Neurol Med Chir (Tokyo) 51, 664¿666, 2011

Development of Cervical Subarachnoid Hematoma
Following Coronal Artery Stenting for Angina Pectoris
—Case Report—
Takao YASUHARA,1,2 Yasuyuki MIYOSHI,1 and Isao DATE1
1Department of Neurological Surgery, Okayama University Graduate School of Medicine,

Dentistry and Pharmaceutical Sciences, Okayama, Okayama;
2Department of Spinal Surgery, Shin-Komonji Hospital, Kitakyushu, Fukuoka

Abstract
A 78-year-old man presented with a rare massive subarachnoid hematoma (SAH) in the cervical spine
after coronary stenting for angina pectoris. Chest pain and electrocardiographic changes were resolved
after administration of coronary dilator and coronary stenting, but shoulder pain persisted. At 6 hours
after stenting, left hemiparesis was found with deteriorated shoulder pain. Computed tomography and
magnetic resonance imaging revealed massive SAH in the cervical spine. Emergent hematoma evacuation with laminoplasty was performed because of rapid progression of the hemiparesis and pain. The
hemiparesis was ameliorated after surgery. Spinal hematoma should be considered in the differential
diagnosis in patients receiving anti-platelet or anti-coagulant drugs with rapid progression of pain.
Key words:

referred pain,

spine,

subarachnoid hematoma

Introduction

our department.
On admission, he had no sensory dysfunction with normal level of tendon reflexes. Head CT revealed scattered
lesions of SAH (Fig. 1A–C). Head magnetic resonance
(MR) imaging revealed SAH and a high signal intensity lesion in the right corona radiata on high b-value diffusionweighted images (b value ＝ 2000) (Fig. 1D), but no lesion
in the right corona radiata was detected by other b-value
diffusion-weighted imaging (b value ＝ 0 or 1000) or fluidattenuated inversion recovery imaging. MR angiography
revealed no hemorrhagic vascular lesion. We initially
thought of incidental cerebral infarct with SAH due to the
medication, because his shoulder pain might have been
referred pain from the coronary lesion and he just presented with pure hemiparesis. However, we also considered
the possibility of spinal hematoma because the shoulder
pain worsened with rapid progression of the left hemiparesis (MMT 2/5). Spinal CT and MR imaging revealed spinal hematoma (Fig. 1E, F). Our diagnosis was subdural
spinal hematoma based on the location of the hematoma
on MR imaging. Spinal CT with contrast medium and
three-dimensional CT (3D-CT) angiography showed no
vascular lesion in the spine.
Emergent decompression was performed because of the
deterioration of the hemiparesis. Laminotomy (C3–C5) exposed high tension dura without epidural hematoma. After dural incision, thick SAH appeared (Fig. 2A) without
hematoma between the dura and arachnoid. We confirmed that the spinal cord was decompressed and pulsative after hematoma removal without vascular lesions.
Then GoreTex sheet (0.3 mm thickness; W. L. Gore & As-

Subarachnoid hematoma (SAH) in the cervical spine
without vascular lesion is rare. We describe a case of massive SAH in the cervical spine after coronary stenting for
angina pectoris.

Case Report
A 78-year-old man suffering pain in the left shoulder and
chest visited the department of cardiovascular internal
medicine of our institute. He had been an outpatient for
angina pectoris with coronary artery bypass for 7 years.
He was taking oral anti-platelet medication. On admission, cardiac electrography (EKG) demonstrated ST
depression. After administration of coronary dilator, his
chest pain disappeared with normalization of ST level on
EKG, although his shoulder pain persisted. Computed
tomography (CT) excluded aorta dissection, and emergent
coronary angiography revealed 90% stenosis of the left circumflex artery. Drug eluting stent (Cypher Stent; Cordis
Corp., a Johnson & Johnson company, Bridgewater, New
Jersey, USA) was inserted with efficient dilation of the lesion, but his shoulder pain gradually exacerbated. Systemic heparinization and additional anti-platelet drug administration was started. His blood pressure was unstable
with peak values of 190/110 mmHg. At 6 hours after stenting, left hemiparesis (manual muscle test [MMT] 4/5) and
deteriorated shoulder pain occurred, so he was referred to
Received

January 6, 2011;

Accepted

March 10, 2011

664

SAH in the Cervical Spine After Coronary Artery Stenting

665

Discussion

Fig. 1 A–C: Head computed tomography (CT) scans revealing
intracranial scattered lesions of subarachnoid hematoma (arrows). D: Head magnetic resonance (MR) image showing a
high signal intensity lesion in the right corona radiata (arrow)
on high b-value diffusion-weighted imaging (b value ＝ 2000).
E, F: Spinal sagittal CT scan (E) and axial T1-weighted MR image (F) revealing a spinal hematoma (arrow) and the dura as
black rim outside the hematoma compressing the spinal cord.
The location of the hematoma indicated subdural hematoma.

Fig. 2 A, B: Intraoperative photographs after dural incision
showing thick subarachnoid hematoma (A), and dural plasty
with GoreTex sheet with drainage tube below the dura (B). C:
Postoperative sagittal computed tomography scan showing that
the hematoma was removed with decompressed spinal cord.

sociates, Inc., Medical Products Division, Flagstaff, Arizona, USA) was used for decompressive dural plasty (Fig.
2B). A drainage tube was placed inside the dura with
laminoplasty using Apaceram spacers (HOYA Corp., PENTAX New Ceramics Division, Tokyo) (Fig. 2C).
Immediately after surgery, his weakness ameliorated
(MMT 3/5). At 2 months after surgery, he underwent walking training with a walker and transferred to another
hospital for rehabilitation (MMT 5－/5).

Neurol Med Chir (Tokyo) 51, September, 2011

The present case of SAH in the cervical spine occurred after coronary dilation stenting for angina pectoris, with
subsequent resolution of chest pain and abnormal EKG
findings. After the treatment for angina pectoris, left
hemiparesis appeared and deteriorated with consequent
surgical treatment. Symptoms of hemiparesis with severe
pain might be essential diagnostic indicators for spinal
hematoma, although in this case the initial shoulder pain
may have been related to the preceding spinal hematoma.
In this case, intracranial scattered SAH and high signal intensity lesion on diffusion-weighted imaging (b value ＝
2000) were also confusing for the correct diagnosis. Clearly, spinal hematoma is an important differential diagnosis
in patients with strong anti-platelet/anti-coagulant therapy.
Spinal hematoma is well known after administration of
anti-coagulant or anti-platelet drugs.1,2,11) In our case, the
medication was probably responsible for the deteriorated
symptoms due to the increased size of the hematoma. Before admission, the patient had taken oral anti-platelet
agent for 7 years. In addition, systemic heparinization for
coronary stenting might have promoted SAH in the cervical spine and cranium. SAH in the cervical spine sometimes occurs from vascular lesions in the spine.10) Spinal
angiography, 3D-CT angiography, and MR angiography
should be considered for the hemorrhagic vascular lesion,
although in our case, intraoperative findings and repeated
3D-CT angiography and MR angiography did not reveal
any hemorrhagic lesions. Spontaneous spinal subdural
hematoma is sometimes treated conservatively with subsequent recovery of the symptoms.5,8) However, hematoma
evacuation and rehabilitation are required for many cases
with rapid progression of symptoms.6) High b-value
diffusion-weighted imaging provides better identification
of extension of cerebral ischemia, although imaging artifact might increase.12) In our case, the high signal intensity lesion in the right corona radiata on high b-value
diffusion-weighted imaging (b value ＝ 2000) might have
been an artifact, which made the correct diagnosis
difficult.
Review of 106 cases of non-traumatic acute spinal subdural hematoma found that 70% of patients presented
with lumbar or thoracolumbar lesions.3) Over half of the
patients were related to the spinal puncture and/or
hemostatic disability. Fourteen of 59 cases receiving surgical treatment presented with SAH with relatively poor
prognosis. The onset and location of our case was atypical, although anti-platelet/anti-coagulant agents and coronary intervention were risk factors for spinal hematoma.
Neuroradiological findings of spinal subdural hematoma
were clarified in several reports.7) Because of the semicircular distribution of the subdural hematoma, the imaging
finding is less conspicuous with caudocranial extension
than epidural hematoma.9) Subdural hematoma is usually
located ventrally,4) which might be due to the tight attachment of the dura to the posterior longitudinal ligament. In
our case, CT revealed spinal hematoma on the ventral side
in the canal with relatively long caudocranial extension.

T. Yasuhara et al.

666

MR imaging, especially axial T1-weighted imaging,
demonstrated the dura as a rim of low signal intensity and
the hematoma extending to the left inside the dura.
The present rare case of SAH after coronary stenting for
angina pectoris shows that we should always think of the
possibility of spinal hematoma in patients with risk factors
and likely symptoms.

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Address reprint requests to: Takao Yasuhara, MD, PhD, Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical
Sciences, 2–5–1 Shikata–cho, Kita–ku, Okayama 700–8558,
Japan.
e-mail: tyasu37＠cc.okayama-u.ac.jp

Neurol Med Chir (Tokyo) 51, September, 2011