Unveiling the stealth threat: Cervical epidural hematoma

Rachana Bardia. S

Emergency Physician, Kauvery Hospitals, Alwarpet, Chennai

Abstract

Spontaneous Cervical Epidural Hematoma (SCEH) is defined as an epidural hematoma that does not have a known etiological reason. Arteriovenous malformations, tumors, trauma, or postoperative complication s were blamed as possible causes. The most common site of SCEH is the cervicothoracic area. Patients usually complain of acute neck pain or interscapular pain. As a result of pressure on the spinal cord, sensory and motor loss can occur[1]. SCEH is a rare disease, but can cause severe neurologic impairment [5]. Patients with spinal epidural hematoma typically present with acute hemiparesis. Neuroimaging of the brain may not detect the lesion. Indeed, there are several case reports in which patients with spinal epidural hematoma were misdiagnosed with ischemic stroke and treated with anti-thrombotic therapy, including intravenous thrombolysis,  occasionally leading to hematoma expansion⁴.

In two previous studies, all patients with spinal epidural hematoma had pain, including headache, neck pain, and back pain (13 and 27 patients, respectively)[2,3]. In another study, only 1 of 16 patients with spinal epidural hematoma did not have pain. Therefore, pain is a potential predictor of spinal epidural hematoma.

Case presentation

A 65 years old female patients was presented to ER with complaints of sudden onset of pain and weakness, right upper since 3:30 am, along with tingling sensation in left upper limb, noticed when she got up and walked to washroom and returned, 15 min following which she developed weakness of right lower limb. Hence, she came to the ER.

No H/O headache, vomiting, palpitations, giddiness, seizures, vision or speech disturbance, amnesia, confusion, sensory deficits, fever, neck  or other complaints.

Initial evaluation at the ER

Patient conscious, oriented, afebrile, with mild dehydration

  • Vitals: BP: 130/80mmhg, HR: 72b/min, Temperature normal, SpO2:98% RA, CBG: 167mg/dl
  • CVS: S1, S2 +, JVP: Normal, peripheral pulses well felt
  • RS: B/L AE+, NVBS+
  • P/A: Soft, BS+, nontender
  • CNS: GCS E4V5M6
  • NIHSS Score: 7
RightLeftRightLeft
PowerSensory
Upper limb1/55/5Upper limb Normal Normal
Lower limb 3/55/5Lower limb Normal Normal
TonePlantarFlexorFlexor
Upper limbHypotonic Normal No dysdiadokinesia
Lower limb Hypotonic Normal No Cerebellar signs
Deep tendon Reflexes Rombergs : N/A
Upper limbReducedNormalGait : N/A
Lower limb Reduced NormalNo Nystagmus, B/L PERL

Initial investigations

  • ECG : Normal Sinus Rhythm

No acute ST/T changes

  • POC (Chem8)

Na: 140, K: 4.9, Cl: 108, HCO3:21, Glu: 162, Urea: 19, Cr: 0.9, Hb: 12.6

  • CT Brain Perfusion Study: No signs of Infarct/ hemorrhage seen. No signs of core ischemia or ischemic penumbra seen
  • MRI Brain: No evidence of hemorrhage, mass lesion, vasogenic edema, demyelination or infarct seen.

Course in ER

  • On reassessment : NIHSS 5 ( Power of UL  increased to 3/5 )
  • Based on Neurologist orders : T. Ecosprin 150 mg P/O stat and T. Clopilet 75 mg P/O stat given in view of suspicious infarct
  • Later decision was made to do an MRI of C-Spine

MRI C-Spine

  • Hyperintense fluid like collection measuring 2.5*1.3*0.5cm seen in Right posterior Epidural space at C2-C4 level -? Infective etiology /? Hematoma
  • Indentation of cord on right side

 

Course in OT

Patient Shifted to OT for immediate decompression

  • Under aseptic conditions,C2- C5 region opened, fasciectomy and laminectomy done
  • A huge hematoma found over C2-C4 region
  • Hematoma evacuated and specimen sent for biopsy
  • Drain placed with vacuum suction and wound closed in layers
  • Biopsy confirmed diagnosis of hematoma.

Course in hospital

Patient developed immediate improvement in her clinical condition post evacuation of hematoma. Post op day 1: Power increased to 4+/5 in both right upper and lower limb. She was treated with supportive medications and physiotherapy. Drain removed as collection reduced and patient discharged home.

Discussion

SCEH is defined as the accumulation of blood in the epidural space in the absence of trauma or vertebral iatrogenic interference. Some authors included coagulopathy, bleeding from a vascular malformation , or hemorrhagic tumor in this clinical entity while some other authors  consider only idiopathic bleeding in this definition. Idiopathic SCEH constitutes 40–61% of the cases.  Most common localization sites are C6 and T12 levels [1]

The most common initial symptom of SCEH is sudden neck or back pain that spreads to a dermatome depending on the localization area of the hematoma. Due to the compression of the spinal cord and nerve roots, sensation and motor deficits have been seen in the patients. Mostly, paraparesis or quadriparesis was seen depending on the level of compression of the spinal cord. Hemiparesis is a rare clinical feature⁷. Hemiparesis may be produced by anything that interrupts the corticospinal tract from its origin down to the cervical spine. Etiologies include lesions of the cerebral hemisphere as tumor, traumatic brain pathologies, vascular, and infection or lesions of internal capsule, brain stem, and unilateral spinal cord above C5. In 2012, Matsumoto et al. reported cases of SCEH that reveal hemiparesis similarly to our case [9]. Unlike cerebral infarction, pain exists in SCEH. Depending on the size of the lesion, the pain may be followed by loss of sensory or motor deficits and motor deficits are seen more frequently [9].

Computed tomography (CT) is the first choice of imaging in the suspicion of cerebral hemorrhage. In the presence of ischemic lesions, diffusion weighted MRI is a better choice for imaging than CT. Cerebral infarction can be detected in diffusion weighted MRI in a couple of hours after the onset of complaints ¹⁰. For the assessment of spinal lesions, MRI gives detailed information about the localization and size of hematomas, spinal cord edema, and severity of the pressure. In the early stages, SCEH is seen iso or hypointense in T1-weighted imaging and hyperintense in T2-weighted imaging [3].

SCEH is usually a surgical emergency. The most effective treatment is to perform a decompressive laminectomy and quickly evacuate the hematoma ⁹. Conservative treatment preferred in patients with serious high surgical risk or regressive complaints. Recently, studies showed that conservative treatment of cervical lesions is associated with poor outcomes. In SCEH, postoperative mortality rate is around 3–6% [11]

The prognosis of SCEH is closely related to the level and size of the hematoma, the degree of preoperative neurological deficit, and the time between the onset of symptoms and surgery. Recent studies showed that hematomas extending between 2 and 10 spinal segments are associated with poor outcomes ⁸.

Surgery performed in the first 36 hr on patients with severe deficits and surgery performed in the first 48 hr on patients with mild deficits increase the possibility of recovery [11]

Conclusion

Although SCEH is a rare condition, it can cause severe morbidity and mortality. Early diagnosis and treatment are crucial for the best outcomes. SCEH can imitate different pathologies such as a stroke and this diagnosis should come to mind especially in patients with bleeding diathesis. In the absence of a definitive confirmation of CVA in neuroimaging, possibilities for alternative diagnosis and stroke mimics must be reconsidered. Thrombolysis with tPA, frequently used as first-line therapy for acute ischemic stroke, may increase cervical hematoma leading to clinical deterioration.  We hope this case report would promote awareness about SCEH, facilitate its early recognition and prompt clinical intervention that improve neurological outcomes

Acknowledgement

For guiding me with the article, I would like to thank Dr. Aslesha, (Consultant & Clinical lead – Department Of Emergency Medicine)

The author declares no conflict of interest

References

  • Spontaneous Cervical Epidural Hematoma with Hemiparesis Mimicking Cerebral Stroke, Mehmet Tiryaki, Recep Basaran et al. Case Reports in Emergency Medicine, vol. 2014, Article ID 210146, 3 pages, 2014. https://doi.org/10.1155/2014/210146
  • Emergency diagnosis and treatment of spontaneous spinal epidural hematoma.Ikegami K, Inoue Y, Miyajima M et al. J Jpn Assoc Acute Med. 2016; 27 : 107-113
  • Spontaneous spinal epidural hematoma: findings at MR imaging and clinical correlation. Holtås S, Heiling M, Lönntoft M, Radiology. 1996; 199: 409-413
  • Spinal epidural hematoma as a stroke mimic.Yuichiro Inatomi et al. September 2020, Journal of Stroke and Cerebrovascular disease, VOLUME 29, ISSUE 9, 105030.
  • Acute Spontaneous Cervical Epidural Hematoma Mimicking Cerebral Stroke: A Case Report and Literature Review, Jin Kyu Kim, Tae Hong Kim et al. Sept 2013, PMID: 24757481
  • The Syndrome of Spontaneous Spinal Epidural Hematoma- Report of Three Cases James W. Markham, Harold N. Lynge, and Gray E. B. Stahlman, California, Journal of Neurosurgery, 1967, Page Range: 334–342 Volume 26, Issue 3.
  • “Spontaneous spinal epidural hematoma causing Brown- Sequard syndrome: case report and review of the literature,” S. Riaz, H. Jiang, R. Fox, M. Lavoie, and J. K. Mahood,Journal of Emergency Medicine, vol. 33, no. 3, pp. 241–244, 2007.
  • S. Greenberg, Handbook of Neurosurgery, vol. 914, Georg Thieme, New York, NY, USA, 2006.
  • “Spontaneous spinal epidural hematoma with hemiparesis mimicking acute cerebral infarction: two case reports,”H. Matsumoto, T. Miki, Y. Miyaji et al., Journal of Spinal Cord Medicine, vol. 35, no. 4, pp. 262–266, 2012
  • “Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison,” J.A. Chalela, C. S. Kidwell, L. M. Nentwich et al.,The Lancet, vol. 369, no. 9558, pp. 293–298, 2007.
  • “Experience in the surgical management of spontaneous spinal epidural hematoma,” C.-C. Liao, S.-T. Lee, W.-C. Hsu, L.-R. Chen, T.-N. Lui, and S.-C. Lee,Journal of Neurosurgery, vol. 100, no. 1, pp. 38–45, 2004.

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