Journal of Computer Assisted Tomography
27(4):530–533
© 2003 Lippincott Williams & Wilkins, Inc., Philadelphia

Case Report

Uncommon Magnetic Resonance Imaging Observation of
Lumbar Subdural Hematoma with Cranial Origin
Frédéric E. Lecouvet, Laurence Annet, Thierry P. Duprez, Guy Cosnard, Victor Scordidis, and
Jacques Malghem

Abstract: A patient with a history of pain, paresthesias, and weakness in both legs is
reported. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated subacute subdural hematoma. Brain MRI obtained 1 day later because of progressive headache showed hemorrhagic cortical metastasis and extensive subdural hematoma. It is
hypothesized that the lumbar hematoma originated from the intracranial bleeding, which
was substantiated by the observation of a thin hemorrhagic collection connecting cranial
and lumbar hematomas on MRI. Cranial origin should be included in the differential
diagnosis of spontaneous spinal subdural hematomas. Index Terms: subdural hematoma, lumbar spine, magnetic resonance imaging, cauda equina, compression

both legs, and discrete headache. Other than lower limb symptoms, the neurologic examination was normal.
MRI of the lumbar spine was obtained, consisting of sagittal
T1- and T2-weighted images and transverse T1-, T2-, and fatsaturated T1-weighted images. This examination demonstrated
subacute subdural hematoma extending from L1 to the distal
sacrum (Fig. 1A). The lesion had high signal intensity on both
T1-weighted (see Figs. 1A, B) and fat-saturated T1-weighted
images (see Fig. 1C) and was pathognomonic for extracorpuscular methemoglobin, which is observed at the subacute stage
of hematomas. The lesion was separated from the posterior
epidural fat by the dura mater (see Figs. 1A, B), was mainly
located in the posterolateral aspects of the dural sac, and determined mass effect on the nerve roots of the cauda equina,
featuring a “3-branch star” appearance.
This lumbar subdural hematoma showed a thin cranial extension within the posterior subdural spaces of the thoracic
spine and cervical spine, which reached the posterior cranial
fossa (see Fig. 1D).
MRI of the brain was performed 1 day later because of
increasing headache and consisted of sagittal and transverse
T1-weighted images obtained before and after injection of gadolinium and T2-weighted images. This examination revealed a
hemorrhagic cortical lesion within the left occipital lobe with
extensive subdural hematoma (Fig. 2).
There was no general or local cause for the lumbar subdural
hematoma; the patient had no previous history of trauma, lumbar puncture, or surgery. Laboratory tests revealed a normal
platelet count and other coagulation parameters.
Because the lumbar hematoma remained well tolerated by
the patient with progressive resolution of lower limb weakness
and pain, conservative therapy was chosen.
The cortical brain tumor was resected surgically, and the
cranial subdural hematoma was evacuated to prevent tonsillar
herniation if lumbar decompression was necessary. An occipi-

Lumbar subdural hematoma is a rare condition, but its
frequency is probably underestimated, and it has been
observed more often since magnetic resonance imaging
(MRI) became available.1 Causative factors include lumbar puncture, surgery, trauma, bleeding diathesis, and
vascular malformations.2 In 5% of the cases, there is no
evidence of any potential cause and the hematoma is
regarded as “spontaneous.”
We report the case of a patient who presented with a
symptomatic lumbar subdural hematoma, revealing a
cranial subdural hematoma associated with a hemorrhagic cortical brain metastasis. This uncommon lumbar
expression of a brain metastasis and hematoma is discussed, with emphasis on the contribution of MRI to the
diagnosis and demonstration of the association between
cranial and lumbar subdural hematomas.
CASE REPORT
A 31-year-old man with a previous history of metastatic
melanosarcoma treated by immunotherapy presented to the
emergency room with pain, paresthesias, moderate weakness in

From the Departments of Medical Imaging (F. E. Lecouvet, L.
Annet, T. P. Duprez, G. Cosnard, J. Malghem) and Neurosurgery
(V. Scordidis), Saint Luc University Hospital, Université Catholique de
Louvain, Brussels, Belgium. Address correspondence and reprint requests to Dr. F. Lecouvet, Department of Radiology, Saint Luc
University Hospital, Université Catholique de Louvain, Hippocrate
Avenue 10/2942 B, 1200 Brussels, Belgium. E-mail: lecouvet@rdgn.
ucl.ac.be

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MRI Observation of Lumbar Subdural Hematoma with Cranial Origin

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FIGURE 1. Magnetic resonance imaging (MRI) showing concurrent spinal and cranial subdural hematoma in a 31-year-old man. MRI of
the spine. A, Sagittal T1-weighted image of the lumbar spine demonstrates high signal intensity collection within the posterior aspect of
the spinal canal extending from L1 to the distal sacrum (arrows in A). The lesion is separated from the posterior epidural fat by the dura
mater (arrowheads in A). Cranial extension of the collection is seen at the thoracic level (curved arrows in A). Transverse T1-weighted
(B) and fat-saturated T1-weighted (C) images show the high signal intensity of the lesion (arrows in B and C) typical of extracellular
methemoglobin, which is suggestive of subacute hematoma. The hematoma is separated from the posterior epidural fat by the dura mater
(arrowhead in B) and determines mass effect on the nerve roots of the cauda equina (leading to a “3-branch star” appearance in B
and C). D, Sagittal T1-weighted image of the cervicothoracic spine demonstrates continuum between lumbar and cranial hematomas
(arrows in D).

tal craniotomy enabled resection of the occipital tumor and
evacuation of a large subdural hematoma from the left paramedian subdural space and upper surface of the tentorium cerebelli. A posterior frontal craniotomy was used to evacuate the
hemispheric subdural hematoma. There was no sign of meningeal carcinomatosis. The postoperative period was uncomplicated. The diagnosis of high-grade melanosarcoma metastasis
was confirmed on histologic examination.
A 2-month follow-up MRI study showed a significant decrease in the size of the lumbar subdural hematoma and associated mass effect (Fig. 3).
The patient did not present with any further neurologic
symptoms but, unfortunately, died 6 months later of an unrelated cause.

DISCUSSION
Lumbar subdural hematomas may be related to lumbar
puncture, surgery, trauma, bleeding diathesis, or vascular
malformations.2,3 A small proportion of these hematomas are considered spontaneous if none of these potential causes is observed. In our patient, we speculate that
the lumbar hematoma originated from the cranial hematoma, leading to an unusual clinical presentation: leg
pain and paresthesias revealing hemorrhagic cortical
brain metastasis and hematoma.
Although exceptional, this propagation of blood from
the cranial to the lumbar subdural spaces is explained by
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Lecouvet et al

FIGURE 2. Magnetic resonance imaging of the brain showing cranial subdural hematoma and metastasis. A, Sagittal T1-weighted image
shows high signal intensity of cranial subdural hematoma within the posterior fossa (arrow) and occipital fossa (arrowhead). Transverse
T1-weighted images obtained before (B) and after (C) injection of gadolinium show intracranial subdural hematoma (arrowheads in B) and
occipital cortical tumor (arrow in B) with adjacent hemorrhage. Signal enhancement of the metastasis is seen on postcontrast image
(arrow in C).

the anatomic continuity between these subdural spaces.
In the current case, this continuum is substantiated by the
presence of a high signal intensity linear collection in the
posterior subdural space on sagittal MRI of the cervicothoracic spine (see Figs. 1A, D). Lumbar accumulation
of blood, leading to the symptomatic compression of
the cauda equina, most likely results from the effect of
gravity.
Cranial subdural hematomas may be observed after
diagnostic lumbar puncture, especially in cases with an
underlying cranial abnormality (eg, aneurysm, tumor, arteriovenous malformation), and after lumbar myelography with or without associated lumbar subdural hema-

FIGURE 3. Follow-up magnetic resonance imaging study of the
spine. Transverse image (same level as Fig. 1B) shows marked
regression of subdural hematoma and associated mass effect on
the dural sac.

J Comput Assist Tomogr, Vol. 27, No. 4, 2003

toma.4–6 In these cases, the cranial subdural hematoma
appears as an iatrogenic consequence of the lumbar procedure as a result of cerebrospinal fluid leakage or neurotoxicity of the contrast material. Our patient presented
with the opposite situation—lumbar expression of presumably preexisting cranial bleeding. Although spinal
extension of postsurgical cranial bleeding has been reported,7,8 we found no previous observation of the lumbar expression of a noniatrogenic cranial hematoma.
The MRI appearance of lumbar subdural hematoma is
well known.1 Evolution of its signal intensity over time
parallels that of cranial hematomas.9 High signal intensity on T1-weighted images is most commonly observed
in fat tissue but is also observed in relation to the presence of paramagnetic agents such as methemoglobin and
melanin. In this case, because the patient had a previous
history of melanosarcoma, the possibility of metastatic
subdural involvement had to be discussed. This hypothesis was highly unlikely, not only because tumoral involvement would have presented a more nodular pattern
but, most importantly, because the “fluid-like” shape of
the hematoma, its spontaneous resolution over time, and
the associated cranial subdural hematoma drained at surgery definitively supported the diagnosis of lumbar subdural hematoma.
Of note, a possible 3-branch star or “inverted Mercedes star” appearance has already been reported in lumbar subdural hematomas.10 This was observed on transverse MRI of the lower lumbar segment in our patient
(see Figs. 1B, C). A potential explanation is the central
accumulation of the nerve roots within the dural sac. The
posterior “branch” or prominence is most likely explained by the presence of the filum terminale in the
posterior aspect of the sac on its way down to its distal
attachment on the posterior wall of the sacral canal. The
anterolateral branches are presumably explained by the
presence of the emerging nerve roots.

MRI Observation of Lumbar Subdural Hematoma with Cranial Origin
Surgical management is indicated in most acute forms
of spinal subdural hematomas, especially when the patient’s neurologic status deteriorates.3 In the absence of
severe or progressive neurologic deficit, spontaneous
resolution may be observed, which can be monitored
using MRI as in our patient.9
This case report illustrates an unusual presentation of
a hemorrhagic cortical brain metastasis revealed by
lower limb symptoms related to lumbar subdural extension of a cranial subdural hematoma.
When facing an unexplained lumbar subdural hematoma, the possibility of a cranial hemorrhagic origin
should be considered, especially if MRI suggests cranial
extension of the subdural hemorrhagic collection within
the spinal canal.
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