Fallberichte - Case Reports
99

Acute spinal subdural haematoma
M. Gabl. H. Kostron
Un iversitätsklinik für Neuroc hirurgie Innsbru ck (Vors ta nd: Prof. Dr. V. Gru ne rt)

A 55 -year-old fem ale was brought to our outpatient clinic with an initially as cending, acut e hem iplegia .
Th e following des cending myelograp hy and CT sca n disclosed a mass lesion at C6-D4. Th e acute spi nal suba rac hnoidal haemorrhage found at operation, its genesis , diagnosis, tr eatment and rehabilitation ar e discussed .
Ak utes su bd ur a les Hämatom der Wirbe lsä ule
Eine 55 Jahre alte Frau wurde mit eine r aufsteigend en akuten Halbs eiten sympt omatik an uns er e
Ambula nz gebrac ht. Die durchgeführte absteigende Myelogra phie sowie die CT-Untersu chung ergaben eine Mass en läsion in Höh e C6 bis Th4 . Die intrao pera tiv gefunde ne
a kute spina le suba rac hnoi da le Blutun g. ihr e Genese. Diagno se . Beh andlun g und Nachbeha ndlung werd en im lachfolgend en diskutiert.
Key-Words
Subdural haem at oma - Intraspi nal mass
lesion

Introduction
In the following we report on a fema le suffering
from an acut e subdural spi na l haematoma following anticoag ulation th er ap y given after a heart attack three yea rs ago .
Although the re are a number of recent publi cations on spina l
vas cular disord er s th er e still remains a need for a rap id and
accu rat e diagn osis and tr eatm ent of this disea se. Myelography
and CT enable us today to identify mass lesion s but for diagnosing a n a rte riovenous malformation (AVM) spina l angiography,
first performed by Henson & Croft in 1953, is still th e most
powerful diagn ostic measure (4). Vascular malformations a re
freque ntly th e ca use of spinal suba rac hnoid ha em orrhages
(SAH). In almost 50 % of th ese cases AVMs could be found
wher eas solita ry spina l arteri al ane urys ms we re quit e rare (2).
In a case of spo nta neo us tetraplegia one has ther efor e to think
of a n ac ute ha em at om a which is almos t a lways caused by a
spina l subdural AVM and may be provoked by pr egnan cy, or
a nticoag ulation th er apy (2. 6).

Neuroc hirurgia 31 (1988) 99-100
© GeorgThiem e Verlag Stuttgart · New York

On February 11 th , a 55-yea r-old woman was bro ught
to a per iph er al hospital showing signs of as cending hem iplegia combined with opisthotonus . She had been under a nticoag ulation thera py
for three yea rs on acco unt of myocar dial infarction . We were able to
examine her in our clinic four teen hou rs later. Movement and se nsory
functio n in the upp er extre mities were nor mal but st re ngth was
reduced. Tendo n reflexes of biceps and triceps were norm al. On the
right side ofth e thor ax we found a sha rp se nso ry level at D10 an d one on
the oth er side at D4. The lower extremities showe d total hemiplegia a nd
a pos itive Babinski on both sides . In addi tion a neurog enie pa re sis oft he
bladd er beca me obvious . Laboratory findin gs revealed a PT of 15 %
whi ch could be increased to 53 % by app lication of proth rom bin cornplexes. A subseq uent myelogra phy from below showed an incom plete
hold-up at D4 (Fig, 1). On the right side the contrast could be seen up to
the level of D1. According to th e CT scan an expa nding mass lesion
above D4 was expected (Fig. 2). Becaus e ofthe as cending hemi plegia a n
imm ediate laminectom y was perfo rm ed . At operation a haemorrhage
into th e subdura l a nd subarachnoid sp ace was found . Two thirds ofthe
subdura l space wer e occupied by this pr ed omin antl y Ieft sided blood
clot. The blood clot was remov ed and for furth er decompress ion a
lioph ylised dur al graft was inse rte d. A slight beginning of th e initiall y
blocked CSF circu lation could be seen during th e operation. On th e first
postoper ative day a significant improvem ent of th e sensory deficit was
obvious. wh er eas th er e was no motor resp onse to a vari ety ofstimuli. A
myelograph y perform ed on the fifth postoper ative day st ill showed a
defect in the subdural filling betw een C7 and D4. On th e followingdays
the pati ent started to move her legs. Recurrent lumbar pun ctu res
showed very blood-stai ned CSF. A motor and sensory par esis of the
bladd er was diagnos ed in our ur ological dep art me nt. On the next day we
sta rt ed a new treat men t with transur ethral electric stim ulatio n,
myocholine and lioresal. All this resu lted in a first spontaneous rnictu rition duri ng a sti mulation one week later. At the sa me tim e th e pati ent
starred to wa lk with the help of two physiotherapists. In mid-June she
could walk a round without help. The sensory a nd tactile state of her
right arm had recovered to normal. her moveme nts were spastic but
nor mal in streng th . Within th e following days th e woman lea rn ed how to
ca the terise hers elf and was sent to a sp ecia l centre for furt her reh ab ilitati on.

Discu ssion
Acute spina l mass lesions due to a ruptured
AVM are quite rare and at our clinic only one has been seen
with in the last ten yea rs . As recent st udi es reveal wome n are
mor e often affected wit h spinal SAHthan men and in mos t oft he
cases th e cervical spi ne was the preferred site (6). Meanwhile it
is weil known , tha t a lumbar punctur e in a pa tien t having
anticoagulation therapy might cause a spinal SDH (5). From the
statistical point ofview primarily pregnant wom en were suffer ing from ruptured AVMs (2,5). This fact ca n be explaine d by
sudden rises of blood pr essure dur ing pregnancy. In our case it
looked as though a too high dosage offib rinolytic dru gs initiated
the sud de n ru pture of this cervica l AVM , although her blood
press ur e always remain ed within the norma l ra nge . Th e
sudden ons et of th is rapidly asce nding hemiplegia combine d
with a men ingea l reaction was the most significant clini cal

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Case report
Su mma ry

Ne urochi ru rgia 3 1 (1988)

M. Gabl, 11. Kostr oll
Fig. 1 The ascending
myelography shows an
incomplete hold-up 01
the contrast at D4

We consi dered that th e clinical picture of this
ac ute as cend ing hem iplegia due to an intradural mass lesio n
was decis ive for an immediate surgical intervention. A laminectomy at several levels, th e rem oval of the blood clots and a n
enlarging dura patch ensure d the spina l decompression
necessar y for restoring neural function . The subsequent postoperative recover y showed a discrepancy betw een the clinical
state and th e radiological control examinations. A furth er
descending myelogra phy revealed only a thinl y distributed contr ast at the ope ra ted ar ea whe reas on th e cont ra ry th e
neurological defect had diminish ed. To our mind th e decision
on furth er tr eat ment depend s on regular follow-ups of th e
neurolo gical condition. Radiological examinations should be
valued as worth -while but ancillary factors in diagnosing th e
pr esent clinical situa tion.

Literature
A minoff. M. J.: Lett er to the editor. Arc h. Neuro l. 38 (19 81) 6 7
Caros cio, 1. T.. T. Bra nn an , M. Budo bin. Yun Peng Hu anq, M. D.
Yahr. Sub arach no id he morrhage seconda ry to arter iovenous ma lform ati on a nd a ne urysm. Arc h. Neurol. 37 (19 80) 101 - 10 3
3 Gar cia, C. A.. S. Dulcey. J. Dulcey : Ru ptured a neurysm of the s pin al
artery of Ada mkiewicz during pregnancy. eurology 3 (1979)
39 4- 39 7
4 Leech, P. J.. Bryant A . R. St ok es. Trevor A ps imon, C. Harper: Unruptured a neurysm of the a nte rior spi nal a rtery pres enti ng as parapa res is. J. Neuro surg. 45 (1976) 33 1-333
5 Kunc, Z.. J. Bret: Diagn osis a nd treatment of vasc ula r malforma tion s of the spin al cord . J. Neurosurg. 30 (1969) 436-44 5
6 Ruf], R. I.: Cord compr ess ion from spin al suba rac hnoid hemorrhage. Arch. Neurol. 37 (1980) 467
7 Suia nn, K. w.. A . 11. Bopp er. P. F. 1. Ne ui, C. E. Paletti : Spo nta neo us
spinal sub a rac hno id hemor rhage an d sub dura l hem al om a . J . Ne urosurg. 61 (1984) 975 - 98 0
8 Zilkha. A .. J. M. Nicoletti : Acut e spinal subdura l hematoma. J .
Neuros urg . 4 1 (19 74) 627- 63 0
I

2

Dr. M . Gabl

Fig.2 The expandingsubdurallesion is outlined by contras!. The cord is
delormed to a thin dorsa lly situated lucid mass

asp ecl. Quite often th e clinica l signs of an acut e spinal SOH ma y
includ e symptoms usually typical for a cere bral iesion (1).
Therefor e th e possibl e simulta neo us pr esen ce of a cere bra l
SAH mu st be excluded by CT or angi ogr aphy. In this case th e
clini cal signs of spinal SAH wer e similar to vascular neoplastic
lesions or a cere bral SAH, as a cer ebral CT revealed that
meningeal reactions had occurred because of to the ascending
subarachnoidal haemo rrhage. The subseq uent exa minatio ns
had to be qu ick an d adeq uate enough to detect poss ible existing
vascular a nd neop last ic lesions or spinal infarctions . Thu s, thi s
acute spin al mass lesio n was diagnos ed by a CT sca n of th e
cervical spin e and a desc ending myelography (Fig. 1, 2). For
detectin g a n AVM or an an eurysm a spinal ang iography would
be necess ary. Th e rapid pr ogress of th e clinical picture was
seen as a contraindica tion for this relati vely tim e-consuming
a nd invasive examination . Th e nature of this mass lesion was
thus detected intraop er atively. Th e bleedin g was most likely
due to an AVM pa cked int o dens e blood clots which were
attached to th e spi nal cord.

Universitä tsklinik für Neur ochirurgie
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A·6 02 0 Innsbru ck

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