Abstract

Background: Spontaneous spinal subdural-epidural hematoma during pregnancy is rare.

Case Description: A 29-year-old gravida II patient experienced the onset of vomiting, headache, and progressive paraparesis. The initial non-contrast brain computed tomography and coagulation profiles were negative. The next day, the spine magnetic resonance imaging (MRI) revealed a C7–T4 epidural hematoma; contrast studies revealed no accompanying vascular lesions. On day 3, she underwent a cesarean delivery followed by a C3–T1 laminectomy. Her sensory and sphincteric function returned on postoperative day 2, but at 6 postoperative months, she continued to exhibit a 3/5 paraparesis.

Conclusion: Pregnant patients with acute paraparesis should undergo STAT MRI screening of the spine to look for epidural/subdural hematomas.

Keywords: Epidural hematoma, Laminectomy, Magnetic resonance arteriography, Pregnancy, Spinal, Subdural hematoma

INTRODUCTION

Spontaneous spinal subdural and/or epidural hematomas variously attributed to vascular malformations, coagulopathies, thrombolytic drug administration, previous epidural anesthesia, cardiac surgery, and lumbar puncture are rare.[ 7 ] Although pregnancy induces a hypercoagulable state, accompanying high blood pressure and increased blood volume may contribute to a spinal bleed. Here, a 29-year-old presented with a spontaneous magnetic resonance (MR)-documented C7–T4 epidural hematoma during pregnancy was successfully managed with urgent surgical decompression.

CASE REPORT

History

A 29-year-old G2P0+0+1+0 female at 37 weeks 4 days gestational age presented with the spontaneous onset of a progressive paraparesis. Her neurological examination revealed -1/5 lower extremity motor function, a bilateral T4 pin level, hyperactive lower extremity reflexes with bilateral Babinski signs, and loss of sphincter function. On day 2, the brain MR was negative for stroke, but on day 3, the spine magnetic resonance imaging (MRI) documented an epidural hematoma from C7 to T4 (i.e., maximal thickness T1–T2) [ Figures 1 - 3 ]; MR arteriogram/venograms were negative for vascular lesions [ Figures 1 - 3 ]. Notably, her laboratory coagulation studies were normal (i.e., prothrombin time 12.8 s and international normalized ratio of 0.91).

Figure 1:

(a) Upper cervical magnetic resonance imaging T2 sagittal and (b) axial showing hypointense lesion extending from C1 to T3 spine with maximal thickness at the level of T1-T2 (arrow mark at the lesion) suggestive of extradural hematoma.

Figure 2:

Upper cervical with T1 axial image showing hypointense lesion in the left paracentral, intradurally compressing adjacent nerve root and cord (Arrow mark at the lesion) suggestive of subdural hematoma.

Figure 3:

Upper cervical magnetic resonance imaging T2 axial image showing hypointense lesion on the right paracentral location compressing the cord (arrow mark at the lesion), suggesting subdural hematoma.

Delivery and spinal surgery

She had undergone a cesarean delivery on the day of admission, but the C3–T1 laminectomy was performed on post-admission day 3. Operative findings indicated both an intradural and extradural bleed with maximal thickness at the level of T1vertebral level [ Figure 4 ]. Although much of her sensory and bladder function improved by postoperative day 2, at 6 postoperative months, she still has a 3/5 paraparesis.

Figure 4:

Intraoperative picture showing blood clots in intradural and extradural space extending from C3 to T1 vertebra.

DISCUSSION

Spinal subdural and epidural hematomas are rare entities reported during pregnancy. Predisposing factors may include trauma, vascular malformation, bleeding disorders, use of anticoagulants, hypertension, surgical manipulation, idiopathic, lumbosacral epidural anesthesia, severe hypertension, and coagulopathy.[ 1 , 2 , 6 - 9 ]

Our patient was not in labor, had no history of any coagulopathy, and was not taking any antiplatelet or anticoagulant.

MRI is the diagnostic study of choice for demonstrating spinal hematomas. This patient demonstrated subarachnoid hemorrhage, a cervicothoracic extradural, and subdural hematoma from C6 to T3 level without any vascular anomaly on angiography. Haraga et al. reported complete neurological recovery in a pregnant patient managed within 60 h of presentation with an emergency cesarean section and concurrent spinal decompression.[ 4 ] Alternatively, Jiang et al. and Siasios et al. reported the non-operative management of a spinal hematoma occurring in a pregnant patient after epidural anesthesia.[ 5 , 7 ] In our patient, complete neurological recovery did not occur due to the delay in performing a spinal decompression [ Table 1 ].

Table 1:

Review of similar cases reported in the literature.

Therefore, the most critical predictive factors for recovery after a spontaneous spinal epidural hematoma in a pregnant patient are the severity of the preoperative neurological deficit and the interval between the onset of the neurological deficit and surgery.[ 3 ]

CONCLUSION

Spontaneous intradural/epidural spinal hematomas in pregnant patients are rare. When pregnant patients present with the new/acute onset of significant neurological deficits, emergency MR and spinal surgery are indicated.

Ethical approval

The Institutional Review Board has waived the ethical approval for this study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

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