CASE 11258 Published on 17.09.2013

Post-traumatic compressive cervical epidural haematoma

Section

Neuroradiology

Case Type

Clinical Cases

Authors

Nitesh Shekhrajka1, Vidhi Mehta2, Krishnakumari A. Modi,

1Department of Radiology,
Aalborg University Hospital,
Hobrovej 18-22,
9100 Aalborg, Denmark;
Email:nitesh1703@gmail.com
2 Sydvestjysk Sygehus,
Finsensgade 35, 6700 Esbjerg
Patient

44 years, male

Categories
Area of Interest Spine ; Imaging Technique MR, CT
Clinical History
Patient admitted to ER in the evening after a fall in inebriated condition. He was unable to move his lower limbs and had weakness in the upper limbs. CTC was normal and symptoms were thought to be due to lack of cooperation to neurological examination. Symptoms hardly improved even by morning.
Imaging Findings
Initial CT brain scans revealed no abnormalities.
Patient's symptoms didn't improve by morning. A CT of cervical spine was ordered which showed fractured right transverse process of C-7 vertebra with fracture of superior articular process and pedicle of anterior arc on the same side. At the same time an epidural haematoma at the level of C6/C7 was suspected.
An MRI of cervical spine was performed and showed lens-shaped lesion in the epidural space behind the posterior border of C5/C7, which was isointense on T1 WI and hyperintense on T2 WI and STIR. It was diagnosed to be an epidural haematoma at the level of C5-C7 with compression on medulla/spinal cord and oedema in the spinal cord. In addition to epidural haematoma, post-traumatic disc prolapse at C6/C7 was diagnosed.
Discussion
BACKGROUND:
In the medical literature, spinal epidural haematomas (SEH) have been regarded as rare lesions. [1] The most common sites of these lesions are the cervical and thoracic spine, and most SEHs are located dorsal to the dural sac because of the firm adherence of the dural sac to the posterior longitudinal ligament in the ventral aspect of the spinal canal. [1] The pathophysiology is poorly understood but the most widely accepted aetiology is valveless epidural veins rupture secondary to trauma or increased venous pressure. [2]

CLASSIFICATION:
SEHs have been classified into 5 broad groups depending on the most probable etiological factors. [3]
1. Spontaneous spinal epidural haematoma - Can be associated with triggering factors such as straining-associated events, mild exertion of normal daily life (defecation, coughing, sneezing, sexual activity). [3]
2. Secondary spinal epidural haematoma - in patients with many other pathological or physiological states (such as coagulation disorders, hypertension, infection, alcoholism, cocaine use, and pregnancy) with or without pre-disposing factor. [3]
3. Iatrogenic spinal epidural haematoma - after any invasive spinal procedure/ spine surgery. [3]
4. Traumatic spinal epidural haematoma - after a major or a minor trauma. [3]
5. Idiopathic spinal epidural haematoma - SEH with neither identifiable aetiological factors nor triggering factors. [3]

CLINICAL PERSPECTIVE:
Most SEH are classified as acute or subacute and characterised by an established archetypal clinical presentation including abrupt spinal pain, around the involved vertebrae, followed, more or less rapidly, by various degrees of neurological deficit. [3, 4]

IMAGING PERSPECTIVE:
MRI should be preferred in the setting of clinical suspicion of SEH. MRI features of acute SEH are relatively specific. Acute SEH is an isointense-to-hyperintense dorsal convex lens-shaped lesion on T1 WI and hyperintense on T2 WI, whereas increased signal intensity on both T1 and T2 WI is seen in subacute SEH. MRI modifications of SEH are similar to those described for brain haematomas. MRI also can estimate the extent of compression and its effect on the spinal cord. This may provide indications for decompressive surgery. [3]

Moreover, contrast enhancement does not rule out the diagnosis of SEH, as various patterns of contrast enhancement have been described. [3] Spinal angiography plays a small role in the diagnostic setting of SEH, and it should be performed when suspicious of a vascular malformation. [3]
Differential Diagnosis List
Post-traumatic compressive cervical epidural haematoma at C5-C7.
Intraspinal space-occupying lesions
Spinal subdural haematoma
Metastatic diseases
Spinal epidural abscess
Epidural haemangioma
Final Diagnosis
Post-traumatic compressive cervical epidural haematoma at C5-C7.
Case information
URL: https://www.eurorad.org/case/11258
DOI: 10.1594/EURORAD/CASE.11258
ISSN: 1563-4086