Case Report

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American Journal of Emergency Medicine

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Spontaneous spinal epidural hematoma presenting as Brown-Sequard syndrome

Abstract

Spontaneous spinal epidural hematoma (SEH) is a rare disease. Furthermore, Brown-Sequard syndrome due to spontaneous SEH has been rarely reported. Early detection of spontaneous SEH is not easy because early symptoms are often atypical and neurologic findings are often absent in the early stage. Early diagnosis and urgent surgical management are needed to prevent permanent neurologic deficits. We report a case of a 30-year-old patient who presented with Brown-Sequard syndrome due to spontaneous SEH. The patient has recovered successfully without any complications through surgical decompression within 12 hours of onset.

A 30-year-old man was admitted to the emergency department (ED) due to anterior chest pain and back pain. His symptom has developed before 1 hour on the way to work in the subway. The nature of his chest symptom was squeezing, and his back symptom was tearing. The pain was continuous from the onset without aggravating and relieving factors. There was no recent history of trauma, infection, and drug administration.

Initial blood pressure was 162/78 mm Hg, heart rate was 75 beats per minute, respiratory rate was 20 breaths per minute, body temperature was 36.4?C, and oxygen saturation was 100%. He did not complain any other symptoms except the chest and back pain. Heart and respiratory auscultation was normal. In addition, there was no skin lesion. His mentation was alert, but muscle strength on the right leg was grade 4+.

There was no mediastinal widening on the chest X-ray. In addition, initial electrocardiography revealed no ST-segment change. Labora- tory data including cardiac enzyme and coagulation battery were unremarkable. We conducted computed tomography to rule out aortic dissection. However, there were no abnormal findings including dissection in major vessels.

Chest and back pain has improved during observation. However, he complained subtle sensory change on the left leg after 3 hours from admission. Weakness on right leg has progressed to grade 2, and the sensory deficit on the left leg has aggravated after 5 hours. Sensations of pain and temperature have decreased on left trunk below T4 level. Magnetic resonance imaging of thoracolumbar spine was performed after 6 hours. A well-defined mass lesion compressing the right-lateral side of spinal cord at T2-3 level was observed. Spinal epidural hematoma was suspected because isosignal intensity on T1-weighted image and heterogeneous signal intensity on T2-weighted image was observed (Fig.).

Emergency laminectomy and hematoma evacuation were per- formed after 11 hours from ED visit. Intraoperatively, coagulated blood was observed. After operation, the sensory deficit has

completely improved, and the muscle strength has also improved after 7 days postoperation. The mass was a typical hematoma, without evidence of arteriovenous malformation in histopathologic evalua- tion. No clotting abnormalities were detected in extensive hemato- logic investigations.

Spinal epidural hematoma (SEH) is classified into spontaneous and secondary SEH. Secondary SEH is caused by trauma, anticoagulant therapy, vascular malformation, hemorrhagic disease, hypertension, infection, pregnancy, and others [1,2]. However, some authors categorize SEH, caused in patients who are taking anticoagulant, have vascular malformation, or have hemorrhagic disease, as spontaneous SEH [3,4].

Brown-Sequard syndrome was first reported by Brown-Sequard in 1846 by the case of a patient who has spinal hemisection due to stab injury [5]. It is diagnosed by finding motor paralysis on the same side as the lesion and deficits in pain and temperature sensation on the opposite side. These are due to injury of lateral corticospinal tract, dorsal column, and spinothalamic tract, respectively. Brown-Sequard syndrome can be caused by intraspinal and extraspinal lesion, herniation of intervertebral disk, and hematoma, but trauma is the most common cause. Brown-Sequard syndrome caused by SEH has been rarely reported. Only 28 cases were reported, up to date. Among those, only 16 cases were caused by spontaneous SEH [6-8].

Early detection of spontaneous SEH is not easy because early symptoms such as interscapular pain or back pain are often atypical. Furthermore, neurologic symptoms are often absent in early stage, so it can be misdiagnosed as ischemic heart disease or aortic dissection in early stages. Pain at the interscapular or back area and neurologic symptom should be differentially diagnosed as herniated intervertebral disc, epidural neoplasm, congenital cyst, stroke, transverse myelitis, epidural abscess, spinal fracture, and aortic dissection [9].

Surgical decompression is the treatment of choice in SEH. When neurologic deficit progresses due to spinal cord compression, prompt surgical management is needed. In a study about postsurgical prognosis of SEH, patients whose neurologic deficits were not severe and who got surgical intervention within 12 hours after onset showed good prognosis [10].

In conclusion, we should suspect spontaneous SEH and Brown- Sequard syndrome when patients complain nontraumatic chest pain, back pain, and asymmetric neurologic deficit of both leg, and through serial follow-up examination, we have to detect the change of symptoms and signs early in ED.

Jung-In Ko MD Department of Emergency Medicine National Medical Center, Seoul, South Korea

0735-6757/$ - see front matter. Published by Elsevier Inc.

Fig. Initial thoracic magnetic resonance imaging studies. A and B, T1-weighted sagittal and axial images show an isosignal intensity mass (arrow) in the dorsal portion of the epidural space from T2 to T3 level with cord compression. C and D, T2-weighted sagittal and axial images show a heterogeneous signal intensity mass (arrow) in the dorsal portion.

Taikwan Kim MD Cheol Su Jwa MD Department of Neurosurgery National Medical Center Seoul, South Korea

Ji Yeon Jang MD Ki Young Jeong MD

Department of Emergency Medicine

National Medical Center Seoul, South Korea

Gil Jun Suh MD Department of Emergency Medicine Seoul National University Hospital

Seoul National University, College of Medicine

Seoul, South Korea

Taejin Park MD

Department of Emergency Medicine

National Medical Center Seoul, South Korea

E-mail address: Emergency@nmc.or.kr http://dx.doi.org/10.1016/j.ajem.2012.11.018

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