Elsevier

Surgical Neurology

Volume 59, Issue 5, May 2003, Pages 408-412
Surgical Neurology

Surgery complications
Spinal subdural hematoma: a sequela of a ruptured intracranial aneurysm?

https://doi.org/10.1016/S0090-3019(03)00016-8Get rights and content

Abstract

Background

A case of spinal subdural hematoma (SSDH) following subarachnoid hemorrhage (SAH) because of a ruptured internal carotid aneurysm is described. Such a case has never been reported.

Case description

A 52-year-old woman underwent a craniotomy for a ruptured internal carotid aneurysm. A computed tomography scan showed that SAH existed predominantly in the posterior fossa and subdural hematoma beneath the cerebellar tentorium. Intrathecal administration of urokinase, IV administration of fasudil hydrochloride, and continuous cerebrospinal fluid (CSF) evacuation via cisternal drainage were performed as prophylactic treatments for vasospasm. On the sixth postoperative day, the patient complained of severe lower back and buttock pain. Magnetic resonance imaging showed a subdural hematoma in the lumbosacral region. Although the mass effect was extensive, the patient showed no neurologic symptoms other than the sciatica. She was treated conservatively. The hematoma dissolved gradually and had diminished completely 15 weeks later. Her pain gradually subsided, and she was discharged 7 weeks later without any neurologic deficit.

Conclusion

Although the exact mechanism of SSDH in this case is unclear, we speculate that this SSDH was a hematoma that migrated from the intracranial subdural space. Low CSF pressure because of continuous drainage and intrathecal thrombolytic therapy may have played an important role in the migration of the hematoma through the spinal canal. It is important to recognize the SSDH as a possible complication of the SAH accompanied with intracranial subdural hematoma.

Section snippets

Case report

A 52-year-old woman presented with left oculomotor nerve palsy and subarachnoid hemorrhage (SAH) because of the rupture of a left internal carotid artery aneurysm. Preoperative computed tomography (CT) showed SAH predominantly in the prepontine cistern and subdural hematoma beneath the cerebellar tentorium. However, SAH was not prominent in the supratentorial region, such as the basal cistern or Sylvian fissures (Figure 1). The patient underwent left temporo-parietal craniotomy and clipping of

The location of the spinal hematoma

We considered that the exact location of the spinal hematoma in our case was not the subarachnoid space but the subdural extra-arachnoid space for the following reasons: (1) Axial T2-weighted MR images showed that the hematoma was located between the high signal intensity of the triangle-shaped epidural fat tissue and the CSF [1]; (2) it took more than a month for the hematoma to diminish completely. If the hematoma were located in the subarachnoid space, the diminution would be more rapid.

The pathogenesis of SSDH

Conclusion

Spinal subdural hematoma is rare. However, it must be considered a possible sequela of a ruptured intracranial aneurysm when the patient shows neurologic symptoms related to the spinal cord or roots. When intracranial subdural hematoma is present in the pre- and postoperative CT images, intrathecal thrombolytic therapy should be performed with great care.

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