Hospital: Hospital of Guadalajara.
Ciudad:
Nº:
Aut@r o Autores: C. Marco Schulke, L. Nicolás Liza, B. Sastre Borregón, J. Martínez Ollero, L. Gil Abadía. General University,
Presentación:
A 74-year-old man with chronic limb ischemia was admitted to hospital due to femoropopliteal bypass graft occlusion. Thromboembolectomy was performed and perioperative intravenous heparin was given. An experienced anesthesiologist administered epidural anesthesia and the procedure was atraumatic with no blood in the catheter. In the recovery room, the patient presented a hypertensive crisis and intense pain (upper abdomen and lower chest) and radiated to the back. CT angiography excluded the presence of pulmonary embolism or acute aortic syndrome. The next day, he developed a severe back pain, sensory and motor deficits, and rapidly developing paraplegia. Emergency MRI revealed a large epidural hematoma extending from T6 to the L2 level, with acute spinal cord compression and myelopathy at D9-L1 level. Emergency decompressive laminectomy was performed and evacuation of the hematoma was achieved. The use of topical hemostatic agents during the surgery stopped the active epidural bleeding. Postoperatively there was no improvement in neurological function.
Discusión:
Spinal epidural hematoma (SEH) is a rare but serious complication. Common causes include spontaneus factors (bleeding disorder or over- anticoagulation), trauma and iatrogenic etiologies (e.g. lumbar puncture, epidural anesthesia). Clinical manifestations are characterized by an acute onset of back pain with progressive neurological deficits (radicular pain and weakness, paraplegia or quadriplegia). Epidural collections are located in the extradural neural axis compartment, between the dura mater and periosteum. It may causes mass effect on the spinal cord. In almost all patients with non-specific symptoms the CT is the first imaging test. In a retrospective review of CT images and a careful evaluation, epidural hematomas may be visualized in form of an extradural mass of high attenuation (50-70 HU). Currently MR is considered as the diagnostic test of choice for SEH symptoms. The images vary based on the age of the blood and clot. Within the first 24 hours after symptom onset, the hematoma appears as isointense on T1WI and hyperintense on T2WI. After 24 hours, it appears as a high signal on T1WI and as a low signal on T2WI. Gradient-echo sequence is sensitive to magnetic susceptibility effects and is commonly used for the detection of hemorrhage, it reveals multiple hypointense hemosiderin deposits.
Conclusión:
Spinal epidural hematoma (SEH) is a rare but serious complication. Common causes include spontaneus factors (bleeding disorder or over- anticoagulation), trauma and iatrogenic etiologies (e.g. lumbar puncture, epidural anesthesia). Clinical manifestations are characterized by an acute onset of back pain with progressive neurological deficits (radicular pain and weakness, paraplegia or quadriplegia). Epidural collections are located in the extradural neural axis compartment, between the dura mater and periosteum. It may causes mass effect on the spinal cord. In almost all patients with non-specific symptoms the CT is the first imaging test. In a retrospective review of CT images and a careful evaluation, epidural hematomas may be visualized in form of an extradural mass of high attenuation (50-70 HU). Currently MR is considered as the diagnostic test of choice for SEH symptoms. The images vary based on the age of the blood and clot. Within the first 24 hours after symptom onset, the hematoma appears as isointense on T1WI and hyperintense on T2WI. After 24 hours, it appears as a high signal on T1WI and as a low signal on T2WI. Gradient-echo sequence is sensitive to magnetic susceptibility effects and is commonly used for the detection of hemorrhage, it reveals multiple hypointense hemosiderin deposits.
Bibliografía:
– Pierce JL, Donahue JH, Nacey NC, Quirk CR, Perry MT, Faulconer N, et al. Spinal Hematomas: What a Radiologist Needs to Know. RadioGraphics, 2018, 38:1516–1535. – Litz RJ, Gottschlich B, Stehr SN. Spinal Epidural Hematoma after Spinal Anesthesia in a P