Case of idiopathic cervical spinal subarachnoid hematoma mimicking an epidural hematoma: A case report

Abstract

Background:

Cervical spinal subarachnoid hematoma (SSAH) is rare and may mimic epidural or subdural hematoma on magnetic resonance imaging (MRI). This makes it difficult to correctly localize the hematoma on the preoperative magnetic resonance, thus typically warranting surgery.

Case Description:

A 78-year-old female presented with the sudden onset of neck pain and progressive left hemiparesis. The cervical MRI showed a left dorsolateral C3-C5 compressive hematoma, thought initially to represent an epidural clot. The accompanying computed tomography angiogram (i.e., without preoperative digital subtraction angiography) showed no vascular abnormality. Due to rapid neurological deterioration, the patient underwent an emergency decompression. At surgery, no epidural hematoma was found; rather, following a durotomy, arachnoid dissection revealed an organized SSAH without abnormal vessels that were removed en bloc. The patient improved immediately after surgery, and the postoperative MRI confirmed adequate decompression.

Conclusion:

Idiopathic cervical SSAH should be included in the differential diagnosis of acute cervical compressive hematomas. As MRI may not reliably define the location of the hematoma, those demonstrating progressive neurological deterioration typically warrant surgery, even without a full vascular work-up.

INTRODUCTION

Spinal hematomas in the epidural, subdural, or subarachnoid space can all present with the sudden onset of neck pain and a rapidly progressive myelopathy.[6] Of these, spinal subarachnoid hematomas (SSAH) are uncommon, while idiopathic cervical SSAH are even more rare.[2,8] Notably, magnetic resonance imaging (MRI) alone without a full vascular workup (i.e., magnetic resonance angiography, computed tomography [CT] angiography, digital subtraction angiography [DSA]) may not reliably diagnose the exact etiology of the SSAH.[7] Here, we report a 78-year-old female with an idiopathic cervical SSAH and a rapidly progressive myelopathy that warranted immediate surgical decompression before a full preoperative vascular workup could be completed.

CASE DESCRIPTION

A 78-year-old female presented with the sudden onset of neck pain and left upper-extremity weakness that within 4 days progressed to a severe left hemiparesis (1/5 upper but 0/5 lower extremities). There was no history of trauma or the use of anticoagulants/antiplatelets agents. The brain MRI showed no intracranial lesions. However, the cervical MRI demonstrated a left dorsolateral intraspinal mass from C3 to C5 that was hypointense on T1- and T2-weighted images, causing cord edema and marked right cord displacement [Figure 1a-f]. The CT and CT angiogram (CTA) suggested a hematoma but showed no vascular abnormality [Figure 2a-d]. As she demonstrated rapid neurological deterioration, an emergency decompression was performed without a confirmatory DSA. After a partial C2 and C3-C5 laminectomy, no epidural hematoma was found. However, when the dura and arachnoid were opened, an organized subarachnoid hematoma without abnormal vessels was found and removed en bloc [Figure 3a and b]. The histopathological examination confirmed an organized hematoma. Within 2 postoperative weeks, her left-sided strength improved to 4/5, and postoperative MRI confirmed complete hematoma removal and adequate cord decompression [Figure 4a-c].

Figure 1:

Preoperative MRI imaging findings. (a-c) Admission sagittal MRI (a) T1-weighted, (b) T2-weighted, (c) STIR T1- and T2-hypointense masses identified in cervical spinal canal C3–C5. STIR image showing intramedullary hyperintensity C2 to C6, likely cord edema. (d-f) (d) Axial T2-weighted MRI images at the C3 vertebral body level, (e) C3/4 intervertebral level, and (f) C4 vertebral body level. A mass suggestive of a hematoma was observed on the left side of the cervical canal, causing spinal cord compression. MRI: Magnetic resonance imaging, STIR: Short tau inversion recovery.

Figure 2:

Preoperative CT imaging findings. (a-d) Multiplanar reconstruction images of admission contrast-enhanced CT (a) sagittal, (b) coronal, (c) axial showing a hyperdense lesion on the left side of the cervical canal at C3–4, suggestive of hematoma, (d) 3D CTA of cervical vessels showing no arteriovenous fistula, vascular malformation, or other vascular abnormalities. CT: Computed tomography, CTA: Computed tomography angiography.

Figure 3:

Intraoperative findings. (a) Intraoperative photograph after dural opening showing subarachnoid hematoma extending from caudal C3 to C4. (b) Intraoperative photograph after en bloc hematoma removal. Minor oozing from a small vessel (arrow head) observed at the hematoma bed controlled using low-power bipolar coagulation.

Figure 4:

Postoperative MRI imaging findings. (a-c) MRI obtained 2 weeks postoperatively (a) Sagittal T2-weighted, (b) sagittal STIR, (c) axial T2-weighted showing complete hematoma removal without recurrence and adequate cord decompression. MRI: Magnetic resonance imaging, STIR: Short tau inversion recovery.

DISCUSSION

SSAH are uncommon, and idiopathic cervical SSAH (i.e., in the absence of trauma and anticoagulants/antiplatelet use) is particularly rare.[2,3,8] Several cases of traumatic and spontaneous SSAH have been reported in the literature, and a summary of these cases is presented in Table 1. Although MRI can define the presence of a compressive hematoma, it cannot reliably distinguish between an epidural, subdural, or subarachnoid clot.[7] Patients who develop rapid neurological worsening may warrant emergent surgical intervention before completion of a full workup for a vascular malformation. Notably, although CTA revealed no vascular abnormality, small spinal vascular lesions may be missed on CTA. DSA, the gold standard for diagnosing spinal vascular pathology, was not performed in this case.[4,5] If intraoperatively surgeons do not encounter an epidural hematoma, they should be prepared to look for a subdural or subarachnoid hematoma.[1] Our patient’s immediate postoperative recovery and early radiographic decompression supported this approach.

Table 1:

Summary of the 8 key references.

CONCLUSION

Idiopathic cervical SSAH should be included among the differential diagnoses of acute cervical spinal hematomas, and emergency surgery should not be delayed in the presence of acute neurological deterioration.

Ethical approval:

Institutional Review Board approval is not required.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for their images and other clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.