Case Report
Brown-Séquard syndrome and cervical post-traumatic subarachnoid hematoma
Síndrome de Brown-Séquard y hematoma subaracnoideo espinal cervical postraumático
Fernando Rascón-Ramírez
, Josué M. Avecillas-Chasín, Albert Trondin, Javier Arredondo Montero
Autor para correspondencia
Department of Neurosurgery, San Carlos University Hospital, Madrid, Spain
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Avecillas-Chasín, Albert Trondin, Javier Arredondo Montero" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Fernando" "apellidos" => "Rascón-Ramírez" "email" => array:1 [ 0 => "ferrascon@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Josué M." "apellidos" => "Avecillas-Chasín" ] 2 => array:2 [ "nombre" => "Albert" "apellidos" => "Trondin" ] 3 => array:2 [ "nombre" => "Javier" "apellidos" => "Arredondo Montero" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Neurosurgery, San Carlos University Hospital, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de Brown-Séquard y hematoma subaracnoideo espinal cervical postraumático" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1677 "Ancho" => 2913 "Tamanyo" => 406200 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Radiological imaging of cervical subarachnoid hematoma. Cervical CT. A big acute cervical spinal hematoma, probably epidural type. (1.A) and (1.B.) Arrowhead: C3–C5 cervical hematoma. (3.C), (4.D), (5.E), (6.F) Arrow: right anterolateral hematoma.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Spinal subarachnoid hematoma (SSH) is commonly caused by lumbar puncture (44.9%) followed by coagulopathy (40.5%) and trauma (15.9%). It can occur in isolation or in combination with subdural hematoma. The most affected segment is the thoraco-lumbar junction (D10-L3, 50%). The most common location is dorsal 60%, ventral 26% and lateral 8.9%.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–4</span></a> The MRI is able to depict useful information regarding the topography of the hemorrhage and the spinal cord involvement. However, CT remains useful when MRI is contraindicated. In an extensive review published by Domenicucci of a total of 69 cases of SSH, only 12 occurred in the cervical region, 4 of these cases were localized in the ventral region, and none of the cervical cases were caused by traumatic injuries. Here, we report a unique case of a ventrolateral SSH due to mild traumatic brain injury (TBI).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">An 83-year-old woman with a previous history of atrial fibrillation treated with acenocumarol, and an implanted cardiac pacemaker (not compatible with MRI), was admitted after suffering a 4–5 stairs fall. The patient presented right hemiparesis 3/5, predominantly in right forelimb (RFL), 1/5 distal paresis of the flexor carpi and fingers extension, loss of proprioception and vibration in the right hemi body. She also presented loss of pain and temperature sensitivity in the left hemi body, without autonomic involvement (Brown-Séquard syndrome). Cranial CT: showed a minimal subarachnoid hemorrhage in the left insula. No other brain lesions were detected. Cervical CT: showed an extensive right C3–C5 ventrolateral cervical hematoma (Possibly epidural), and severe acute spinal cord compression (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In the presence of recent trauma, in an anticoagulated patient, the rapid progression of symptoms, the results shown in the cervical CT and the impossibility of performing MRI; We decided that the origin of the lesion was most likely of traumatic origin (hematoma) and to operate it urgently was the priority. No CT angiography was performed. The patient underwent emergent surgical decompression with a posterior cervical approach. A C4–C5 hemi laminectomy was done with dural opening. Careful mobilization of the spinal cord with micro dissection was performed and the right ventrolateral subarachnoid hematoma was evacuated (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The postoperative CT scan shows more than 95% of the hematoma evacuated and absence of spinal cord compression (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). After the first 24<span class="elsevierStyleHsp" style=""></span>h, the patient partially recovered RFL strength. The patient was finally discharge to a rehabilitation center with a good neurological condition, being able to walk after a month and slight distal paresis (4+/5) in RFL.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">To our knowledge this is the first case reported of a ventrally located traumatic subarachnoid hematoma in the cervical region. In this report, we demonstrate the feasibility of a very common approach (posterior hemilaminectomy) for a very rare condition with a good outcome. The most challenging feature of this case is the lack of a precise anatomy showed by the CT scan due to a contraindication of the MRI. In this sense, the clinical presentation (right Brown-Sèquard syndrome) plus the information given by the CT scan were useful in determining the side for the approach. Spinal subarachnoid hematomas (SSH) are rare lesions, and their origin is unknown. Some cervical subarachnoid hematomas may be the result of the caudal migration of cranial hematomas and in more rare cases they are presented in isolation as in this case.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> We think that the TBI resulted in a sudden cervical flexion-extension movement with the subsequent rupture of vessels crossing the subarachnoid space. This, associated with anticoagulation and osteoarthritic changes may cause a blood “wash out” difficulty along the subarachnoid space, which results in an organized hematoma in subarachnoid space that produces acute spinal cord compression.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> The cervical location is very rare and especially at ventral or ventrolateral position. The majority of cases reported in this location were not caused by trauma but by cardiopulmonary diseases.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Rader et al. suggested that a sudden abdominal or chest pressure increase could cause a breakdown of the spinal vessels, which would explain why cardiopulmonary diseases have been historically the most common causes of cervical SSH.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5,6</span></a> MRI scan is the best form to evaluate the type of lesion, extension, localization and spinal cord damage. The management of extramedullary hematomas could be two scenarios: in patients without neurological deficit, observation and in case of deterioration, surgical management. In patients with neurological deficit, urgent surgery is mandatory. We believe that large hematomas, even without a neurological deficit, should be treated surgically as soon as possible. The surgical approach consists of a partial hemilaminectomy with or without laminoplasty. We do not consider that the anterior approach is a reasonable option. Surgical difficulties of posterior subarachnoid hematomas can be summarized as: small spinal canal, difficulty in mobilizing the cervical cord, these hematomas are wrapped and attached to the spinal cord or nerve roots by multiple arachnoid bands, requiring techniques of Microdissection for its evacuation unlike the epidural and subdural hematomas that are easily aspirated. Neurological recovery could be satisfactory in early-intervention cases.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Cervical Traumatic SSH are very rare in literature. They are usually caused by cardiopulmonary diseases that increase vascular pressure leading to spinal vessels rupture. In TBI, an abrupt extension–flexion movement could have caused the rupture of subarachnoid vessels. This, accompanied by the slowed blood “wash out” (probably due to the previous osteoarthrosis and spinal canal stenosis), lead to the formation of an organized clot, which caused an acute spinal cord compression syndrome. The posterior approach (partial hemilaminectomy with or without laminoplasty) with microsurgical technique is feasible, fast and simple to evacuate a cervical ventrolateral hematoma with good results.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1769474" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1554882" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1769473" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1554883" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-04-26" "fechaAceptado" => "2017-09-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1554882" "palabras" => array:3 [ 0 => "Spinal cord compression" 1 => "Spinal puncture/adverse effects" 2 => "Subarachnoid hemorrhage" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1554883" "palabras" => array:3 [ 0 => "Compresión medular espinal" 1 => "Punción lumbar/efectos adversos" 2 => "Hemorragia subaracnoidea" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cervical Traumatic SSH are very rare in literature. They are usually caused by cardiopulmonary diseases that increase vascular pressure causing spinal vessels rupture.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In thoracolumbar spine, the spinal puncture is the most common cause. The ventrolateral position is even more unusual.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In traumatic brain injury (TBI), an abrupt extension–flexion movement could have caused the rupture of subarachnoid vessels. This, accompanied by the slowed blood “wash out” (probably due to the previous osteoarthrosis and spinal canal stenosis), led to the formation of an organized clot, which caused an acute spinal cord compression syndrome.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Cervical subarachnoid spinal hematoma can present as Brown-Séquard syndrome. The treatment is prompt surgical removal and decompression. The posterior approach (partial hemilaminectomy with or without laminoplasty) with microsurgical technique is feasible, fast and simple to evacuate the hematoma with good results. Surgical nuances in posterior approach are: small spinal canal, difficulty in mobilizing the cervical cord, these haematomas are wrapped and attached to the spinal cord or nerve roots by multiple arachnoid bands, requiring techniques of Microdissection for its evacuation unlike the epidural and subdural haematomas that are easily aspirated.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Here, we report a unique case of a ventrolateral SSH due to TBI.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los hematomas subaracnoideos espinales cervicales postraumáticos son muy infrecuentes en la literatura. Generalmente son causados por enfermedades cardiopulmonares que incrementan la presión vascular y producen la rotura de los vasos espinales.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En la columna toracolumbar la causa más frecuente es la punción lumbar. La posición ventrolateral dentro del canal es todavía más inusual.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En el traumatismo craneoencefálico, un movimiento súbito de flexoextensión podría causar la rotura de vasos subaracnoideos. Si lo anterior se acompaña de un «lavado» enlentecido de la sangre (probablemente debido a la presencia de osteoartrosis y estenosis de canal), podría llevar a la formación de un coágulo organizado, el cual, si es de gran tamaño, podría causar un síndrome de compresión medular aguda.</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Los hematomas subaracnoideos espinales cervicales pueden presentarse como un síndrome de Brown-Séquard. El tratamiento en caso de compresión medular aguda es la evacuación del coágulo y la descompresión del canal urgente. El abordaje posterior (hemilaminectomía parcial con o sin laminoplastia) con técnica microquirúrgica es factible, rápido y sencillo para evacuar el hematoma, con buenos resultados. Los matices quirúrgicos en el abordaje posterior son: pequeño canal espinal y dificultad para movilizar la médula cervical. Estos hematomas están envueltos y adheridos a la médula espinal o a las raíces nerviosas por múltiples bandas aracnoideas, requiriendo técnicas de microdisección para su evacuación, a diferencia de los hematomas epidurales y subdurales, que son fácilmente aspirados.</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Presentamos un caso único de un hematoma subaracnoideo espinal cervical ventrolateral debido a traumatismo craneoencefálico leve.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1677 "Ancho" => 2913 "Tamanyo" => 406200 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Radiological imaging of cervical subarachnoid hematoma. Cervical CT. A big acute cervical spinal hematoma, probably epidural type. (1.A) and (1.B.) Arrowhead: C3–C5 cervical hematoma. (3.C), (4.D), (5.E), (6.F) Arrow: right anterolateral hematoma.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2628 "Ancho" => 1583 "Tamanyo" => 301421 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Surgical removal trough posterior approach. Posterior cervical approach. (2.A) Well delineated subarachnoid hematoma (arrow) adhered to right C5 nerve root. (2.B) Piece meal resection (arrow). (2.C) Subtotal removal (arrow) due to C5 nerve root involvement (arrowhead). (*): Cervical spinal cord; C: cranial; R: right.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2315 "Ancho" => 2158 "Tamanyo" => 521192 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Postoperative CT. Postoperative CT. C4–C5 Hemi laminectomy and subtotal removal >95%. No spinal cord compression. (3.A)–(3.B): Evacuation of anterolateral hematoma (arrowhead). (3.C)–(3.D): Hemi laminectomy and subtotal removal (Arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical Article Spinal subarachnoid hematomas: our experience and literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Domenicucci" 1 => "A. Ramieri" 2 => "S. Paolini" 3 => "N. Russo" 4 => "G. Occhiogrosso" 5 => "C. 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