Acute spontaneous spinal epidural hematomas

Abstract

Background and purpose: Although previous reports have characterized MR imaging features of spinal epidural hematomas (EDH), few cases have been reported during the acute or hyperacute phase within the first 48 hours. Our goal in this investigation was to correlate the MR imaging features of acute (< or =48 hours) spontaneous EDH with clinical management and outcome.

Methods: Eight patients with acute spontaneous EDH (five men and three women; age range, 31-81 years) underwent MR imaging at 1.5 T (T1-weighted, n = 8; T1-weighted after the administration of 0.1 mmol/kg contrast material, n = 6; T2-weighted, n = 8; and T2-weighted, n = 4). The interval from symptom onset to hospital admission ranged from immediate to 5 days. Two neuroradiologists reviewed the MR images for signal characteristics, contrast enhancement, and cord compression. Treatment and clinical outcome were correlated with the imaging findings.

Results: The EDH were located in the cervical (n = 3), cervicothoracic (n = 2), thoracolumbar (n = 2), and lumbar (n = 1) regions. On T1-weighted images, the signal intensity of the EDH was isointense to spinal cord in five cases, hyperintense in two cases, and hypointense in one case and did not correlate with time to imaging. Isointensity on T1-weighted images persisted for 5 days in one case. On T2-weighted images, all EDHs were hyperintense with focal, heterogeneous hypointensity. Cord compression was severe in six patients, moderate in one patient, and minimal in one patient. Four cases were treated conservatively with complete resolution or improvement of symptoms within 1 to 3 weeks.

Conclusion: MR imaging findings were useful in establishing the diagnosis of EDH but did not influence management or predict outcome in this series. Heterogeneous hyperintensity to cord with focal hypointensity on T2-weighted images should suggest the diagnosis of acute spinal EDH. Severity of neurologic impairment had the greatest impact on management and outcome. Nonoperative treatment may be successful in cases with minimal neurologic deficits, despite cord compression revealed by MR imaging.

fig 1.

Patient 3. A, Initial sagittal T1-weighted image (600/8/2 [TR/TE/excitations]), obtained 120 hours after symptom onset, reveals a long-segment EDH that is isointense in signal to spinal cord and is causing severe cord compression (arrows). B, Sagittal T1-weighted image (400/8/2), obtained after the intravenous administration of contrast material, shows a mixed pattern of central (arrowheads) and peripheral (straight arrows) enhancement that likely reflects both enhancement of the hematoma itself and dural enhancement. Linear enhancement within the hematoma (curved arrow) may represent septa or vessels in lateral extensions of epidural fat. C, Axial T1-weighted image (500/9/2), obtained at the level of the central enhancement seen in B, shows the absence of hyperintensity within the hematoma before the administration of contrast material (arrows). D, Axial T1-weighted image (650/9/2), obtained after the intravenous administration of contrast material and at the level of the central enhancement seen in B, shows a mixed pattern of central (arrowheads) and peripheral (curved arrow) enhancement. E, Sagittal T2-weighted image (4000/98/2) shows that the hematoma is hyperintense to spinal cord with focal hypointensity that may represent deoxyhemoglobin and/or fibrous septa (arrows). F, Follow-up sagittal T2-weighted image, obtained 6 days after the initial imaging was performed, shows that nearly complete resolution of the EDH (arrows) was achieved with conservative management.

fig 2.

Patient 5. A, Initial sagittal T1-weighted image (483/15/23), obtained 14 hours after the ictus, reveals a short-segment EDH that is isointense to spinal cord (arrows). B, Sagittal T1-weighted image (400/15/2), obtained after the administration of contrast material, shows faint, peripheral enhancement (arrows). C, Enhanced axial T1-weighted image (433/17/2) shows minimal peripheral enhancement and severe cord compression (arrowheads). D, Sagittal T2-weighted image shows that the hematoma is slightly hyperintense to cord with focal hypointensity (arrows). E, Axial CT image, obtained during percutaneous sampling of the epidural mass (described in the methods), shows the tip of the needle within the epidural collection. F, Follow-up sagittal T1-weighted image (500/10/2), obtained 22 days after the initial imaging and percutaneous aspiration were performed, shows complete resolution of the hematoma.

fig 3.

Patient 8. A, Initial sagittal T1-weighted image (400/14/3), obtained 48 hours after the onset of headache and neck pain that clinically was suspicious for subarachnoid hemorrhage, reveals an EDH at C2−C3 (arrowheads) that is isointense to spinal cord. B, Sagittal T1-weighted image (733/20/2), obtained after the administration of contrast material, shows striking central enhancement. C, Axial gradient-echo image (500/12/2; flip angle, 20°), obtained at the C5 level, shows minimal deformity of the spinal cord from the posterolateral EDH (arrowheads).