Spinal subdural hematoma
Spinal subdural hematomas (SSDH) are much less common than epidural hematomas; however, progression of symptoms due to compression tends to be faster 1.
Spinal subdural hematomas are a rare entity, much more so than epidural hematomas. In a meta-analysis of over 600 spinal hematomas, only 4% were subdural 2.
Factors that predispose to subdural hematoma include:
- anticoagulant therapy 3,4
- spinal vascular malformations
- percutaneous spinal intervention 5
- back surgery 6,7
- trauma 8: uncommon cause
- a combination of any of the above
Subdural hematomas occur within the dural sac; therefore, in contradistinction to epidural hematomas, the epidural fat is preserved and the dura is not displaced inward. The hematoma is bounded by the paired lateral denticulate ligaments and the dorsal septum, forming the inverted Mercedes-Benz sign on axial images 1. As such, it compresses the nerve roots but does not extend into the neural foramina or make direct contact with bone. Naturally, smaller collections will not expand the potential subdural space and will, therefore, not create the inverted Mercedes-Benz sign.
CT is the workhorse of emergency medicine and is usually utilized before MRI for emergencies. However, spinal hematomas can easily be missed in the acute setting, especially if it is small. After having identified a subdural hematoma on MRI, it is good practice to revisit the CT study and use a narrow window in an attempt to identify the hematoma. Moreover, revisiting the CT study can sometimes help clarify the diagnosis 1.
A crescentic hyperdense collection may be seen adhering to the inner margin of the dura, separated from the hypodense epidural fat.
MRI is the imaging modality of choice for identifying and characterizing subdural hematomas.
Signal characteristics will vary, depending on the age of the blood.
After having confirmed the location of the collection as subdural on axial images, sagittal images can be utilized for measuring its extent.
Treatment and prognosis
Conservative treatment with watchful waiting (i.e. follow-up with serial MRIs) is acceptable for small collections. In case of significant neurologic defects, laminectomy with clot evacuation is done.
Cervical and thoracic SSDH are associated with a worse outcome than lumbar SSDH, as is coexisting spinal subarachnoid hematoma (SSAH).
It is important to distinguish between subdural hematomas and other entities which can occupy the spinal subdural space:
- subdural empyema: rare
- different history and clinical picture, including fever
- local extension or haematogenous spread, or iatrogenic
- behaves differently on MRI
- subdural hygroma: CSF collection
- epidural lipomatosis: fat-sat sequences will help differentiation between early subacute SSDH and lipomatosis
- intradural-extramedullary mass: meningiomas and nerve sheath tumors (both common) enhance avidly, while arachnoid cysts follow CSF signal on all sequences
- arachnoiditis: nerve root clumping surrounded entirely by CSF (i.e. not the inverted Mercedes-Benz appearance)
- 1. Pierce JL, Donahue JH, Nacey NC, Quirk CR, Perry MT, Faulconer N, Falkowski GA, Maldonado MD, Shaeffer CA, Shen FH. Spinal Hematomas: What a Radiologist Needs to Know. (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (5): 1516-1535. doi:10.1148/rg.2018180099 - Pubmed
- 2. D. Kreppel, G. Antoniadis, W. Seeling. Spinal hematoma: a literature survey with meta-analysis of 613 patients. (2003) Neurosurgical Review. 26 (1): 1. doi:10.1007/s10143-002-0224-y - Pubmed
- 3. Zaarour, Mazen, Hassan, Samer, Thumallapally, Nishitha, Dai, Qun. Rivaroxaban-Induced Nontraumatic Spinal Subdural Hematoma: An Uncommon Yet Life-Threatening Complication. (2018) Case Reports in Hematology. 2015: 275380. doi:10.1155/2015/275380 - Pubmed
- 4. Koji Akita, Taishi Wada, Shunpei Horii, Mitsuyo Matsumoto, Takeshi Adachi, Fumihiko Kimura, Kenji Itoh. Acute Spinal Subdural Hematoma in a Patient with Active Systemic Lupus Erythematosus: A Case Report and Literature Review. (2018) Internal Medicine. 53 (8): 887. doi:10.2169/internalmedicine.53.1624
- 5. Neha Singhal, Priyanka Sethi, Jitesh Kumar Jain, Saurabh Agarwal. Spinal subdural hematoma with cauda equina syndrome: A complication of combined spinal epidural anesthesia. (2015) Journal of Anaesthesiology Clinical Pharmacology. 31 (2): 244. doi:10.4103/0970-9185.155158 - Pubmed
- 6. Harinder Gakhar, Rajendranath Bommireddy, Zdenek Klezl, Denis Calthorpe. Spinal subdural hematoma as a complication of spinal surgery: can it happen without dural tear?. (2013) European Spine Journal. 22 (3): 346. doi:10.1007/s00586-012-2427-4 - Pubmed
- 7. Tobias A. Mattei, Azeem A. Rehman, Dzung H. Dinh. Acute Spinal Subdural Hematoma after Vertebroplasty: A Case Report Emphasizing the Possible Etiologic Role of Venous Congestion:. (2015) Global Spine Journal. 5 (5): e52-8. doi:10.1055/s-0035-1544155 - Pubmed
- 8. Spinal Subdural Effusion – An Additional Sonographic Sign of Child Abuse. (2012) Ultraschall in der Medizin - European Journal of Ultrasound. 33 (07): E339. doi:10.1055/s-0031-1281670 - Pubmed
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