Spinal Epidural Hematoma MRI

A 26 yo male with sudden onset backache and chest pain for last 2 days. An associated bilateral upper limb tingling numbness. Both lower limb weakness is of sudden onset and non progressive.

Power: Rt arm 4-5, Lt arm 4-5, Rt leg 0, Lt leg 0.

No history of trauma or any heavy weight lifting. 

BT CT PT and other related caugulation profile normal.

On admission MRI dorsal region spine done with contrast. 

MRI Findings: 

A focal posterior epidural lentiform shaped collection extending from C6-7 to D2-3 disc level

Collection is hypo intense on sagittal T2 images with low signal intensity 'blooming'on GRE. No significant enhancement within the collection on post contrast T1 and fat sat T1. Thin enhancement noted along the normal dura.

Significant cord compression with focal cord edema.

Imaging wise Diagnosis: Possible DDs given were as Epidural Hematoma more likely than Abscess.

Post operative findings:

Operated with C6-D3 Laminectomy, posterior epidural hematoma / blood clot evacuated with coagulation of dural AV fistula along left D2 root.

Final Diagnosis : Posterior epidural hematoma secondary to Spinal Dural AV Fistula - Malformation.

Discussion:

In this case possibility of Epidural hematoma is more likely due to sudden onset of symptoms clinically, low signal intensity of collection on T2w and T2*GRE, iso to hyper intensity on T1w images, non enhancing on post contrast on imaging, thought there no history of history of trauma and normal coagulation profile. So one should entertain a possibility of Hematoma for a spinal Epidural lesion as Epidural Hematoma can present without history of trauma and moreover blood has variable signal and enhancement pattern on MRI.

Spinal Epidural hematoma (EDH)

Extra vasation of blood into the epidural space of spine.

Imaging

MRI is best.

Typically lentiform shaped long segmental extra axial collection mass encasing or displacing cord or cauda equina.

Location anywhere along spinal canal, commonly in dorsal region. 

vertical extent variable depending upon severity of bleed, often multi segmental,rarely focal when associated with an adjacent fracture.

On CT, density on CT varies with age of hematoma high density in acute stage to low density in chronic. 

On MRI 

TIWI: Hypo-, iso- or hyperintense (depending on age)

T2WI: Inhomogeneous low (if acute), or high signal (if subacute) intensity.

T2* GRE: low signal.

T1 C+: None to marginal enhancement along the dural outling of collection. Avid enhancement if bleeding is active. 

DSA

Often negative. Rarely, may show AVM or vascular tumor as Source of bleeding. 

DDs

Epidural abscess: Usually vivid enhancement, associated osteomyelitis or paraspinous infection, constitutional signs like fever, pain, chills.

Epidural tumor: Typically quite focal, adjacent bone often involved, Lymphoma may simulate EDH, enhances vividly. 

Etiology

o Spontaneous in 1/3

• Pressure elevation in vertebral venous plexus due to minor exertion, like sit-ups with Valsalva.

• Chiropractic manipulation

o Therapeutic anticoagulation

• Coumadin

• Anti platelet agents

o Instrumentation

• Epidural anesthetic

• Nerve block

• Facet joint injection

• Lumbar puncture

o Vascular malformation

Clinical Presentation

Most common signs/symptoms are intense, knife-like pain.

Associated extremity weakness, sphincter disturbance

Age: 35-70 Gender: Male > Female

Treatment

o Surgical for significant cord compression is decompressive Laminectomy and evacuation of hematoma. 

o Non-surgical for minor neurological signs.