Pre-operative embolisation of vertebral metastases has been known to effectively devascularise hypervascular vertebral tumours and to reduce intra-operative bleeding. However, the complications that occur during the procedure are rarely reported. This case study attempts to highlight one rare complication, which is epidural tumoural haemorrhage intra-procedure. It may occur due to the fragility of the tumour and presence of neovascularisation. A small arterial dissection may also have occurred due to a slightly higher pressure exerted during injection of embolising agent. Haemostasis was secured via injection of Histoacryl into the area of haemorrhage. The patient was able to undergo the decompression surgery and suffered no direct complication from the haemorrhage.
We report a case of a young man who presented with proptosis as a delayed manifestation of a frontal extradural haematoma (EDH) following a minor head injury. A computed tomography (CT) of the brain done 72 hours after trauma revealed a large extradural haematoma in the right anterior cranial fossa with orbital roof fracture and subperiosteal clot extension into the orbital cavity. Right frontal craniotomy with evacuation of haematoma was done and the proptosis completely resolved after surgery. The clinical course, possible mechanism and management of the patient are discussed.
Between January 1982 and December 1989, 12 patients with 13 acute extradural haematomas as a result of injury involving the venous sinuses were treated by the first author. The CT scan appearances in 6 cases were remarkable in that there were large bubbles of low density in the hyperdense haematomas and liquid blood was found during the operation. The possible underlying pathophysiological changes that gave rise to this appearance are discussed. The CT scan appearance and the proximity of the clot to the venous sinuses should alert the neurosurgeon to the high probabilities of venous sinus tear such that proper treatment can be offered.
Delayed post-operative spinal epidural haematoma (DPSEH) is diagnosed when the onset of symptoms is more than three days from the index surgery. DPSEH is a rare but serious complication of spinal surgery. Missed diagnosis will result in irreversible neurological deficit which may lead to permanent disabilities. We report two cases of DPSEH who presented with worsening neurological deficit four days after the index surgery. Magnetic resonance imaging (MRI) showed the presence of an epidural haematoma compressing the spinal cord. Surgical evacuation of haematoma were performed for both patients. Both patients experienced neurological improvement. Surgeons should have high index of suspicion to identify delayed onset of spinal epidural haematoma (SEH) and timely intervention should be taken to avoid irreversible neurological damage.
Warfarin is an anticoagulant that is commonly used as thrombo-prophylaxis in patients at risk of thrombo-embolic events. However, the use of warfarin is known to cause hemorrhage due to its anticoagulation effect. Although the common sites of hemorrhage are gastrointestinal and genitourinary tract, it can also occur in the least expected location. We report a rare case of spinal cord compression secondary to intraspinal epidural hematoma as a result of overwarfarinization in a patient who had undergone liver transplant. The patient underwent emergency decompression laminectomy of spinal cord and hematoma evacuation after the reversal of overwarfarinization to normal levels.
This case reports a patient who developed central retinal artery occlusion following spinal surgery in the prone position. When placed in this position, especially as a result of malposition of the head, the patient may develop external compression of the eye which leads to central retinal artery occlusion. Therefore, a special precaution must be given for adequate eye protection during prolonged prone-positioned spine surgery.
Combined factor V and VIII deficiency is a rare bleeding disorder. Diagnosis of congenital coagulation factor deficiency in a neonate is challenging due to "immaturity" of the hemostatic system. A 2-day-old baby girl presented with spontaneous cephalhematoma. She was found to have persistent abnormal coagulation tests and finally diagnosed as combined factor V and VIII deficiency. Interestingly, factor V and factor VIII in developmental hemostasis are quite similar with adult levels in newborn, and hence early diagnosis is possible. An investigation to detect underlying hemostatic defects is recommended in newborns with spontaneous cephalhematoma.
A total of 76 patients with traumatic extradural haematoma were treated within a period of 3 years. Four patients developed delayed extradural haematomas. These cases are reported in view of the unusual sequence and the importance of early diagnosis.
Full recovery from tetraplegia is uncommon in cervical spine injury. This has not being reported for cervical spine fracture in a patient with ankylosing spondylitis causing spinal epidural hematoma. We report on a case of cervical spine fracture in a patient with ankylosing spondylitis who came with tetraplegia. He underwent a two stage fixation and fusion. He had a complete recovery. Two hours after the operation he regained full strength in all the limbs while in the Intensive Care Unit. He went back to full employment. There are only two other reports in the literature where patients with ankylosing spondylitis and extradural hematoma who underwent treatment within 12 h and recovered completely from tetraparesis and paraplegia respectively. Patient with ankylosing spondylitis has a higher incidence of spinal fracture and extradural hematoma. Good outcome can be achieved by early diagnosis and treatment. This can ensure not only a stable spine, but also a rapid and complete recovery in a tetraplegic patient.
Spontaneous spinal epidural hematoma is a rare condition defined by bleeding in the epidural space of the spine with no identifiable causes such as trauma, vascular malformation, or bleeding disorders. This is a case of a 79-year-old woman with a medical history of diabetes mellitus, dyslipidemia, and hypertension presented with the sudden onset of severe thoracolumbar back pain associated with weakness and numbness in her bilateral lower limb. Examination of the lower limb showed bilateral lower limb motor and sensory deficits. Laboratory investigations showed normal results. MRI showed posterior extradural intraspinal hematoma from T11 to L3 vertebrae. Patient underwent right hemilaminectomy and posterior decompression of T12 and L1 vertebrae to evacuate the hematoma. Postoperatively, her neurologic complications improved gradually. Decision was made not to restart aspirin. On follow-up at 1 year, the patient had complete recovery of neurologic complications of both lower limb and had no recurrence of bleeding. In short, this is a case of spontaneous spinal epidural hematoma associated with long-term use of low-dose aspirin in an elderly patient requiring surgical evacuation of hematoma with good functional outcome after the surgery. Therefore, aspirin should be prescribed cautiously especially to elderly patients.
The use of thrombolytic agent e.g. streptokinase is indicated in patients with early acute ST elevation myocardial infarction (MI) (if there are no contraindications) is becoming increasingly routine. Its use is however significantly limited by bleeding complications. Spinal epidural haematoma (SEH) is haemorrhage in the spinal epidural space after spinal anaesthesia. SEH may be acute or chronic, spontaneous, posttraumatic, or iatrogenic but its occurrence appears to be particularly associated with acquired coagulopathy from medications and disease states. Patients usually present with acute axial spine pain and evolving focal neurological deficits. With increasing number of available anticoagulants and patient receiving them, anaesthesiologists today have to face the challenge of balancing between risks and benefits of regional anesthesia in patients under such medications. The treatment of this condition involves the principles of conservative follow-up directed by an improving examination and an understanding of the pathophysiology of coagulopathy-induced spontaneous epidural bleeds. When the diagnosis is accomplished rapidly, surgical decompression can result in full functional recovery.