Intracranial Vasospasm without Intracranial Hemorrhage due to Acute Spontaneous Spinal Subdural Hematoma

Abstract

Spontaneous spinal subdural hematoma (SDH) is very rare. Furthermore, intracranial vasospasm (ICVS) associated with spinal hemorrhage has been very rarely reported. We present an ICVS case without intracranial hemorrhage following SDH. A 41-year-old woman was admitted to our hospital with a complaint of severe headache. Multiple intracranial vasospasms were noted on a brain CT angiogram and transfemoral cerebral angiography. However, intracranial hemorrhage was not revealed by brain MRI or CT. On day 3 after admission, weakness of both legs and urinary incontinence developed. Spine MRI showed C7~T6 spinal cord compression due to hyperacute stage of SDH. After hematoma evacuation, her symptoms gradually improved. We suggest that spinal cord evaluation should be considered in patients with headache who have ICVS, although intracranial hemorrhage would not be visible in brain images.

Keywords: Headache; Intracranial vasospasm; Spinal subdural hematoma; Subarachnoid hemorrhage.

Fig. 1. Brain CT angiography, CT and MRI. (A, B) Brain CT angiography 2 days after symptom onset shows multifocal intracranial vasospasms (arrows) without intracranial hemorrhage. (C, D) Brain fluid-attenuated inversion recovery (C) and susceptibility-weighted (D) imaging 9 days after symptom onset also do not show intracranial hemorrhage.

Fig. 2. Transfemoral cerebral angiography 9 days after symptom onset. Multifocal vasospasms are shown in the left carotid (A, arrows) and left vertebral (B, arrowheads) angiograms.

Fig. 3. T2-weighted sagittal MRI of spinal cord shows an acute hematoma (black arrows) at the level of C7~T6 segments with cord compression. There is also mildly increased T2 signal intensity within T1 and T2 segments. T2 axial MRI at the T2 spine level shows a hematoma (white arrows) within the extramedullary and intradural space, which means that the lesion is of the subdural origin (left lower corner box).

Fig. 4. (A, B) Brain diffusion MRIs 17 days after symptom onset. Acute bilateral multifocal infarctions are shown in the corpus callosum area. (C) MR angiography reveals no vasospasm in any of the intracranial arteries about 1 year after symptom onset.