American Journal of Emergency Medicine 32 (2014) 291.e1-291.e3

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American Journal of Emergency Medicine

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Case Report

Rapid spontaneous recovery after development of a spinal epidural hematoma: a case report

Abstract

Spontaneous spinal epidural hematoma is a very rare clinical emergency. A permanent neurological deficit or even death may result if diagnosis and treatment are delayed. Many cases can be diagnosed upon detailed Neurological examination and magnetic resonance imaging. Usually, surgery is required, but rarely, the condition may improve spontaneously. A 46-year-old male patient was admitted to our emergency department because of rapidly evolving severe paraplegia following development of sudden-onset neck pain. Spinal MR imaging detected an epidural hematoma compressing the spinal cord at the C5-T1 level. Clinical and radiological follow-up showed that the patient recovered spontane- ously in 48 hours without any need for surgical treatment.

Spinal epidural hematomas, which usually occur in the cervical and thoracic regions, are very rare pathologies causing compression of the spinal cord. However, patients with this condition often require emergency attention because the hematomas can trigger acute Neurological deficits [1,2]. We present a case of spontaneous spinal epidural hematoma (SSEH). Clinical and radiological data showed that our patient improved rapidly, and spontaneously, over 48 hours of follow-up. We also review the relevant literature.

A 46-year-old male patient was admitted to our emergency room complaining of sudden-onset back pain spreading to the neck, and thereafter, weakness in the arms and legs. The condition progressed rapidly, and the lower extremities were completely paralyzed within 45 min. Upon neurological examination, weakness of grades 2/5 and 3/5 was noted in the lower and upper extremities, respectively. All of the blood count; the levels of urea, creatinine, electrolytes, and platelets; the activated partial thromboplastin time; and the interna- tional normalized ratio were within normal limits, as was the clotting time. Our patient had no history of systemic illness (hypertension, diabetes, or malignancy) and was not taking any drug. His blood pressure was 145/85 mm Hg, slightly higher than normal.

Cervical magnetic resonance imaging (MRI) revealed a solid lesion in the posterior epidural space, compressing the C5-T1 region of the spinal cord at the right posterior level. The lesion was slightly hyperintense on T1-T2-weighted imaging (Fig. 1) and did not exhibit Contrast enhancement. T1-weighted axial imaging showed that Spinal cord compression was more pronounced on the right side. The patient began to improve soon after diagnosis of SSEH, and MRI (Fig. 2) and computed tomography (CT) (Fig. 3) performed 48 h later revealed that both the clinical and radiological findings had significantly regressed. The patient remained in hospital for 1 more day and was

then discharged with a follow-up plan. No abnormality was noted upon follow-up.

SSEH is a very rare cause of neck pain [3]. Although most cases present with acute myelopathy or radiculopathy, chronic cases are also encountered [4,5]. The clinical presentation usually features sudden- onset neck pain with accompanying motor or sensory deficits [6]. In some cases, the Sfinker dysfunction or the Brown-Sequard syndrome may be noted [7]. Such clinical findings are not SSEH-specific; rather, they are associated with a number of different pathologies. Thus, SSEH cannot be diagnosed using clinical data alone [8].

MRI, myelography, and CT are used to diagnose spinal epidural hematomas. CT shows an epidural bleed as a hyperdense mass and is of limited utility in terms of differential diagnosis. Similarly, CT data cannot be used to determine when bleeding commenced. MRI affords a superior diagnostic capability. Sagittal MRI clearly identifies the upper and lower borders of an epidural hematoma [8] and determines whether the hematoma is located in the anterior or posterior region and whether cord compression is in play [9].

SSEH is usually treated via Decompression surgery, commonly featuring Hematoma evacuation and Decompressive laminectomy [2]. Patients in whom neurological deficits do not develop, and whose clinical signs are stable, may be followed up without surgical intervention. Although reports of spontaneous resolution are very rare, a few such patients have been described [3], but all had only mild neurological symptoms. Our patient developed severe paraplegia but, nonetheless, experienced spontaneous recovery within 48 hours.

Diagnosis and treatment of SSEH remain controversial because very few cases have been reported. Such patients often present to emergency rooms and are diagnosed with the aid of MRI and CT. Surgery is often immediately performed. However, our patient recovered rapidly and spontaneously. Clinical and radiological follow-up is required prior to surgery in such patients, and a surgical option should be rapidly available if the condition deteriorates.

Ramazan Buyukkaya

Department of Radiology School of Medicine, Duzce University

Duzce, Turkey E-mail address: [email protected]

Omer Aydin Bahattin Hakyemez Department of Radiology

Uludag University, School of Medicine Bursa, Gorukle 16285, Turkey

0735-6757/$ - see front matter (C) 2014

291.e2 R. Buyukkaya et al. / American Journal of Emergency Medicine 32 (2014) 291.e1-291.e3

Fig. 1. T2 (A) and T1 (B) sagittal MR imaging reveal a slightly hyperintense acute hematoma at the C5-T1 level (arrow). Axial MR imaging shows bleeding into the right posterior and epidural spaces (arrow), and significant spinal cord compression (*) (C and D).

Dogan Seref

Department of neurosurgery Uludag University School of Medicine Bursa, Gorukle 16285, Turkey

http://dx.doi.org/10.1016/j.ajem.2013.10.019

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   Fig. 2. Axial T2-weighted MRI performed 48 hours after admission shows that bleeding into the epidural space has significantly decreased (arrowhead) and spinal cord compression had disappeared.

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   Fig. 3. Axial CT performed 48 hours after admission shows a minimally hyperdense acute hematoma in the epidural space (arrow).

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