Spontaneous anterior cervicothoracic spinal epidural hematoma extending to clivus in SARS-CoV-2 infection
- Department of Neurosurgery, Highly Specialized Hospital and of National Importance “Garibaldi”, Catania, Italy.
- Department of Neurosurgery, Cannizzaro Hospital, Trauma Center, Gamma Knife Center, Catania, Italy.
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, AOUP “Paolo Giaccone”, Palermo, Italy.
- Department of Diagnostic Imaging, Interventional Radiology and Neuroradiology, Highly Specialized Hospital and of National Importance “Garibaldi”, Italy.
- Department of Emergency, Acute Care and Observation Medicine, Highly Specialized Hospital and of National Importance “Garibaldi”, Catania, Italy.
Department of Neurosurgery, Highly Specialized Hospital and of National Importance “Garibaldi”, Catania, Italy.
DOI:10.25259/SNI_40_2021Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Gianluca Scalia1, Giuseppe Emmanuele Umana2, Salvatore Marrone3, Francesca Graziano1, Angelo Giuffrida1, Giancarlo Ponzo1, Massimiliano Giuffrida1, Massimo Furnari1, Gianluca Galvano4, Santo Bonanno5, Giovanni Federico Nicoletti1. Spontaneous anterior cervicothoracic spinal epidural hematoma extending to clivus in SARS-CoV-2 infection. 26-Apr-2021;12:181
How to cite this URL: Gianluca Scalia1, Giuseppe Emmanuele Umana2, Salvatore Marrone3, Francesca Graziano1, Angelo Giuffrida1, Giancarlo Ponzo1, Massimiliano Giuffrida1, Massimo Furnari1, Gianluca Galvano4, Santo Bonanno5, Giovanni Federico Nicoletti1. Spontaneous anterior cervicothoracic spinal epidural hematoma extending to clivus in SARS-CoV-2 infection. 26-Apr-2021;12:181. Available from: https://surgicalneurologyint.com/?post_type=surgicalint_articles&p=10764
Background: The treatment of spontaneous spinal epidural hematomas (SSEHs), depending on the lesion size and myeloradicular involvement, can be surgical or conservative. Here, we present a 55-year-old patient who sustained a SSEH several months following a systemic SARS-CoV-2 infection.
Case Description: A 55-year-old immunocompromised female (i.e., history 17 years ago of Hodgkin’s lymphoma, nodular sclerosis variant) recently developed a SARS-CoV-2 infection treated with nonsteroidal anti-inflammatory agents. She then reported the sudden onset of cervicodorsalgia after a slight cervical flexion/extension maneuver. The brain and cervicothoracic spine MRI studies documented a clival anterior spinal epidural hematoma with maximum spinal compression at the T1-T2 level; it also extended inferiorly to the T6 level. Two weeks later, the follow-up MRI showed a remarkable reduction in the anteroposterior diameter of the hematoma that correlated with significant neurological improvement and almost complete pain regression. She was discharged after a total 15-day hospital stay, with complete symptoms relief.
Conclusion: We present a 55-year-old chronically immunocompromised (i.e., due to the history of Hodgkin’s lymphoma) female who, following a SARS-CoV-2 infection, developed an anterior SSEH extending from the clivus to the T6 spinal level that spontaneously regressed without surgical intervention.
Keywords: COVID-19, Epidural, Hematoma, Spinal, Spontaneous
Epidural spinal hematomas have an estimated incidence of 0.1/100,000 patients/year. Most occur in the second and seventh decades, due to hematological, infectious, neoplastic conditions, or the use of anticoagulants. They are more frequently seen in the posterior vertebral canal and can be spontaneous or secondary (e.g., traumatic and iatrogenic) in origin. Treatment of spontaneous spinal epidural hematomas (SSEHs) can be surgical or conservative, depending on the lesion size and neurological deficit (i.e., myeloradicular involvement). The COVID-19 infection may result in severe thromboembolisms, cardiovascular/cerebrovascular accidents, or hemorrhagic complications occurring even months following active infections. Here, we report a 55-year-old chronically immunocompromised female who, following a recent COVID-19 infection, spontaneously developed a SSEH extending from the clivus to T6 which spontaneous resolved on successive MR studies without the need for surgery.
History and neurological examination
A 55-year-old female had a history of Hodgkin’s lymphoma (nodular sclerosis variant CD15− and CD30+) diagnosed 17 years earlier based on a left hypertrophic/confluent supraclavicular lymph nodes biopsy. She had 4 cycles of chemotherapy (ABVD scheme) and supraclavicular lymph nodes excision. The subsequent repeated PET studies were negative (i.e., without radiopharmaceutical captures).
Recent COVID-19 infection
She recently had a paucisymptomatic SARS-CoV-2 infection treated with nonsteroidal anti-inflammatory agents (NSAIDs). She reported the sudden onset of cervicodorsalgia after a routine cervical flexion/extension maneuver. The pain increased despite the administration of NSAIDs (VAS score 7/10), and she remained neurologically intact. Her laboratory studies, however, demonstrated an elevated white blood cell count, a low mean platelet volume, and elevated erythrocyte sedimentation rate [
The patient underwent brain, cervical, and thoracic spine MR studies that documented a clival through T6 anterior spinal epidural hematoma. There was a high signal in the cord opposite the T1-T2 level of maximum compression. Further, T1-weighted Gd-enhanced MRI sequences confirmed peripheral epidural and meningeal contrast enhancement consistent with the diagnosis of a SSEH [
Sagittal (a), axial (b) T1-weighted cervicothoracic spine MRI images and axial brain MRI (c) documented an anterior spinal cervicothoracic and clival epidural hyperintensity and hypointensity in sagittal (d) and axial (e) T2-weighted sequences with maximum spinal compression at Th1-Th2 level and extension to Th6. T1-weighted Gd-enhanced MRI sequences (f) also showed a peripheral epidural and meningeal contrast enhancement.
The patient underwent a multidisciplinary assessment that required serial MR/other imaging and hematological evaluations. Notably, the cervico/thoracic spine MRI repeated 14 days later showed a progressive SSEH reduction; this also correlated with near-complete pain regression [
The ability to treat SSEH with/without surgery depends on their location, severity of MR-documented cord compression, and neurological deficits. Groen showed that 80% of patients with SSEH could be managed conservatively and fully recovered.[
COVID-19 hypocoagulability syndromes
Although the correlation between anticoagulant therapy (i.e., NSAIDs) and SSEH risk has long been known, it is newly documented that COVID-19 infections may lead to disseminated intravascular coagulation and/or other bleeding diatheses (MOD).[
Chronic vasculitis/hyper-hypocoagulation syndromes persist long term after COVID-19
It is likely that a vascular phlogistic processes may persist even after regression of COVID-19. The malacia of post-COVID vasculitis would be an essential prerequisite to explain the subsequent SSEH in this patient.
Two pathogenic hypotheses leading to SSEH
There are two enteropathogenic hypotheses attributed to COVID-19 that could have led to the SSEH in this patient. The first related to increasing in intrathoracic pressure, the second to microtrauma between vessels – pathological structures (i.e., spondylosis-osteophytes or hypertrophic posterior longitudinal ligament).
Evolution of SSEH
Slow progression of bleeding with SSEH is mostly of venous origin, although there are cases of rapid progression as reported by Liao et al.[
The authors described a peculiar case of a 55-year-old female with a recent COVID-19 infection, and a likely persistent postinfection vasculitis that developed an extensive spontaneous anterior clivus-T6 SSEH, spontaneously resolved on successive MR studies without surgery.
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