. A number of other entities have been reported to cause spinal SAH [ 191. Coagulopathy, both iatrogenie and pathologic, has been associated with spinal W-l [3,12]. Mechanical or hematologic stress in nature such as extreme physical exertion or external trauma has been reported. In particular, subarachnoid hematoma after lumbar puncture has frequently been reported [2,5,7,8,11,13,15-17,22,23,27]. The occurrence of lumbodorsal subarachnoid hematoma, however, secondary to lumbar puncture and of sufficient magnitude to cause compression of

NEUROLOGIC DEFICIT AT OPERATION

NEUROLOGIC RECOVERY

drowsy spastic paraparesis flaccid paraplegia drowsy spastic paraparesis

none

T3-T7

flaccid paraplegia

none

T2-T7

flaccid paraplegia

good

T12-Ll

good

good

the cauda equina is extremely rare. Acute leukemia [4], collagen vascular disorders, such as systemic lupus erythematosus [lo], and Behcet’s disease [l] have also been associated with isolated causes of spinal SAH. However, four cases of spontaneous spinal subarachnoid hematoma have previously been reported (Table 1) [14,18,19]. True spinal subarachnoid hematoma is very rare, because the diffusion and pulsation of CSF tend to dilute the blood and prevent the formation of clots. Moreover, CSF has a fibrinolytic activity that increases after W-l [25]. Probably only rapid or massive subarachnoid hemorrhage leads to formation of clots in the subarachnoid space [19]. Disturbance of CSF clearance due to arachnoid adhesion or angulation of the vertebral canal may favor clotting [ 151, but most reports have not identified such mechanical factors. Rader postulated that the vessels traversing the subarachnoid space are subjected to rapid increases in intraluminal pressures [ 2 11. The CSF pressure lags momentarily behind the intravascular pressure, therefore causing vessel rupture. Masdeu et al confirmed the laceration of radicular vessels entering the subarachnoid space with each segmental nerve root at autopsy [ 161. The use of water soluble myelographic contrast material and the development of safe and accurate spinal angiographic techniques have probably decreased the incidence of spinal SAH with an undetermined origin. However, the distinction between epidural, subdural, and subarachnoid spinal masses based on myelography is occasionally difficult [ 111. MRl provides a lot of accurate information, especially the correct extent of the hematoma, which is very useful for operation planning. Involve-

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ment of the subarachnoid space, however, is still difficult to diagnose correctly even with greater MRI resolution. Our case is the first to be diagnosed based only on preoperative MRI without myelography. Most authors have recommended immediate decompressive laminectomy and hematoma evacuation [3,8,12,13,18,19,23]. No patient has achieved a good outcome without operation including aspiration. The prognosis is significantly influenced by the preoperative neurologic status, duration between onset and operation, and rapidity of symptom progression. Prompt and complete removal of the hematoma is necessary to correct the neurologic deficits. The postoperative outcome of all spinal subarachnoid hematoma is generally poor, and seems to be the same for spontaneous ones. We emphasize the importance of early diagnosis and operative removal of spinal subarachnoid hematoma to achieve the best outcome. We wish to thank Ms. Masayo Ikeda, Ms. Hitomi Nishino, Ms. Mitsuyo Inoue, and Dr. Hisashi Ijichi for their assistance in the preparation of this manuscript. REFERENCES 1. Arias MJ, Caler E, Gil JF, Paz J. Spinal subarachnoid hematoma in Behcet’s disease. Neurosurgery 1987;20: 62-3. 2. Bellamy EA, Prez DJ, Husband JE. CT demonstration of a spinal subarachnoid hematoma following lumbar puncture. J Comput Assist Tomogr 1984;8:791-2. 3. Bernsen RA, Hoogenraad TU. A spinal haematoma occurring in the subarachnoid as well as in the subdural space in a patient treated with anticoagulants. Clin Neural Neurosurg 1992;94:35-7. 4. Blade J, Gaston F, Montserrat E, Marin P, Grariena A, Baths A, Rozman C. Spinal subarachnoid hematoma after lumbar puncture causing reversible paraplegia in acute leukemia. J Neurosurg 1983;58:438-9. 5. Brem SS, Hafler DA, Van Uitert RL, Ruff RL, Reichert WH. Spinal subarachnoid hematoma: A hazard of lumbar puncture resulting in reversible paraplegia. N Engl J Med 1981;303:1020-1. 6. Caroscio JT, Brannan T, Budabin M, Huang YP, Yahr MD. Subarachnoid hemorrhage secondary to spinal arteriovenous malformation and aneurysm. Report of a case and review of the literature. Arch Neurol 1980; 37:1013. 7. Dupeyrat A, Dequire PM, Merouani A, Moullier P, Eid G. Subarachnoid hematoma and spinal anesthesia. Ann Fr Anesth Reanim 1990;9:560-2. 8. Diaz FG, Yock DH Jr, Rockswoid GL. Spinal subarachnoid hematoma after lumbar puncture producing acute thoracic myelopathy. Neurosurgery 1978;3: 404-6. 9. Fincher EF. Spontaneous subarachnoid hemorrhage

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