210146

8162019 210146

httpslidepdfcomreaderfull210146 14

Case Report Spontaneous Cervical Epidural Hematoma withHemiparesis Mimicking Cerebral Stroke

Mehmet Tiryaki1 Recep Basaran1 Serdar Onur Aydin1 Mustafa Efendioglu1

Ece Balkuv2 and Naci Balak 3

983089 Department of Neurosurgery Dr Lut1047297 Kirdar Kartal Education and Research Hospital Kartal 983091983092983096983097983088 Istanbul urkey 983090 Department of Neurology Istanbul Medeniyet University Goztepe Education and Research Hospital 983091983092983095983091983088 Istanbul urkey 983091 Department of Neurosurgery Istanbul Medeniyet University Goztepe Education and Research Hospital 983091983092983095983091983088 Istanbul urkey

Correspondence should be addressed to Recep Basaran drrecepbasarangmailcom

Received 983090983088 July 983090983088983089983092 Revised 983090983088 September 983090983088983089983092 Accepted 983090983090 September 983090983088983089983092 Published 983090 October 983090983088983089983092

Academic Editor Kazuhito Imanaka

Copyright copy 983090983088983089983092 Mehmet iryaki et al Tis is an openaccess article distributed underthe CreativeCommons AttributionLicensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Aim Spontaneous cervical epidural hematoma (SCEH) is de1047297ned as an epidural hematoma that does not have an etiologicalexplanation Te most common site or SCEH is cervicothoracic area Early diagnosis and treatment are important or prognosisand good results In this paper we aimed to present a case who complains o sudden weakness on right extremities imitatingcerebral stroke and that neuroimaging reveals spontaneous cervical epidural hematoma Case A 983095983090-year-old woman was admitted

to our hospital with acute neck pain and loss o strength on right extremities On neurological examination the patient had righthemiparesis P aP andINR results were 983093983088983093 983092983090983096 and 983092983096 respectively Cranial MRIwas in normal limits Spinal MRIrevealeda lesion that extends rom C983092 to C983095 located on the right side and compatible with epidural hematoma Te patient was operatedafer normalization o INR values Conclusion Even though SCEH is a rare condition it can cause severe morbidity and mortalityEarly diagnosis and treatment are quiet important or prognosis SCEH can easily be mistaken or stroke as with other pathologiesand this diagnosis should come to mind especially in patients who have diathesis o bleeding

1 Introduction

Spontaneous cervical epidural hematoma (SCEH) is de1047297nedas an epidural hematoma that does not have a known eti-ological reason [983089] Although arteriovenous malormations

tumors trauma or postoperative complications are blamedor causes o this situation the most common site o SCEH iscervicothoracic area [983090] Patients usually complain o acuteneck pain or interscapular pain As a result o spinal cordpressure sensory and motor loss can be seen [983089] SCEH isan important and urgent cause o spinal cord pressure Itsincidence is estimated as 983088983089983089983088983088983088983088983088 patients [983091] Maleemaleratio is 983089983092983089 [983092] Early diagnosis and treatment are essentialor a good prognosis

We aimed to present a patient with right hemiparesisinitially mistaken or a cerebrovascular disease Further testsrevealed cervical epidural hemorrhage and the patient hasbeen operated on

2 Case Report

A 983095983090-year-old emale patient was brought to the emergency department with a sudden onset o severe sharp neck painupper back pain and weakness on right arm and leg Approx-

imately 983093 years ago the patient had a mitral valve replacementand uses wararin On neurological examination her strengthwas 983090-983091983093 in right upper limb and 983090983093 in right lower limb Inlaboratory test results P value was 983093983088 983093 AP value was983092983090 983096 and INR value was 983092 983096 Cranial C scan results werein normal limits and there was no sign o bleeding ( Figure 983089)Cranial magnetic resonance imaging (MRI) was also withinnormal limits and there were no evidence pathologies such astumor or ischemia (Figure 983090) Spinal MRI revealed a rightly localized lesion compatible with epidural hematoma thatextended rom C983092 to C983095 (Figure 983091) Following the inusiono three units o resh rozen plasma (FFP) INR value was983089983096 and the patient underwent surgery Right partial C983092ndashC983095

Hindawi Publishing CorporationCase Reports in Emergency MedicineVolume 2014 Article ID 210146 3 pageshttpdxdoiorg1011552014210146

8162019 210146


983090 Case Reports in Emergency Medicine

F983145983143983157983154983141 983089 C scan showed no sign o hemorrhage

F983145983143983157983154983141 983090 MRI o brain was normal there is no sign o ischemic ortumor lesion

and C983093-C983094 total laminectomy was perormed Trombosedhematoma has been discharged On postoperative cervicalMRI hematoma was totally emptied On postoperative neu-rological examination o the right upper and lower extremitymuscle strength on the right side was 983092983093 Te patient was ableto walkwithout aidafer three months o physical therapy andrehabilitation program

3 Discussion

SCEH was 1047297rst described by Jackson in 983089983096983094983097 [983093] Te 1047297rstsurgery was realized byBain in 983089983096983097983095[983094] Te annual incidence

F983145983143983157983154983141 983091 MRI o spine showed epidural hematoma lining rightlateral to spinal cord in cervical region

is estimatedas 983088983089983089983088983088983088983088983088 [983091]SCEHis de1047297nedas theaccumu-lation o blood in the epidural space in the absence o trau-ma or vertebral iatrogenic intererence Some authors includ-

ed coagulopathy vascular malormation bleeding or hemor-rhagic tumor in this recognition by some authors only idio-pathic bleeding was evaluated in this de1047297nition IdiopathicSCEH constitutes 983092983088ndash983094983089 o the cases [983089] Most commonlocalization sites are C983094 and 983089983090 levels [983090]

Lo et al listed some actors that cause SCEH such asthe use o anticoagulants thrombolytic therapy uncontrolledhypertension long-term use o antiplatelet actor XI de1047297-ciency and congenital disorders such as hemophilia B [983095]Tere are some controversies whether the source o bleedingis venous or arterial Many authors claim that the source o bleeding is venous and it is due to a lack o tissue cover inthe epidural venous plexus A sudden pressure increase in theabdominal cavity or thoracic venous pressure is thought tocause tearing and bleeding [983096] Afer all according to someauthors because the arterial pressure in the epidural spaceis higher than the venous pressure and because o the rapidprogression o neurological deterioration the bleeding thatcauses SCEH is an arterial bleeding not a venous one [983089]In our case we did not observe any arterial bleeding duringsurgery Still there is a need or more studies in order toclariy the pathogenesis o SCEH

Te most common initial symptom o SCEH is suddenneck or back pain that spreads to a dermatome dependingon hematomarsquos localization area Due to the compressiono the spinal cord and nerve roots sensation and motorde1047297cits may be seen in the patients Mostly paraparesis or

quadriparesis is seen depending on the level o compressiono the spinal cord Hemiparesis is a rare clinical eature [983097]Hemiparesis may be produced by anything that interruptsthe corticospinal tract rom its origin down to the cervicalspine Etiologies include lesions o the cerebral hemisphere astumor traumatic brain pathologies vascular and inection orlesions o internal capsule brain stem and unilateral spinalcord above C983093 Hypoglycemia can sometimes be associatedwith hemiparesis that clears afer the administration o glucose [983089983088] In 983090983088983089983090 Matsumoto et al reported cases o SCEH that reveal hemiparesis similarly to our case [983089983089]Unlike cerebral inarction pain exists in SCEH Dependingon the size o the lesion the pain may be ollowed by loss o

8162019 210146


Case Reports in Emergency Medicine 983091

sensory or motor de1047297cits and motor de1047297cits are seen morerequently [983089983089]

Computed tomography (C) is the 1047297rst choice o imagingin the suspicion o cerebral hemorrhage In the presence o ischemic lesions diffusion weighted MRI is a better choiceor imaging than C Cerebral inarction can be detected

in diffusion weighted MRI in a couple o hours afer theonset o complaints [983089983090] For the assessment o spinal lesionsMRI gives detailed inormation about the localization andsize o hematomas spinal cord edema and severity o thepressure In the early stages SCEH is seen iso or hypointensein 983089-weighted imaging and hyperintense in 983090-weightedimaging [983095]

SCEH is usually a surgical emergency Te most effectivetreatment is to perorm a decompressive laminectomy andhematoma evacuation quickly [983089983091] Conservative treatmentmay be preerred in patients with no neurological deteriora-tion or cases withserious highsurgical risk or regressive com-plaints Recently studies showed that conservative treatmento cervical lesions is associated with poor outcomes [983089983092] InSCEH postoperative mortality rate is around 983091ndash983094 [983096]

Te prognosis o SCEH is closely related to the level andsize o the hematoma the degree o preoperativeneurologicalde1047297cit and the time between the onset o symptoms andsurgery Recent studies showed that hematomas extendingbetween 983090 and 983089983088 spinal segments are associated with pooroutcomes [983089983093] Also surgery perormed in the 1047297rst 983091983094 hourson patients with severe de1047297cits and surgery perormed inthe 1047297rst 983092983096 hours on patients with mild de1047297cits increase thepossibility o recovery [983096] In a study realized by Shin etal the surgical recovery rates were ound as 983096983091 or thepatients operated in the 1047297rst 983089983090 hours afer the onset o initialsymptoms 983094983091983094 or the patients operated between the 983089983090thand the 983090983092th hours afer the onset o initial symptoms and983092983094983095 or the patients operated 983090983092 hours ollowing the onseto initial symptoms [983089983094]

4 Conclusion

Although SCEH is a rare condition it can cause severemorbidity and mortality Early diagnosis and treatment arecrucial or the best outcomes SCEH can imitate differentpathologies such as a stroke and this diagnosis should cometo mind especially in patients with bleeding diathesis

Conflict of InterestsTe authors declare that there is no con1047298ict o interestsregarding the publication o this paper

References

[983089] R M Beattyand K R WinstonldquoSpontaneous cervical epiduralhematomaa consideration o etiologyrdquo Journal of Neurosurgery vol 983094983089 no 983089 pp 983089983092983091ndash983089983092983096 983089983097983096983092

[983090] R J M Groen and J Goffin ldquoNon-operative treatment o spon-taneous spinal epidural hematomas a review o the literatureand a comparison with operative casesrdquo Acta Neurochirurgica vol 983089983092983094 no 983090 pp 983089983088983091ndash983089983089983088 983090983088983088983092

[983091] S Holtas M Heiling and M Lonntof ldquoSpontaneous spinalepidural hematoma 1047297ndings at MR imaging and clinical cor-relationrdquo Radiology vol 983089983097983097 no 983090 pp 983092983088983097ndash983092983089983091 983089983097983097983094

[983092] M M C Lonjon P Paquis S Chanalet and P GrellierldquoNontraumatic spinal epidural hematoma report o our casesand review o the literaturerdquo Neurosurgery vol 983092983089 no 983090 pp983092983096983091ndash983092983096983095 983089983097983097983095

[983093] R Jackson ldquoCase o spinal apoplexyrdquo Te Lancet vol 983097983092 no983090983091983097983090 pp 983093ndash983094 983089983096983094983097

[983094] W Bain ldquoA case o haematorrachisrdquo British MedicalJournal vol983090 article 983092983093983093 983089983097983089983090

[983095] C-C Lo J-Y Chen Y-K Lo P-H Lai and Y- Lin ldquoSponta-neous spinal epiduralhematoma a case report andreview otheliteraturesrdquo Acta Neurologica aiwanica vol 983090983089 no 983089 pp 983091983089ndash983091983092983090983088983089983090

[983096] C-C Liao S- Lee W-C Hsu L-R Chen -N Lui and S-C Lee ldquoExperience in thesurgical management o spontaneousspinal epidural hematomardquo Journal of Neurosurgery vol 983089983088983088no 983089 pp 983091983096ndash983092983093 983090983088983088983092

[983097] S Riaz H Jiang R Fox M Lavoie and J K Mahood ldquoSpon-

taneous spinal epidural hematoma causing Brown- Sequardsyndrome case report and review o the literaturerdquo Journal of Emergency Medicine vol 983091983091 no 983091 pp 983090983092983089ndash983090983092983092 983090983088983088983095

[983089983088] M S Greenberg Handbook of Neurosurgery vol 983097983089983092 GeorgTieme New York NY USA 983090983088983088983094

[983089983089] H Matsumoto Miki Y Miyaji et al ldquoSpontaneous spinalepidural hematoma with hemiparesis mimicking acute cerebralinarction two case reportsrdquo Journal of Spinal Cord Medicine vol 983091983093 no 983092 pp 983090983094983090ndash983090983094983094 983090983088983089983090

[983089983090] J A Chalela C S Kidwell L M Nentwich et al ldquoMagneticresonance imaging and computed tomography in emergency assessment o patients with suspected acute stroke a prospec-tive comparisonrdquo Te Lancet vol 983091983094983097 no 983097983093983093983096 pp 983090983097983091ndash983090983097983096983090983088983088983095

[983089983091] C-C Liao P-C Hsieh -K Lin C-L Lin Y-L Lo andS-C Lee ldquoSurgical treatment o spontaneous spinal epiduralhematoma a 983093-year experience clinical articlerdquo Journal of Neurosurgery Spine vol 983089983089 no 983092 pp 983092983096983088ndash983092983096983094 983090983088983088983097

[983089983092] S J Hentschel A R Woolenden and D J Fairholm ldquoResolu-tion o spontaneous spinal epidural hematomawithout surgeryreport o two casesrdquo Spine vol 983090983094 no 983090983090 pp E983093983090983093ndash983093983090983095 983090983088983088983089

[983089983093] Z Liu Q Jiao J Xu X Wang S Li and C You ldquoSpontaneousspinal epidural hematoma analysis o 983090983091 casesrdquo Surgical Neu-rology vol 983094983097 no 983091 pp 983090983093983091ndash983090983094983088 983090983088983088983096

[983089983094] J-J Shin S-U Kuh and Y-E Cho ldquoSurgical managemento spontaneous spinal epidural hematomardquo European Spine Journal vol 983089983093 no 983094 pp 983097983097983096ndash983089983088983088983092 983090983088983088983094

8162019 210146


Submit your manuscripts at

httpwwwhindawicom

8162019 210146


983090 Case Reports in Emergency Medicine

F983145983143983157983154983141 983089 C scan showed no sign o hemorrhage

F983145983143983157983154983141 983090 MRI o brain was normal there is no sign o ischemic ortumor lesion

and C983093-C983094 total laminectomy was perormed Trombosedhematoma has been discharged On postoperative cervicalMRI hematoma was totally emptied On postoperative neu-rological examination o the right upper and lower extremitymuscle strength on the right side was 983092983093 Te patient was ableto walkwithout aidafer three months o physical therapy andrehabilitation program

3 Discussion

SCEH was 1047297rst described by Jackson in 983089983096983094983097 [983093] Te 1047297rstsurgery was realized byBain in 983089983096983097983095[983094] Te annual incidence

F983145983143983157983154983141 983091 MRI o spine showed epidural hematoma lining rightlateral to spinal cord in cervical region

is estimatedas 983088983089983089983088983088983088983088983088 [983091]SCEHis de1047297nedas theaccumu-lation o blood in the epidural space in the absence o trau-ma or vertebral iatrogenic intererence Some authors includ-

ed coagulopathy vascular malormation bleeding or hemor-rhagic tumor in this recognition by some authors only idio-pathic bleeding was evaluated in this de1047297nition IdiopathicSCEH constitutes 983092983088ndash983094983089 o the cases [983089] Most commonlocalization sites are C983094 and 983089983090 levels [983090]

Lo et al listed some actors that cause SCEH such asthe use o anticoagulants thrombolytic therapy uncontrolledhypertension long-term use o antiplatelet actor XI de1047297-ciency and congenital disorders such as hemophilia B [983095]Tere are some controversies whether the source o bleedingis venous or arterial Many authors claim that the source o bleeding is venous and it is due to a lack o tissue cover inthe epidural venous plexus A sudden pressure increase in theabdominal cavity or thoracic venous pressure is thought tocause tearing and bleeding [983096] Afer all according to someauthors because the arterial pressure in the epidural spaceis higher than the venous pressure and because o the rapidprogression o neurological deterioration the bleeding thatcauses SCEH is an arterial bleeding not a venous one [983089]In our case we did not observe any arterial bleeding duringsurgery Still there is a need or more studies in order toclariy the pathogenesis o SCEH

Te most common initial symptom o SCEH is suddenneck or back pain that spreads to a dermatome dependingon hematomarsquos localization area Due to the compressiono the spinal cord and nerve roots sensation and motorde1047297cits may be seen in the patients Mostly paraparesis or

quadriparesis is seen depending on the level o compressiono the spinal cord Hemiparesis is a rare clinical eature [983097]Hemiparesis may be produced by anything that interruptsthe corticospinal tract rom its origin down to the cervicalspine Etiologies include lesions o the cerebral hemisphere astumor traumatic brain pathologies vascular and inection orlesions o internal capsule brain stem and unilateral spinalcord above C983093 Hypoglycemia can sometimes be associatedwith hemiparesis that clears afer the administration o glucose [983089983088] In 983090983088983089983090 Matsumoto et al reported cases o SCEH that reveal hemiparesis similarly to our case [983089983089]Unlike cerebral inarction pain exists in SCEH Dependingon the size o the lesion the pain may be ollowed by loss o

8162019 210146








4 Conclusion



References


















8162019 210146



httpwwwhindawicom

8162019 210146








4 Conclusion



References


















8162019 210146



httpwwwhindawicom

8162019 210146



httpwwwhindawicom

210146

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