Answer for BIR CoW 26 July 2020
SPONTANEOUS SPINAL EPIDURAL HEMATOMA
Findings
Large posterior epidural T1 hyperintense / T2 heterointense lesion noted extending from upper end plate of C5 vertebra to lower end plate of T4 vertebra with areas of blooming on susceptibility weighted images and patchy diffusion restriction. It causes significant mass effect with severe spinal canal compromise and spinal cord compression. On contrast administration lesion , no significant enhancement noted in subtracted images.
Discussion
These Features were suggestive of spinal epidural hematoma involving C5 to T1 vertebral level with spinal cord compression. A workup revealed no evidence of coagulopathies The patient was taken up for emergency decompression and C5-D1 laminectomy with evacuation of posterior epidural hematoma around 10ml done . The epidural space is a fat-containing space between the dura mater and the osseous and ligamentous components of the vertebral spinal canal Superiorly, the space is bounded by the duramater attachment onto the foramen magnum and inferiorly by the posterior sacrococcygeal ligament, which closes the sacral hiatus. Laterally, this space extends into the neuroforamina Spinal epidural hematoma is the most common intraspinal hematoma ,owing to a rich vascular supply. Epidural hematomas are most commonly idiopathic, comprising up to 40% of cases, other common causes include trauma, iatrogenic diagnostic or pain management interventions, vascular malformations, and coagulopathy or anticoagulant medications . The valveless state of the epidural venous plexus is thought to predispose it to rupture with sudden changes in pressure. An additional consideration is the rupture of small arterioles in the epidural space. 75% of cases show the collection dorsally or dorsolaterally within the spinal canal . This is due to the dura mater being more tightly adherent to the posterior longitudinal ligament than the ligamenta flava, although ventral extension is also seen. Most commonly involving the cervicothoracic or thoracolumbar region. Clinical manifestation depends on the spinal levels involved and characterized by acute onset of back pain with progressive neurologic deficits, Neurologic symptoms may manifest as radicular pain and weakness, paraplegia, or quadriplegia. MRI allows detection of hemorrhage within the epidural space, delineation of the exact levels involved, evaluation of spinal cord compression, and other concomitant soft-tissue or bony injury. The goal of management is to perform decompression within 6–12 hours to prevent permanent neurologic sequelae . The severity of the neurologic deficit at the time of surgical treatment is the most important factor in determining prognosis, long-term outcomes, and recovery to preinsult function However, even in cases with complete loss of neurologic function, many patients will show some postoperative clinical improvement. Differential Diagnosis Epidural Tumor Spread and Metastasis:Epidural tumor typically shows T1 signal hypointensity to the spinal cord, variable T2 signal intensity, and more solid postcontrast enhancement. . Differentiation from epidural hematoma may also be visualized as osseous involvement due to tumor, appearing as multiple vertebral body metastases or scalloping of adjacent vertebral elements. Epidural Abscess Epidural abscess appears as an epidural fluid collection with heterogeneous signal intensity characteristics, but usually shows more homogeneous T1 hypointensity with T2 hyperintensity. Postcontrast imaging shows peripheral enhancement with central nonenhancement. Epidural abscess typically occurs with discitis/ osteomyeliti Epidural Disk, Fibrosis, and Synovial Cysts Epidural Lipomatosis:Increased fat content in the posterior epidural space can at times be confused with the T1 hyperintense signal of a subacute epidural hematoma. Use of fat-suppressed MRI can help differentiate lipomatosis from an epidural hematoma Subdural Hematoma :Subdural hematomas are contained within the wall of the thecal sac. Epidural fatty tissue is preserved, and there is no inward displacement of the hypointense dura mater, which help differentiate subdural collections from those epidural in location
References:
1.Grossman RI, Gomori JM, Goldberg HI, et al. MR imaging of hemorrhagic conditions of the head and neck. Radio- Graphics 1988;8(3):441–454. 2.Braun P, Kazmi K, Nogués-Meléndez P, Mas-Estellés F, Aparici-Robles F. MRI findings in spinal subdural and epidural hematomas. Eur J Radiol 2007;64(1):119–125.
3. Holtås S, Heiling M, Lönntoft M. Spontaneous spinal epidural hematoma: findings at MR imaging and clinical correlation. Radiology 1996;199(2):409–413.
4.Bakker NA, Veeger NJ, Vergeer RA, Groen RJ. Prognosis after spinal cord and cauda compression in spontaneous spinal epidural hematomas. Neurology 2015;84(18): 1894–1903.
5. Chang FC, Lirng JF, Chen SS, et al. Contrast enhancement patterns of acute spinal epidural hematomas: a report of two cases. AJNR Am J Neuroradiol 2003;24(3):366–369.
6.AlMutairA,BednarDA.Spinalepiduralhematoma.JAm Acad Orthop Surg 2010;18(8):494–502. 7. Shin JJ, Kuh SU, Cho YE. Surgical management of spon- taneous spinal epidural hematoma. Eur Spine J 2006;15(6): 998–1004.
Findings
Large posterior epidural T1 hyperintense / T2 heterointense lesion noted extending from upper end plate of C5 vertebra to lower end plate of T4 vertebra with areas of blooming on susceptibility weighted images and patchy diffusion restriction. It causes significant mass effect with severe spinal canal compromise and spinal cord compression. On contrast administration lesion , no significant enhancement noted in subtracted images.
Discussion
These Features were suggestive of spinal epidural hematoma involving C5 to T1 vertebral level with spinal cord compression. A workup revealed no evidence of coagulopathies The patient was taken up for emergency decompression and C5-D1 laminectomy with evacuation of posterior epidural hematoma around 10ml done . The epidural space is a fat-containing space between the dura mater and the osseous and ligamentous components of the vertebral spinal canal Superiorly, the space is bounded by the duramater attachment onto the foramen magnum and inferiorly by the posterior sacrococcygeal ligament, which closes the sacral hiatus. Laterally, this space extends into the neuroforamina Spinal epidural hematoma is the most common intraspinal hematoma ,owing to a rich vascular supply. Epidural hematomas are most commonly idiopathic, comprising up to 40% of cases, other common causes include trauma, iatrogenic diagnostic or pain management interventions, vascular malformations, and coagulopathy or anticoagulant medications . The valveless state of the epidural venous plexus is thought to predispose it to rupture with sudden changes in pressure. An additional consideration is the rupture of small arterioles in the epidural space. 75% of cases show the collection dorsally or dorsolaterally within the spinal canal . This is due to the dura mater being more tightly adherent to the posterior longitudinal ligament than the ligamenta flava, although ventral extension is also seen. Most commonly involving the cervicothoracic or thoracolumbar region. Clinical manifestation depends on the spinal levels involved and characterized by acute onset of back pain with progressive neurologic deficits, Neurologic symptoms may manifest as radicular pain and weakness, paraplegia, or quadriplegia. MRI allows detection of hemorrhage within the epidural space, delineation of the exact levels involved, evaluation of spinal cord compression, and other concomitant soft-tissue or bony injury. The goal of management is to perform decompression within 6–12 hours to prevent permanent neurologic sequelae . The severity of the neurologic deficit at the time of surgical treatment is the most important factor in determining prognosis, long-term outcomes, and recovery to preinsult function However, even in cases with complete loss of neurologic function, many patients will show some postoperative clinical improvement. Differential Diagnosis Epidural Tumor Spread and Metastasis:Epidural tumor typically shows T1 signal hypointensity to the spinal cord, variable T2 signal intensity, and more solid postcontrast enhancement. . Differentiation from epidural hematoma may also be visualized as osseous involvement due to tumor, appearing as multiple vertebral body metastases or scalloping of adjacent vertebral elements. Epidural Abscess Epidural abscess appears as an epidural fluid collection with heterogeneous signal intensity characteristics, but usually shows more homogeneous T1 hypointensity with T2 hyperintensity. Postcontrast imaging shows peripheral enhancement with central nonenhancement. Epidural abscess typically occurs with discitis/ osteomyeliti Epidural Disk, Fibrosis, and Synovial Cysts Epidural Lipomatosis:Increased fat content in the posterior epidural space can at times be confused with the T1 hyperintense signal of a subacute epidural hematoma. Use of fat-suppressed MRI can help differentiate lipomatosis from an epidural hematoma Subdural Hematoma :Subdural hematomas are contained within the wall of the thecal sac. Epidural fatty tissue is preserved, and there is no inward displacement of the hypointense dura mater, which help differentiate subdural collections from those epidural in location
References:
1.Grossman RI, Gomori JM, Goldberg HI, et al. MR imaging of hemorrhagic conditions of the head and neck. Radio- Graphics 1988;8(3):441–454. 2.Braun P, Kazmi K, Nogués-Meléndez P, Mas-Estellés F, Aparici-Robles F. MRI findings in spinal subdural and epidural hematomas. Eur J Radiol 2007;64(1):119–125.
3. Holtås S, Heiling M, Lönntoft M. Spontaneous spinal epidural hematoma: findings at MR imaging and clinical correlation. Radiology 1996;199(2):409–413.
4.Bakker NA, Veeger NJ, Vergeer RA, Groen RJ. Prognosis after spinal cord and cauda compression in spontaneous spinal epidural hematomas. Neurology 2015;84(18): 1894–1903.
5. Chang FC, Lirng JF, Chen SS, et al. Contrast enhancement patterns of acute spinal epidural hematomas: a report of two cases. AJNR Am J Neuroradiol 2003;24(3):366–369.
6.AlMutairA,BednarDA.Spinalepiduralhematoma.JAm Acad Orthop Surg 2010;18(8):494–502. 7. Shin JJ, Kuh SU, Cho YE. Surgical management of spon- taneous spinal epidural hematoma. Eur Spine J 2006;15(6): 998–1004.
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!