Chronic Spinal Hematoma as a Possible Reason for Cognitive Impairment Helmut Niederhofer, MD, PhD, and Markus Huber, MD This case report describes a patient with a chronic spinal subdural hematoma and hemosiderosis revealing cognitive deficits. The effects on cerebral function of a chronic subdural hematoma via hemosiderosis are described. © 2003 by Elsevier Inc. All rights reserved. Niederhofer H, Huber M. Chronic spinal hematoma as a possible reason for cognitive impairment. Pediatr Neurol 2003;28:223-224. Case Report A 17-year-old male patient was admitted to our hospital in October 2000 because of vertigo, gait imbalance, and impaired memory functions, as well as dysthymic mood disorder. Symptomatology began in November 1998 with sudden onset of headache and disorientation for few minutes. Gait imbalance was fluctuant but slowly progressive. Additionally, seizures with loss of consciousness and automatisms of the left upper limb, lasting for about 1 minute and remitting under oxcarbazepine medication, were reported. The patient also had cancer of the prostate since 1997, treated conservatively by hormone therapy, and hypacusis (hearing aid since 1997 right, since 1999 left). A former craniocerebral magnetic resonance image (MRI) (May 1999) revealed superficial brain siderosis, mainly infratentorial. MR-angiography did not demonstrate any pathology. Examination by an otolaryngologist confirmed hypacusis with additional anosmia. Neurologic examination revealed gait ataxia, anosmia, hypacusis, and slight horizontal nystagmus. Dysthymia and mild cognitive impairment were also described. Lumbar puncture revealed a xanthochromic CSF with pleocytosis (21/␮l), siderophages and protein elevation (63mg/dl). Cerebral angiography did not exhibit any relevant abnormality. An ependymoma could be excluded by craniocerebral MRI with gadolinium. No bleeding source could be detected by spinal angiography. The whole examination procedure is summarized in Table 1. Finally, MRI of the whole spine demonstrated a ventrally situated membrane from T1 to T11 (Fig 1). There was no need for neurosurgical intervention. We started medication with trientine hydrochloride. Discussion Introduction Spontaneous spinal chronic hematomas are extremely rare [1-3] and likely combined with chronic intracranial hematomas [4]. They may cause paraplegia [1,5]. Symptomatology can be reduced by surgical intervention [6,7]. Extremely rarely, chronic spinal subdural hematomes can bleed into the cerebrospinal fluid (CSF) and cause hemosiderosis. Hemosiderosis typically causes slowly progressive ataxia, hypoacusis, and dementia, and sometimes also causes pyramidal signs and sphincter disturbances [3,8-12]. Epidural and subdural spinal hematomas can be diagnosed by magnetic resonance tomography [13]. This case report describes a patient with superficial hemosiderosis of the brain and spinal chronic subdural hematoma, demonstrating impact on psychopathology caused by hemosiderosis because of spinal chronic hematoma. The effects on psychopathology of a chronic subdural hematoma via hemosiderosis are described. From the Regional Hospital Bolzano; Paediatria; I-39100 Bolzano (BZ); Italy. © 2003 by Elsevier Inc. All rights reserved. doi:10.1016/S0887-8994(02)00616-1 ● 0887-8994/03/$—see front matter The rare superficial hemosiderosis results from chronic subarachnoid hemorrhage, although only in 54% of the cases a source of bleeding can be reported [9]. This distinct clinical syndrome is characterized by deafness, cognitive impairment, anosmia, cerebellar ataxia, and pyramidal signs. Chronic subocciptal hematoma as a possible bleeding source is only described once [14]. Uncertainity exists regarding the source of bleeding and mechanism of formation of spinal subdural hematoma. Winters et al. [11] suggest that in many cases a spinal subarachnoidal hemorrhage may be the primary lesion that eventually dissects into the subdural space. The same author reports laceration of a radicular vessel to be a possible additional source for spinal subarachnoidal bleeding. Spinal MRI and spinal angiography does not inform about the bleeding source, but patient’s history with no acute episodes of back pain suggests that chronic spinal hematoma may have been the primary lesion. Hypacusis as the cardinal symptom, with its onset much earlier than the episode of headache and brief disorientation, suggests a slow onset of symptoms. Communications should be addressed to: Dr. Niederhofer; Regional Hopital of Bolzano; Paediatria; Via L.Boehler 5; I-39100, Bolzano, Italy. Received January 16, 2002; accepted September 16, 2002. Niederhofer and Huber: Spinal Hematoma and Cognitive Impairment 223 Table 1. Examination procedure Examination Neurologic examination Cerebral computed tomography Evoked potentials Electroencephalography Doppler duplex-sonography Electrocardiogram Laboratory findings Neuropsychology Cerebral magnetic resonance tomography Cerebral magnetic resonance angiography Eye-nose-throat-examination Spinal magnetic resonance tomography Cerebrospinal fluid analysis Spinal and cranial/cerebral angiography Diagnosis Hypacusis, anosmia, nystagmus, gait ataxia Enlarged ventricles and subarachnoidal spaces Delayed V-wave, delayed interpeak latencies I-V and III-V right side Theta focus left side frontotemporal Small plaques arteria carotis interna Sinus rhythm Hyperlipidemia HAWIE: IQ ⫽ 97; Depression status inventory: 61 Arachnoidal hemosiderosis No pathologic results Anosmia and hypacusis Chronic subdural hematoma Siderophages, xanthochromia No aneurysm We consider our patient to be an example of an uncommon clinical manifestation of a chronic spinal hematoma with an impact on psychopathology, caused by hemosiderosis. 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