Neurol Med Chir (Tokyo) 48, 231¿234, 2008

Rapid Spontaneous Remission of a Spontaneous
Spinal Chronic Subdural Hematoma in a Child
—Case Report—
Dong-Hyuk PARK, Tai-Hyoung CHO, Jang-Bo LEE, Jung-Yul PARK,
Youn-Kwan PARK, Yong-Gu CHUNG, and Jung-Keun SUH
Department of Neurosurgery, Korea University, College of Medicine, Seoul, R.O.K.

Abstract
A 13-year-old boy presented with a rare spontaneous spinal chronic subdural hematoma (SCSDH) with
no associated trauma or medical problems manifesting as back and bilateral lower extremity pain persisting for 10 days. Neurological examination revealed mild weakness and paresthesia in both lower extremities. Magnetic resonance (MR) imaging performed 1 week after the appearance of symptoms revealed a chronic subdural hematoma at the thoracolumbosacral region. Follow-up MR imaging performed 1 week later showed significant resolution of the hematoma without the need for surgery. The
patient was discharged with only conservative management. This case of spontaneous SCSDH with
rapid spontaneous remission in a child not associated with coagulopathy indicates that aggressive surgical treatment should be delayed as long as possible in pediatric patients because the spinal structure is
still developing.
Key words:

child,

chronic subdural hematoma,

spinal subdural hematoma,

spontaneous remission

Introduction

Case Report

Spinal chronic subdural hematoma (SCSDH) is a
rare disease that can occur in patients who have
suffered minor trauma, coagulopathy, or anticoagulation therapy. Spontaneous SCSDH is even rarer,
and is occasionally associated with chronic intracranial hematoma,1,11,19) superficial hemosiderosis of the brain,15) spinal arachnoiditis, or syringomyelia.18) Nevertheless, the etiology and pathogenesis of spontaneous SCSDH remain unclear because
unlike the cerebral subdural space, the spinal subdural space does not contain bridging vessels and is
protected by the vertebral column as well as several
paravertebral muscles.2,12,14,19) Only five cases of
spontaneous SCSDH without specific pathology
have been reported.3,4,6,8,17) We report another case of
spontaneous SCSDH in a child with no associated
trauma or medical problems that resolved spontaneously.

A 13-year-old boy presented with back and bilateral
lower extremity pain persisting for 10 days. The
patient had no previous history of trauma or bleeding diathesis. The descending pain had become aggravated. Neurological examination revealed motor
strength of grade 4＋ and mild paresthesia in both
lower extremities, paraspinal muscular spasm, and
marked tenderness of the lumbar spinal processes.
Straight leg rising was limited to 15 degrees, but the
deep tendon reflexes remained within the normal
limits, and there were no pathological reflexes. Magnetic resonance (MR) imaging, performed at a local
clinic 1 week after the back pain had begun, showed
a longitudinal space-occupying lesion encircling the
cauda equina in the spinal canal from T12 to S1. The
lesion appeared hyperintense on both T1- and T2weighted images but without enhancement after infusion of intravenous gadolinium (Fig. 1).
The patient was transferred to the Department of
Neurosurgery at the Anam Hospital of Korea University for further evaluation and management 3
days after the initial MR imaging. Routine laboratory analyses, including complete blood counts and
coagulation screen, were within the normal limits.

Received
2008

August 14, 2007;

Accepted

January 23,

231

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Fig. 1

D.-H. Park et al.

Sagittal T1-weighted (A) and T2-weighted (B)
magnetic resonance images 1 week after the
onset demonstrating a hyperintense longitudinal lesion anterior and posterior to the
dural sac, extending from T12 within the
posterior subdural space and from L3 within the anterior subdural space down to S1,
and compressing the cauda equine. Axial
T1-weighted images (C) and with gadolinium (D) showing no enhancement of the
lesion (L4-5 disc level), with the arachnoid
membrane and subarachnoid components
surrounded by the subdural hematoma appearing as an inverted ``Mercedes star
sign.''

Emergency surgery was withheld and follow-up MR
imaging was performed 3 days after admission to
the hospital because of the tolerable neurological
signs. Neuroimaging revealed remarkable resolution
of the hematoma. His symptoms and the neurological signs had improved progressively. The small
residual hematoma extended only from L3 down to
L5. However, the lesion remained hyperintense on
both T1- and T2-weighted images (Fig. 2). Extensive
spinal angiography and bilateral internal iliac angiography did not reveal any evidence of spinal vascular malformations such as arteriovenous malformation or dural arteriovenous fistula.
Conservative management was chosen because

Fig. 2

Sagittal T1-weighted (A) and T2-weighted
(B), and axial T1-weighted (C) (L4-5 disc level) magnetic resonance images 1 week later
showing significant resolution of the hematoma, with the small residual hematoma extending only from L3 down to L5.

his back pain had recovered rapidly with gradual improvement in the neurological deficits of the bilateral extremities, and the spinal structure was still developing at this young age. He was discharged in
almost normal neurological condition 4 weeks after
the onset of back pain.

Discussion
Two hypotheses have been proposed to explain the
pathogenesis of SCSDH. First, initial hemorrhage
in the subarachnoid space is the primary lesion
that eventually dissects into the subdural space,
and the subarachnoid hemorrhage is washed out by
the cerebrospinal flow through the transitional
state,6,7,9,16,17) as supported by observations of the
transitional state of combined subarachnoid hem-

Neurol Med Chir (Tokyo) 48, May, 2008

Spontaneous Remission of a Spontaneous SCSDH
orrhage and subdural hematoma.2,7) Second, spinal
subdural hematoma might be related to the redistribution of blood from the intracranial subdural
space, and expansion may be secondary to chronic
changes,1) supported by a possible association between SCSDH and intracranial chronic subdural
hematoma.1,11,19)
The mechanism of the spontaneous resolution of
SCSDH is also unknown. The direction of the movement of a hematoma might be reversed, namely from
the subdural to subarachnoid space.13) The liquid
subdural hematoma may reversely penetrate into the
subarachnoid space through the broken arachnoid
membrane prior to healing, and is then washed out
by the cerebrospinal fluid flow. Dissection of subdural hematoma into the subarachnoid space can occur gradually because of the time interval of clot lysis. However, in our case, the cause of the prompt
spontaneous resolution is still unclear.
MR imaging recognition of the blood products is
the most important sign that distinguishes SCSDH
from other extramedullary spinal lesions. Acute subdural hematoma is isointense with the spinal cord
on T1-weighted imaging and mixed intensity on T2weighted imaging, with peripheral hyperintensity
on both T1- and T2-weighted imaging at approximately 4–7 days after bleeding. In the late chronic
stage, hyperintensity is typically observed on both
T1- and T2-weighted imaging.10,19) Extramedullary
tumor or abscess will usually appear with rim or
uniform enhancement on T1-weighted imaging,
whereas SCSDH shows no contrast enhancement.10)
Axial images are essential for differentiating between the epidural and subdural locations of the
hematoma.10,19) Spinal epidural hematoma has a
more lentiform shape, and occasionally extends into
the intervertebral foramina. In contrast, spinal subdural hematoma has a crescent shape and traps the
spinal cord or cauda equina. An inverted ``Mercedes
star sign'' may indicate a subdural location in the
lumbar spine.10) These findings were also observed
in our case (Fig. 1).
Only five previous cases of spontaneous SCSDH
without pathology have been reported.3,4,6,8,17) The
lumbar4,8) and thoracolumbar3,6) regions were the
most common sites for the spontaneous SCSDH.
Only one case was a cervical SCSDH.17) All five
patients, including one pediatric patient, underwent
laminectomy to evacuate the SCSDH.4) Nontraumatic acute spinal subdural hematomas in the pediatric
patients are almost always associated with bleeding
disorders and poor outcomes.5) The present
pediatric case of spontaneous SCSDH in a child was
not associated with coagulopathy at the thoracolumbosacral region and showed rapid spontaneous

Neurol Med Chir (Tokyo) 48, May, 2008

233

remission.
Emergency surgical decompression is generally
the best treatment in patients presenting with acute
deterioration and severe neurological deficits such
as acute spinal subdural hematoma. Percutaneous
drainage might be an option in patients with stable
deficit, dorsally located hematoma of moderate extent in the lumbosacral area, and no bleeding diathesis.2) Conservative management might be an option
in patients with mild neurological deficits and
progressive improvement in the early period, as seen
in our case. In particular, aggressive surgical treatment should be delayed as long as possible in
pediatric patients because the spinal structure is still
developing.

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Address reprint requests to: Tai-Hyoung Cho, M.D.,
Department of Neurosurgery, Korea University
Anam Hospital, Korea University, College of Medicine, 126–1, 5 ga, Anam–dong, Sungbuk–gu, Seoul,
136–705, R.O.K.
e-mail: choth2＠unitel.co.kr

Neurol Med Chir (Tokyo) 48, May, 2008