Review
MRI findings in spinal subdural and epidural hematomas

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Abstract

Background

Spinal hematomas are rare entities that can be the cause of an acute spinal cord compression syndrome. Therefore, an early diagnosis is of great importance.

Patients and Methods

From 2001 to 2005 seven patients with intense back pain and/or acute progressive neurological deficit were studied via 1.5 T MRI (in axial and sagittal T1- and T2-weighted sequences). Follow-up MRI was obtained in six patients.

Results

Four patients showed the MRI features of a hyperacute spinal hematoma (two spinal subdural hematoma [SSH] and two spinal epidural hematoma [SEH]), isointense to the spinal cord on T1- and hyperintense on T2-weighted sequences. One patient had an early subacute SEH manifest as heterogeneous signal intensity with areas of high signal intensity on T1- and T2-weighted images. Another patient had a late subacute SSH with high signal intensity on T1- and T2-weighted sequences. The final patient had a SEH in the late chronic phase being hypointense on T1- and T2-weighted sequences.

Discussion

MRI is valuable in diagnosing the presence, location and extent of spinal hematomas. Hyperacute spinal hematoma and the differentiation between SSH and SEH are particular diagnostic challenges. In addition, MRI is an important tool in the follow-up in patients with conservative treatment.

Introduction

Signs of acute or progressive, painful paraparesis and/or paraparesis with sphincter dysfunction are well known indications for emergency MRI. Inflammatory [1], [2], infectious [3], [4] and metastatic lesions, as well as intraspinal hematomas are diagnostic considerations [5]. Intraspinal hematomas can be post-traumatic [6], [7], [8], post-procedural [9], [10], [11], due to anticoagulant therapy [12], [13], [14] or even spontaneous [13], [15], [16], [17], [18], [19].

Magnetic resonance imaging (MRI) is considered to be the technique of choice for diagnosis [20], [21]. Even though MRI is able to evaluate the location, extent, chemical state and compressive effects of hemorrhage, the diagnosis of hyperacute intraspinal hemorrhage may be difficult due to its imaging characteristics.

The purpose of this study is to review the literature and describe our experience in seven patients with spinal subdural and epidural hematoma.

Section snippets

Patients and methods

A retrospective study of clinical and MRI findings in patients with SSH or SEH was carried out from 2001 to 2005. Seven patients were identified who had spinal hematomas on MRI. Six of them were imaged between 10 h and 3 weeks after onset of symptoms. In one patient, the onset could not be clearly identified.

Imaging was performed on 1.5 T scanner (Signa CVi GE Medical Systems, Milwaukee, WI; Siemens Symphony, Erlangen, Germany) and consisted of sagittal and axial T1-weighted (450–600/10–20 [TR

Results

Three patients had a SSH. All patients were female, between 72 and 87 years. Initial symptoms, etiology, location and extent are summarized in Table 1.

MRI in the hyperacute phase demonstrated an isointense lesion on T1-weighted and hyperintense lesion on T2-weighted images (Fig. 1). MRI in the late subacute phase showed a hyperintense lesion on T1- and T2-weighted images (Fig. 2) (Table 2).

Spinal angiography was carried out in two patients and ruled out vascular malformations.

Surgery was

Discussion

The recent increase of publications of SSH and SEH may be explained by the introduction of MRI in daily medical practice. As a result, more patients with a mild clinical course caused by SSH and SEH are diagnosed. Previously those patients would have escaped medical attention [22]. In a large metaanalysis of 613 patients with spinal hematoma, the mean age at presentation was 63 years [23] with a male predominance (ratio, male:female, 1.7:1).

SSH and SEH normally present with signs of spinal cord

Conclusion

MRI is regarded as the imaging modality of choice to evaluate SSH and SHE. However, there are important considerations to take into account. Spontaneous SSH is a rare lesion that is difficult to diagnose in the hyperacute phase due to the lesion's imaging characteristics. T2-weighted gradient-echo images may be helpful to demonstrate a low-signal rim. In our study, T1-weighted fat suppressed images proved helpful in the subacute phase to differentiate epidural fat from hematoma. We recommend

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