Clinical History
A 68-year-old female patient presented with acute spinal neurosurgical emergency.
Imaging Findings
The patient presented with a four-hour history of pain in the back and epigastrium with paraesthesia and weakness of the lower limbs. There was no trauma. Her medication included aspirin and warfarin
for angina and previous pulmonary emboli. Clinical examination demonstrated flaccid paraplegia of the lower limbs and sensory loss below the umbilicus, T10 dermatome. No perianal sensory perception
was present. The international normalised prothrombin time radio (I.N.R.) was 3.0. Magnetic resonance imaging of the whole spine was performed. Extrathecal haematoma was demonstrated in the spinal
canal dorsal to the theca, compressing the cord and conus from T8 to L1 and extending cranially. The signal characteristics of the haematoma below T8 are higher than the cerebrospinal fluid (C.S.F)
on T1, similar to C.S.F on T2, and higher than C.S.F. on short tau inversion recovery (S.T.I.R.) sequences. The proximal extension has non-homogenous T1 and T2 signals. A decision was made to manage
conservatively given the poor neurological prognosis. Several months later, motor function remained poor.
Discussion
An acute, spontaneous spinal epidural haematoma is a rare condition, which requires prompt assessment by imaging as early surgical evacuation is often indicated. The majority of spinal canal
haematomas are traumatic. Sixty percent of the spontaneous haematomas have a predisposing factor, often anticoagulant therapy. The haematoma is thought to form from a venous bleed and is normally
dorsal to the theca. Compression of the spinal cord causes injury by two mechanisms: mechanical deformation prevents normal axonal flow, and spinal vascular compression causes ischaemia. The absence
of perianal sensation and a bulbocavernosus reflex indicates "Complete Injury", motor function will recover in less than 3%. The presence of these signs indicates "Incomplete Injury" with a potential
for recovery. Surgical response would be best if the surgery is performed within 12 h from the onset of symptoms. Magnetic resonance imaging (MRI) is the method of choice to assess spinal
neurological emergencies. Magnetic resonance characteristics are time dependent. In the first 24 h, oxy- and deoxyhaemoglobin predominate; T1 signal is similar to the cord and higher than CSF. T2
signal is higher than CSF. and may be heterogeneous. After 24 hours, extracellular methaemaglobin influences the signal; T1 signal increases, and T2 signal becomes similar to CSF. After several week,
haemosiderin influences the signal, T1 signal is low and T2 signal is high. Enhancement by intravenous contrast medium has been described, but is rare and occurs more commonly at the rim than the
centre of the haematoma. The myelography demonstrates extrinsic compression of the thecal sac. The computed tomography (CT) may demonstrate high density haematoma in the spinal canal. Neither
myelography nor CT is sensitive at detecting or demonstrating the extent of the haematoma.
Differential Diagnosis List
An acute, spontaneous spinal epidural haematoma.
Final Diagnosis
An acute, spontaneous spinal epidural haematoma.
