April 25, 2016
A 25-year-old woman with sudden-onset weakness of lower limbs, urinary incontinence, and sensory disturbance from the nipple line downward, 8 hours after normal vaginal delivery
Spontaneous Spinal Epidural Hematoma (SSEH) in the Postpartum Period
- Background:
- Among the recognized conditions that could predispose one to SSEH, pregnancy accounts for 1%, and others include anticoagulant therapy, vascular malformations, hemophilia, and vasculitis.
- SSEH in pregnancy or the postpartum period is believed to be associated with rupture of primitive valveless epidural veins owing to elevated thoracic, abdominal, and pelvic pressure during or after pregnancy. Hyperdynamic circulation after uterine contraction, hormonal effects on vessels, and hypercoagulable state are also among the proposed factors.
- Clinical Presentation:
- Sudden-onset pain in the chest-back region, limb weakness and sensation disturbance, paraplegia, urinary retention, or Brown-Sequard syndrome
- Key Diagnostic Features:
- CT: Crescenteric high-intensity mass within the spinal epidural space
- MRI: Acute stage — isointensity on T1WI and slight hyperintensity on T2WI with heterogeneous patchy hypointensity. Hyperintensity on both T1WI and TWI2 can be seen in the subacute stage. Peripheral enhancement of the hematoma is thought to be related to peripheral blood supply and hyperemia. The absence of flow-voids within or surrounding the lesion may help to exclude an underlying arteriovenous malformation, which can be further confirmed by angiography.
- Differential Diagnosis:
- Spinal arteriovenous malformation
- Spinal subdural hematoma
- Epidural abscess
- Metastases or lymphoma
- Treatment:
- A decompressive laminectomy and evacuation of hematoma is crucial for SSEH in the presence of neurologic deficit or acute-onset severe symptoms and signs.
