G Model
ARTICLE IN PRESS
CLINEU-3676; No. of Pages 2
Clinical Neurology and Neurosurgery xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Letter to the Editor Atypical presentations of spontaneous spinal epidural hematomas Keywords: Epidural Hematoma Spontaneous Unusual Stroke
Spontaneous spinal epidural hematoma (SSEH) is a rare and defined as spontaneous collection of blood in the spinal epidural space. It usually presents with acute neurological deficits related to spinal cord compression. Classical presentation includes acute mid dorsal severe pain followed by lower extremity weakness, spinal sensory level, sphincter dysfunction, gait disturbance, hyperreflexia and bilateral Babinsky signs. If not recognized early, SSEH may lead to major or permanent neurologic deficits. We report two cases of SSEH presenting as acute ischemic stroke and myocardial infarction. A 49-year-old man presented with right-sided weakness of one hour duration preceded by neck pain upon flexion. Blood pressure was 220/100 mmHg. Neurological examination revealed intact consciousness and speech, right-sided weakness with hyperreflexia and Babinski signs. The patient was suspected to have left middle cerebral artery stroke, and treatment with intravenous thrombolysis was considered. CT head and neck showed an epidural hyperdense collection, consistent with a hematoma, from C2 to T2 with edema and compression of the spinal cord. Emergency surgical decompression was performed with recovery of the symptoms (Fig. 1). A 66-year-old woman presented with exertional chest pain radiating to the back. Blood pressure was 220/100 mmHg. Physical examination, ECG and cardiac enzymes were normal. Acute coronary syndrome was suspected and anticoagulation was initiated. CT coronary angiography was normal. Few hours later, she developed acute weakness in the lower extremities with loss of sensation to light touch, pin prick, and vibration at T3 level, and Babinski signs bilaterally. MRI of the cervical and dorsal spines revealed an anterior epidural hematoma from C7-T1 level with spinal cord compression. The patient was managed conservatively and recovered completely. SSEH are uncommon and may result in significant neurological deficits. Incidence is estimated at 0.1 per 100,000 individuals [1]. Clinical presentation is sudden neck or back pain that progresses toward paraparesis or quadriparesis [2]. Atypical SEH may present with chest pain, flank pain, monoparesis, or hemiparesis [3]. Etiology is related to coagulopathy, vascular malformation, neoplasms, infections, minor vertebral traumas and idiopathic causes
Fig. 1. Axial T2 weighted MRI sequence revealing the presence of a subdural hematoma compressing the spinal cord between the C3 and C6 cervical level.
[1,4]. The source of bleeding in SEH is postulated to be the epidural venous plexus at the dorsal aspect of the cervical and thoracic spinal canal [5–7]. Early diagnosis requires clinical suspicion and immediate MRI imaging [1]. The type and the degree of preoperative neurological deficit, and time interval to surgery are the most critical factors affecting functional recovery [7]. Conservative treatment is considered if neurological recovery occurs spontaneously [8]. Reported cases of SSEH presenting with pure motor hemiparesis were misdiagnosed as cerebral ischemia and erroneously treated with anticoagulant therapy [9]. The mass effect of the hematoma compromises vascular flow or compresses the lateral columns causing the hemiparesis [6]. SSEH presenting with chest pain is quite rare [10]. The symptoms of chest pain radiating to the back could be attributed to compression of the dorsal root entry zone or anterior spinothalamic tract at the upper thoracic level [11]. In conclusion, SSEH is a rare but disabling condition. Early diagnosis and prompt management improve the prognosis and outcome. Acute chest pain and hemiparesis could be the initial presentation of acute spinal epidural hemorrhage. Proper history
http://dx.doi.org/10.1016/j.clineuro.2013.12.030 0303-8467/© 2014 Elsevier B.V. All rights reserved.
Please cite this article in press as: Estaitieh N, et al. Atypical presentations of spontaneous spinal epidural hematomas. Clin Neurol Neurosurg (2014), http://dx.doi.org/10.1016/j.clineuro.2013.12.030
G Model CLINEU-3676; No. of Pages 2
ARTICLE IN PRESS Letter to the Editor / Clinical Neurology and Neurosurgery xxx (2014) xxx–xxx
2
taking and a full physical examination are essential to prevent catastrophic neurological outcomes. References [1] Liu Z, Jiao Q, Xu J, Wang X, Li S, You C. Spontaneous spinal epidural hematoma: analysis of 23 cases. Surg Neurol 2008;69:253–60. [2] Beatty R, Winston K. Spontaneous cervical epidural hematoma: a consideration etiology. J Neurosurg 1984;61:143–8. [3] Panciani PP, Forgnone S, Fontanella M, Ducati A, Lanotte M. Unusual presentation of a spontaneous spinal epidural haematoma. Acta Neurol Belg 2009;109:146–8. [4] Wang CC, Chang CH, Lin HJ, Lin KC, Kuo JR. Misdiagnosis of spontaneous cervical epidural haemorrhage. Eur Spine J 2009;18:210–2. [5] Hsieh CF, Lin HJ, Chen KT, Foo NP, Te AL. Acute spontaneous cervical spinal epidural hematoma with hemiparesis as the initial presentation. Eur J Emerg Med 2006;13:36–8. [6] Turnbull IM. Microvasculature of the human spinal cord. J Neurosurg 1971;35:141–7. [7] Lawton MT, Porter RW, Heiserman JE, Jacobowitz R, Sonntag VK, Dickman CA. Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological outcome. J Neurosurg 1995;83:1–7. [8] Duffill J, Sparrow OC, Millar J, Barker CS. Can spontaneous spinal epidural haematoma be managed safely without operation? A report of four cases. J Neurol Neurosurg Psychiatry 2000;69:816–9. [9] Kameda T, Doi H, Sugiyama M, Ueda N, Kugimoto C, Baba Y, et al. Three cases of cervical epidural hematoma mimicking acute ischemic stroke. Brain Nerve 2009;61:1429–33. [10] Tsen AR, Burrows AM, Dumont TM, Horgan MA. Spinal epidural hematoma masquerading as atypical chest pain. Am J Emerg Med 2011;29:1236.
[11] Parman SC. Spontaneous spinal epidural hematoma. Ann Emerg Med 1980;9:368–70.
N. Estaitieh Department of Neurology, American University Medical Center, Beirut, Lebanon S. Alam Division of Cardiology, Department of Internal Medicine, American University Medical Center, Beirut, Lebanon R. Sawaya ∗ Department of Neurology, American University Medical Center, Beirut, Lebanon ∗ Corresponding
author at: Professor of Neurology, American University Medical Center, POB: 113-6044/C-27 Beirut, Lebanon. Tel.: +961 1 350000; fax: +961 1 370814. E-mail address: [email protected] (R. Sawaya) 2 November 2013 Available online xxx
Please cite this article in press as: Estaitieh N, et al. Atypical presentations of spontaneous spinal epidural hematomas. Clin Neurol Neurosurg (2014), http://dx.doi.org/10.1016/j.clineuro.2013.12.030
ARTICLE IN PRESS
CLINEU-3676; No. of Pages 2
Clinical Neurology and Neurosurgery xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Letter to the Editor Atypical presentations of spontaneous spinal epidural hematomas Keywords: Epidural Hematoma Spontaneous Unusual Stroke
Spontaneous spinal epidural hematoma (SSEH) is a rare and defined as spontaneous collection of blood in the spinal epidural space. It usually presents with acute neurological deficits related to spinal cord compression. Classical presentation includes acute mid dorsal severe pain followed by lower extremity weakness, spinal sensory level, sphincter dysfunction, gait disturbance, hyperreflexia and bilateral Babinsky signs. If not recognized early, SSEH may lead to major or permanent neurologic deficits. We report two cases of SSEH presenting as acute ischemic stroke and myocardial infarction. A 49-year-old man presented with right-sided weakness of one hour duration preceded by neck pain upon flexion. Blood pressure was 220/100 mmHg. Neurological examination revealed intact consciousness and speech, right-sided weakness with hyperreflexia and Babinski signs. The patient was suspected to have left middle cerebral artery stroke, and treatment with intravenous thrombolysis was considered. CT head and neck showed an epidural hyperdense collection, consistent with a hematoma, from C2 to T2 with edema and compression of the spinal cord. Emergency surgical decompression was performed with recovery of the symptoms (Fig. 1). A 66-year-old woman presented with exertional chest pain radiating to the back. Blood pressure was 220/100 mmHg. Physical examination, ECG and cardiac enzymes were normal. Acute coronary syndrome was suspected and anticoagulation was initiated. CT coronary angiography was normal. Few hours later, she developed acute weakness in the lower extremities with loss of sensation to light touch, pin prick, and vibration at T3 level, and Babinski signs bilaterally. MRI of the cervical and dorsal spines revealed an anterior epidural hematoma from C7-T1 level with spinal cord compression. The patient was managed conservatively and recovered completely. SSEH are uncommon and may result in significant neurological deficits. Incidence is estimated at 0.1 per 100,000 individuals [1]. Clinical presentation is sudden neck or back pain that progresses toward paraparesis or quadriparesis [2]. Atypical SEH may present with chest pain, flank pain, monoparesis, or hemiparesis [3]. Etiology is related to coagulopathy, vascular malformation, neoplasms, infections, minor vertebral traumas and idiopathic causes
Fig. 1. Axial T2 weighted MRI sequence revealing the presence of a subdural hematoma compressing the spinal cord between the C3 and C6 cervical level.
[1,4]. The source of bleeding in SEH is postulated to be the epidural venous plexus at the dorsal aspect of the cervical and thoracic spinal canal [5–7]. Early diagnosis requires clinical suspicion and immediate MRI imaging [1]. The type and the degree of preoperative neurological deficit, and time interval to surgery are the most critical factors affecting functional recovery [7]. Conservative treatment is considered if neurological recovery occurs spontaneously [8]. Reported cases of SSEH presenting with pure motor hemiparesis were misdiagnosed as cerebral ischemia and erroneously treated with anticoagulant therapy [9]. The mass effect of the hematoma compromises vascular flow or compresses the lateral columns causing the hemiparesis [6]. SSEH presenting with chest pain is quite rare [10]. The symptoms of chest pain radiating to the back could be attributed to compression of the dorsal root entry zone or anterior spinothalamic tract at the upper thoracic level [11]. In conclusion, SSEH is a rare but disabling condition. Early diagnosis and prompt management improve the prognosis and outcome. Acute chest pain and hemiparesis could be the initial presentation of acute spinal epidural hemorrhage. Proper history
http://dx.doi.org/10.1016/j.clineuro.2013.12.030 0303-8467/© 2014 Elsevier B.V. All rights reserved.
Please cite this article in press as: Estaitieh N, et al. Atypical presentations of spontaneous spinal epidural hematomas. Clin Neurol Neurosurg (2014), http://dx.doi.org/10.1016/j.clineuro.2013.12.030
G Model CLINEU-3676; No. of Pages 2
ARTICLE IN PRESS Letter to the Editor / Clinical Neurology and Neurosurgery xxx (2014) xxx–xxx
2
taking and a full physical examination are essential to prevent catastrophic neurological outcomes. References [1] Liu Z, Jiao Q, Xu J, Wang X, Li S, You C. Spontaneous spinal epidural hematoma: analysis of 23 cases. Surg Neurol 2008;69:253–60. [2] Beatty R, Winston K. Spontaneous cervical epidural hematoma: a consideration etiology. J Neurosurg 1984;61:143–8. [3] Panciani PP, Forgnone S, Fontanella M, Ducati A, Lanotte M. Unusual presentation of a spontaneous spinal epidural haematoma. Acta Neurol Belg 2009;109:146–8. [4] Wang CC, Chang CH, Lin HJ, Lin KC, Kuo JR. Misdiagnosis of spontaneous cervical epidural haemorrhage. Eur Spine J 2009;18:210–2. [5] Hsieh CF, Lin HJ, Chen KT, Foo NP, Te AL. Acute spontaneous cervical spinal epidural hematoma with hemiparesis as the initial presentation. Eur J Emerg Med 2006;13:36–8. [6] Turnbull IM. Microvasculature of the human spinal cord. J Neurosurg 1971;35:141–7. [7] Lawton MT, Porter RW, Heiserman JE, Jacobowitz R, Sonntag VK, Dickman CA. Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological outcome. J Neurosurg 1995;83:1–7. [8] Duffill J, Sparrow OC, Millar J, Barker CS. Can spontaneous spinal epidural haematoma be managed safely without operation? A report of four cases. J Neurol Neurosurg Psychiatry 2000;69:816–9. [9] Kameda T, Doi H, Sugiyama M, Ueda N, Kugimoto C, Baba Y, et al. Three cases of cervical epidural hematoma mimicking acute ischemic stroke. Brain Nerve 2009;61:1429–33. [10] Tsen AR, Burrows AM, Dumont TM, Horgan MA. Spinal epidural hematoma masquerading as atypical chest pain. Am J Emerg Med 2011;29:1236.
[11] Parman SC. Spontaneous spinal epidural hematoma. Ann Emerg Med 1980;9:368–70.
N. Estaitieh Department of Neurology, American University Medical Center, Beirut, Lebanon S. Alam Division of Cardiology, Department of Internal Medicine, American University Medical Center, Beirut, Lebanon R. Sawaya ∗ Department of Neurology, American University Medical Center, Beirut, Lebanon ∗ Corresponding
author at: Professor of Neurology, American University Medical Center, POB: 113-6044/C-27 Beirut, Lebanon. Tel.: +961 1 350000; fax: +961 1 370814. E-mail address: [email protected] (R. Sawaya) 2 November 2013 Available online xxx
Please cite this article in press as: Estaitieh N, et al. Atypical presentations of spontaneous spinal epidural hematomas. Clin Neurol Neurosurg (2014), http://dx.doi.org/10.1016/j.clineuro.2013.12.030
