epidural hematoma aft”>American Journal of Emergency Medicine 32 (2014) 1555.e3-1555.e5

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Case Report

Spontaneous spinal epidural hematoma after abrupt sneezing with prompt recovery of severe paraparesis?,??

Abstract

Spontaneous spinal epidural hematoma (SSEH) is a rare neurologic condition with threatening consequences when spinal cord compres- sion is present. The diagnosis must be performed quickly using magnetic resonance imaging (MRI), which shows collection of blood in the epidural space. With Spinal cord compression, there is an indication for urgent Surgical decompression. Here, we present a 64- year-old woman who developed sudden thoracic and lower back pain accompanied by severe paraparesis and Urinary retention after sneezing abruptly. An MRI revealed a posterior thoracic epidural hematoma extending from the T6 to T11 vertebral level with spinal cord compression. Decompression was recommended, but the patient refused surgery, while neurologically improving with time. Complete Neurologic recovery was observed within 24 hours after SSEH onset. A conservative therapeutic approach with careful observation may therefore be considered as a treatment of choice in some cases where surgery is refused, (due to high risk or other reasons) and neurologic recovery is early and sustained.

Spontaneous spinal epidural hematoma (SSEH) is a rare and urgent condition with an incidence of less than 1% [1,2]. SSEH is usually characterized by a sudden onset of acute spinal pain, with or without neurologic signs, followed more or less rapidly by various degrees of neurologic deficit. Missed or delayed diagnosis due to unusual and confusing onsets can lead to disabling neurologic sequelae. Although the etiology of SSEH remains unknown, associa- tions with some predisposing conditions have been reported, including coagulopathies, tumors, vascular malformations, or preg- nancy [3,4]. anticoagulant treatment has been reported as a cause of SSEH [5]. However, a low dose of aspirin is rarely presented in the literature [6,7]. For the first time, we report here a patient treated by a low dose of aspirin when an abrupt sneeze had led to SSEH followed by prompt spontaneous neurologic recovery.

A 64-year old woman, with history of hypertension who takes a low dose of aspirin (100 mg daily) as a prevention of stroke, had experienced severe lower thoracic and back pain after an abrupt sneeze. She immediately developed paresthesia and weakness of both her lower limbs. Two hours after the onset, she was submitted to a neurologic department where a clinical examination revealed severe motor weakness in both of her lower limbs (level 1/5 according to a muscle strength test) with the level of hypoesthesia from L1

? Foot of the page: Spinal epidural hematoma with prompt recovery.

?? Supported by the Charles University Prague research projects P34, IGA-NT 13693, 260045/SVV/2014.

dermatome distally. Achilles and patellar tendon reflexes were absent bilaterally. Urgent urinary retention was present. No neurologic signs were found in the upper limbs. A computed tomography angiogram excluded aortal dissection. An MRI showed a collection of posterior thoracic epidural hematomas with compression at the spinal cord levels of T6 to T11 (Fig. 1). The patient was recommended to undergo Urgent surgery, but she refused surgical treatment as she was starting to recover from paraparesis. Therefore, she was managed conserva- tively. Up to 24 hours after SSEH onset, she presented only slight weakness in both of her lower limbs. She was able to urinate and walk without any support. No sensory deficits were present. After 1 week, in which she regained full muscle strength and sensation, we performed a control MRI. The MRI revealed partial resolution of the thoracic epidural hematoma (Fig. 2), and 2 months later, total resorption was observed (Fig. 3).

Spontaneous spinal epidural hematoma is uncommon; however, it can lead to acute compression of the spinal cord with disabling consequences [8]. Spontaneous spinal epidural hematomas are most frequently observed after the forth decade [9]. The etiology of SSEH is still not yet fully elucidated, but there are several Predisposing factors

Fig. 1. Magnetic resonance imaging (T1-weighted images) in sagittal (A) axial

(B) planes show considerable hypersignal and a partially septated lesion in the dorsal part of the epidural space at the level of T6 to T11, corresponding to a hematoma, with spinal cord compression.

0735-6757/(C) 2014

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patient reported here, who developed severe lower thoracic and back pain with irradiation of paresthesia and weakness in the lower extremities. Magnetic resonance imaging (MRI) is the best choice of diagnostic Imaging techniques for SSEH as it defines anatomical structures in detail, especially with regards to the severity of spinal cord impairment. Blood products, such as hemoglobin, are the most important sign that distinguishes SSEH from other spinal extrame- dullary lesions. Early diagnosis followed by immediate surgical decompression may preserve spinal cord function [12]. In this study, an MRI revealed a posterior thoracic epidural hematoma extending from T6 to T11 with marked spinal cord compression. Although there have been occasional reports of nonoperative treatments, surgical decompression and removal of the epidural clot remains the standard management [12,13]. A nonsurgical approach with neurologic recovery has rarely been reported [14-16]. When our patient started to recover, she decided to refuse acute surgical decompression. Normalization of her clinical status was present within 24 hours after SSEH onset. Two months later, an MRI revealed complete resorption of the SSEH within the spinal epidural space.

In conclusion, SSEH is a rare and urgent condition with severe disability and a high morbidity. Diagnosis must be performed quickly

Fig. 2. Magnetic resonance imaging follow-up after 6 days (T1-weighted images) in

sagittal (A) and axial (B) planes reveal partial regression of the thoracic epidural hematoma with only minor spinal cord compression.

[3-5,8]. This hematoma mainly arises from the epidural venous plexus as the result of increased intrathoracic and/or intraabdominal pressure. This can occur after exercise or other maneuvers [2] and, less often, from spinal epidural arteries [9]. A sudden increase in intraabdominal or intrathoracic pressure has been reported as a warning sign of SSEH, albeit rarely [10,11]. In this study, the patient developed SSEH in her lower thoracic spine with severe motor and sensory paraparesis and urinary retention after sneezing abruptly.

Spontaneous spinal epidural hematoma may occur at each level of the spine but is predominantly reported in the lower cervical and thoracolumbar space [12]. Clinical symptoms are variable and may comprise dysfunction of the spinal cord, cauda equina, and nerve roots. Initially, most patients describe sharp or dull back pain that varies in duration. Motor and sensory symptoms of compressive myelopathy or radiculopathy, such as weakness, numbness, and sphincter dysfunction, can develop rapidly. Such is the case for the

Fig. 3. Magnetic resonance imaging follow-up after 2 months (T1-weighted images) in sagittal (A) and axial (B) planes show almost complete regression of the previous epidural hematoma with only signs of hemoglobin level degradation.

and followed by decompressive surgical treatment. Under special circumstances, a conservative therapeutic approach with careful observation may be considered as a treatment of choice when surgery is refused (eg, high risk for general anesthesia or other reasons), and neurologic recovery is early and sustained.

Ivana Stetkarova, MD, PhD? Lenka Jelinkova, MD

Department of Neurology, Third Faculty of Medicine Charles University and University Hospital Kralovske Vinohrady

Prague, Czech Republic

?Corresponding author at: Department of Neurology Third Faculty of Medicine, Charles University of Prague, Ruska 87 Prague 10, Czech Republic, 100 00. Tel.: +420 267162814.

E-mail address: [email protected]

Vaclav Janik, MD

Department of Radiology, Third Faculty of Medicine Charles University and University Hospital Kralovske Vinohrady

Prague, Czech Republic

Tomas Peisker, MD

Department of Neurology, Third Faculty of Medicine Charles University and University Hospital Kralovske Vinohrady

Prague, Czech Republic

http://dx.doi.org/10.1016/j.ajem.2014.04.039

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