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Atypical MRI Presentation of a Surgically Proven Intradural Spinal Hematoma Involving the Cervicothoracic and Lumbar Spine with Imaging Findings Mimicking an Epidural Hematoma 2014

Category General Spine Lindsey Kirk, DO Kathleen Barry, MD Ay-Ming Wang, MD Kenneth Dalen, MD Purpose We present unusual MRI findings of a patient on Coumadin who developed a large intradural spinal hematoma and symptoms of cord compression after a fall. The imaging findings were confusing leading to an initial diagnosis of epidural hematoma which required surgical intervention. At the time of surgery, no epidural hemorrhage was seen. We analyze the MRI findings in an attempt to better understand the appearance of intradural spinal hemorrhage. Materials & Methods Retrospective review of the clinical documents and the MR images of the spine. Results A 70 year old female patient on Coumadin presented to the Emergency Department after sustaining a fall. The patient complained of back pain, and then developed loss of motor and sensory function to her legs. The patient had an MRI of her lumbar spine, which was interpreted as a poorly defined fluid/hemorrhage collection primarily in the ventral spinal canal, presumably in the epidural space extending from T12 through L5 which significantly compressed the distal spinal cord and cauda equina nerve roots at L2 through L4. The examiner recommended an MRI of the thoracic spine which was completed and interpreted as multiple epidural hematomas in the thoracic spine at T3, T5, and T11. On the basis of the MRI examination and the patient's clinical symptoms, the patient went to surgery. The patient had a decompressive laminectomy performed at T1 through T6 and T12 through S1. During the surgical exploration, no evidence of epidural hemorrhage was found. The spine surgeon noted the dura "was tense and much more purplish in appearance consistent with intradural hemorrhage." The dura was opened and partial evacuation of the intradural hemorrhage was accomplished. Follow-up cervical MRI one month later revealed subdural hemorrhage and cervical cord edema. Spinal Hematoma.zip Conclusion Spinal hematomas are difficult to diagnose with certainty on imaging, especially when there is intradural/subarachnoid hemorrhage. This MRI confirms the appearance of a surgically proven intradural hemorrhage. Our case demonstrates the diffuculty in the diagnosis when the clinical picture and the MRI findings mimic an epidural hematoma. It is important for the radiologist to make the correct diagnosis as the treatment of intradural hemorrhage is usually conservative, whereas the treatment of epidural hemorrhage requires surgical intervention. In our case, the significant neurologic deficit led to surgical intervention. Upon review of this case report and the imaging findings, the radiologist will be more familiar with the appearance of an intradural spinal hemorrhage and the pitfalls which make the diagnosis difficult. References Braun P, et al. MRI Findings in spinal and epidural hematomas. Eur J Radiol. 2007; 64; 119-125. Kreppel D, et al. Spinal hematoma: a literature survey with meta-analysis of 613 patients. Neurosurg Rev. 2003; 26; 1-49.