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Spontaneous Spinal Epidural Hematoma: Unusual Site Of Bleeding In A Case Of Dic 2014

Category General Spine Bharanidhar Chandrasekaran, M.D. Brian Midkiff, M.D. Kenneth M. Sicard, M.D. Elias Salloum, M.D. Purpose Spontaneous spinal epidural hematoma (SSEH) is a rare entity characterized by non-traumatic bleeding into the epidural space. The dorsal aspect of the thoracic or lumbar region is most commonly involved. The source of hemorrhage is typically venous but can also be arterial. We present an interesting case of SSEH in the setting of fulminant disseminated intravascular coagulation (DIC) likely secondary to leukemia. Materials & Methods CASE: A 64 yr old female presented to the ED with acute non-traumatic low back pain. She denied a past history of trauma. Physical exam was positive for splenomegaly and subcutaneous ecchymosis. Emergency abdomen/pelvis CT showed a left retroperitoneal hematoma, bleeding into the psoas and thoracolumbar paraspinal muscles, and high density material in the spinal canal consistent with blood products. Follow-up thoracolumbar spinal MRI confirmed a large acute epidural hematoma causing severe spinal cord compression. Additionally, diffuse low signal intensity in the vertebral bodies on T1-weighted images suggested an underlying bone marrow infiltrative process. Subsequent blood work revealed pancytopenia, bandemia and features of DIC. Unfortunately, the patient’s condition progressed to quadriparesis and she expired shortly after. Results DISCUSSION: SSEH is a rare neurological condition. Typical clinical presentation of SSEH is sudden back pain that can rapidly progress to paraparesis or quadriparesis, as with our patient. SSEH is often related to an underlying coagulopathy, infection, or underlying lesion such as a vascular malformation or neoplasm. MRI is considered the first choice diagnostic imaging method for SSEH. MRI typically shows a well circumscribed biconvex epidural hematoma. Acute to subacute hematomas show a characteristic high signal intensity on T1-weighted images. However, the appearance and signal characteristics of the SSEH depends on its age. A CT should be performed if MRI is unavailable, and typically shows a hyperdense epidural collection with features of cord compression. Early surgical intervention is the standard treatment ,however, multilevel acute hematomas may be difficult to treat operatively in patients with underlying coagulopathy, as in our patient. In such cases, conservative treatment has been documented. Conclusion SSEH is a rare but potentially fatal entity that needs to be recognized on early imaging. CT can help with early diagnosis by the presence of blood in the epidural space in the setting of coagulopathy, even before MRI can be obtained. Urgent decompression, in the absence of contraindications like severe coagulopathy can be lifesaving. References Melanie B. Fukuia et al. Acute Spontaneous Spinal Epidural Hematomas.American Journal of Neuroradiology. 1999; 20:1365-1372, Groen RJ et al. The spontaneous spinal epidural hematoma. A study of the etiology. Journal Neurological Science. 1990; 98(2-3):121-38, Alexiadou-Rudolf C et al. Acute nontraumatic spinal epidural hematomas. An important differential diagnosis in spinal emergencies. Spine. 1998 23(16):1810-3 Levi M. Current understanding of disseminated intravascular coagulation. Br J Haematol 2004; 124:567. Gundry C, Heithoff K. Epidural hematoma of the lumbar spine. 18 surgically confirmed cases. Radiology 1993; 187:427-431 Bernsen P, Haan J, Vielvoye G, Peerlinck K. Spinal epidural hematoma visualized by magnetic resonance imaging. Neuroradiology 1988; 30:280