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Neurology > Neurological Emergencies
Spinal Cord Hemorrhage
Article Last Updated: Sep 12, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Richard M Zweifler, MD, Professor, Director of Stroke Center, Director of Neurosonology Lab, Director of Vascular Neurology Fellowship, Director of Medical Student Education, Department of Neurology, University of South Alabama
Richard M Zweifler is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Medical Association, American Society of Neuroimaging, American Stroke Association, Medical Association of the State of Alabama, National Stroke Association, Royal Society of Medicine, Society of Neurosurgical Anesthesia and Critical Care, and Stroke Council of the American Heart Association
Editors: Rodrigo O Kuljis, MD, Esther Lichtenstein Professor of Psychiatry and Neurology, Director, Division of Cognitive and Behavioral Neurology, Department of Neurology, University of Miami School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Howard S Kirshner, MD, Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center; Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital; Helmi L Lutsep, MD, Associate Professor, Department of Neurology, Oregon Health and Science University; Associate Director, Oregon Stroke Center
Author and Editor Disclosure
Synonyms and related keywords:
hematomyelia, spinal subarachnoid hemorrhage, SAH, spinal epidural hemorrhage, EDH, subdural hemorrhage, SDH, subarachnoid space, bleeding in the spinal cord, intramedullary hemorrhage, spinal angioma
Background
Hemorrhage affecting the spinal cord is rare. It most commonly is caused by trauma, vascular malformations, or bleeding diatheses and can be intramedullary, subarachnoid, subdural, or epidural. Onset is usually sudden and painful, causing myelopathic signs and symptoms.
Pathophysiology
Hematomyelia is caused by bleeding within the substance of the spinal cord. The blood tends to dissect longitudinally above and below the hemorrhage, disrupting gray matter more than white matter. Spinal subarachnoid hemorrhage (SAH) may cause symptoms due to blood in the subarachnoid space or blood dissecting into the spinal cord or along nerve root sheaths. Spinal epidural hemorrhage (EDH) and subdural hemorrhage (SDH) cause compressive symptoms due to hematomas in these spaces.
Frequency
United States
Hemorrhage affecting the spinal cord is rare. Spinal SAH accounts for less than 1% of all SAHs. Spinal EDH occurs at least 4 times more commonly than spinal SDH.
Mortality/Morbidity
Spinal hemorrhage can lead to irreversible myelopathy (including conus medullaris and cauda equina syndromes) and/or radiculopathy.
Sex
The incidence of hematomyelia, spinal SAH, and spinal EDH is higher in males than in females. Spinal SDH is more common in women (female-to-male ratio is 2:1).
Age
Spinal EDH has a bimodal distribution, with peaks during childhood and the fifth and sixth decades of life. Spinal EDH is most common in the cervical region in children and in the thoracic and lumbar regions in adults. Spinal SDH predominates in the sixth decade.
History
- Intramedullary hemorrhage
- Sudden, severe, localized back pain with or without radicular pain
- Hemiparesis, paraparesis, or quadriparesis
- Sensory loss below the lesion
- Loss of sphincter control
- Spinal SAH
- Sudden, severe, localized back pain with or without radicular pain
- Headache
- Meningismus
- Spinal EDH and spinal SDH
- Sudden, severe, localized back pain with or without radicular pain
- Hemiparesis, paraparesis, or quadriparesis
- Sensory loss below lesion
- Loss of sphincter control
Physical
- Intramedullary hemorrhage - Myelopathy (eg, Brown-Séquard syndrome, central cord syndrome, transection syndrome, conus medullaris syndrome) with or without radiculopathy
- Spinal SAH
- Myelopathy (eg, Brown-Séquard syndrome, transection syndrome, conus medullaris syndrome, cauda equina syndrome) with or without radiculopathy
- Cranial neuropathies
- Papilledema
- May have cutaneous angioma or bruit over the spine
- Spinal EDH and spinal SDH - Myelopathy (eg, Brown-Séquard syndrome, transection syndrome, conus medullaris syndrome, cauda equina syndrome) with or without radiculopathy
Causes
- Intramedullary hemorrhage
- Trauma
- Vascular malformations
- Bleeding diatheses
- Anticoagulants
- Hemorrhage into tumor
- Venous infarction
- Spinal SAH
- Spinal angioma
- Spinal artery aneurysm
- Intracranial aneurysm
- Bleeding diatheses
- Anticoagulants
- Polyarteritis nodosa
- Hemorrhage into tumor
- Trauma
- Lumbar puncture
- Spinal EDH
- Spontaneous
- Trauma
- Liver disease with portal hypertension
- Bleeding diatheses
- Lumbar puncture
- Epidural anesthesia
- Epidural vascular malformation
- Spinal SDH
- Bleeding diatheses
- Anticoagulants
- Trauma
- Lumbar puncture
- Vascular malformations
- Spinal surgery
- Spontaneous
Arteriovenous Malformations
Blood Dyscrasias and Stroke
Cauda Equina and Conus Medullaris Syndromes
Cerebral Aneurysms
Ependymoma
Epidural Hematoma
Lumbar Puncture (CSF Examination)
Polyarteritis Nodosa
Spinal Cord Infarction
Spinal Epidural Abscess
Subarachnoid Hemorrhage
Subdural Hematoma
Syringomyelia
Other Problems to be Considered
Spinal injury
Spinal cord tumors
Cervical disk syndromes
Lumbosacral disk syndromes
Posttraumatic pain syndromes
Back pain
Lab Studies
- CBC count with platelets
- Prothrombin time/activated partial thromboplastin time - To exclude coagulopathy
Imaging Studies
- Spinal MRI
- Preferred test to confirm presence and delineate location of hemorrhage (see Image 1)
- May indicate underlying pathology
- CT myelography - Use when MRI is unavailable or if patient cannot tolerate MRI
Procedures
- Lumbar puncture: Cerebrospinal fluid (CSF) is usually bloody or xanthochromic and protein content is increased.
- Spinal angiography: Selective spinal angiography may be helpful in delineating the size, location, configuration, and blood flow of a malformation.
Medical Care
Medical therapies for spinal cord hemorrhage are limited.
- If the bleed is caused by a coagulopathy, reversal of the bleeding tendency is crucial. Examples include fresh frozen plasma and vitamin K for warfarin-induced bleeds, protamine sulfate for heparin-induced bleeds, platelet transfusions for thrombocytopenia, specific clotting factor concentrates or fresh frozen plasma for clotting factor deficiencies such as hemophilia and Christmas disease.
- Another potential medical treatment, drug therapy for cord edema, is unproved.
Surgical Care
- Depending on etiology, surgery may be indicated for hematomyelia.
- In general, surgery should be performed in spinal SDH and EDH.
- Treatment of spinal SAH consists of bed rest and surgical resection of extramedullary angiomas, when present.
- Spinal angiomas also can be approached by catheter-based interventional techniques, such as embolization or coiling.
- Focal radiation therapy, as in the gamma knife or cold photon knife, is also a consideration with spinal arteriovenous malformations.
Consultations
- Neurosurgeon
- Interventional neuroradiologist
- Radiation oncologist
- Hematologist
- Rehabilitation physician (physical medicine and rehabilitation, neurology)
The goal of pharmacotherapy is to inhibit the effect of anticoagulants in patients taking such medications. Attempts to treat spinal cord swelling (edema) with mannitol or corticosteroids have not been tested in randomized, double-blind studies. If spinal cord trauma can be taken as a situation similar to cord compression, high-dose corticosteroids may be beneficial.
Drug Category: Antidotes (blood modifiers)
Anticoagulated patients may require a blood modifier.
| Drug Name | Protamine sulfate |
|---|
| Description | Neutralizes heparin effects by forming a salt. |
|---|
| Adult Dose | Dose administered depends upon duration of time since heparin administration
Immediately: Administer 1-1.5 mg/100 U of heparin
30-60 min: Administer 0.5-0.75 mg/100 U of heparin
Over 2 h: Administer 0.25-0.375 mg/100 U of heparin
If heparin was administered by deep SC injection, give 1-1.5 mg protamine/100 U of heparin; do not exceed 50 mg IV over 10 min |
|---|
| Pediatric Dose | Not established |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | IV administration physically incompatible with certain antibiotics, including several cephalosporins and penicillins |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Heparin rebound associated with anticoagulation and bleeding may occur |
|---|
| Drug Name | Phytonadione (AquaMEPHYTON, Mephyton, Vitamin K) |
|---|
| Description | Promotes liver synthesis of clotting factors that in turn inhibit warfarin effects. |
|---|
| Adult Dose | 2.5-10 mg/dose SC or IM (rarely, 25-50 mg may be required); repeat after 6-8 h if PT has not normalized |
|---|
| Pediatric Dose | 1-2 mg/dose IM/SC; repeat after 6-8h if PT has not normalized |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | Antagonizes effects of warfarin sodium and dicumarol |
|---|
| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Monitor PT closely |
|---|
Further Inpatient Care
- Once the patient with spinal cord hemorrhage has been treated, whether medically, via interventional radiology, or surgery, rehabilitation can begin. Usually this is accomplished in an inpatient rehabilitation setting.
Further Outpatient Care
- After the patient is discharged from inpatient care, outpatient therapies continue. Medical treatments are frequently necessary for the late complications of spinal cord hemorrhage, especially spasticity, pain, and neurogenic bladder.
In/Out Patient Meds
- Spasticity secondary to spinal cord hemorrhage is treated in similar ways to spasticity secondary to spinal cord injury or multiple sclerosis. Drugs include baclofen, tizanidine, and diazepam.
- Pain following spinal cord hemorrhage, other than pain directly secondary to spasticity, is treated similarly to neuropathic pain syndromes such as those in multiple sclerosis. Drugs include gabapentin, amitriptyline, and carbamazepine.
- Bladder complications of spinal cord hemorrhage are similar to those of spinal cord injury or multiple sclerosis. Consultation with a urologist may be necessary. Drug therapy with anticholinergic agents may be beneficial for reflex uninhibited bladder (ie, failure to store), and intermittent self-catheterization is essential in patients with inability to void (ie, failure to empty).
Deterrence/Prevention
- Avoid lumbar puncture in patients with hematologic disorders or in those treated with prescribed anticoagulants.
Prognosis
- Prognosis varies but generally is correlated with severity of deficit. A more favorable outcome is seen in patients receiving prompt diagnosis and surgical intervention.
Medical/Legal Pitfalls
- Delays in diagnosis and/or surgical intervention
- Failing to correct treatable coagulopathies
| Media file 1:
T2-weighted sagittal MRI of the cervical spine shows mixed signal intensity within the spinal cord consistent with posttraumatic intramedullary hemorrhage. The hypointensity reflects deoxyhemoglobin and the hyperintensity reflects either early hemorrhage or edema. The C6 vertebral body is distracted from C7 with extensive ligamentous injury. Courtesy of Francis G. Greiner, MD, Department of Radiology, University of South Alabama College of Medicine. |
 |  View Full Size Image | |
Media type: MRI
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- Aminoff MJ. Vascular disorders of the spinal cord. In: Davidoff RA, ed. Handbook of the Spinal Cord. New York: Marcel Dekker;1987:259-97.
- Barth A, Bougousslavsky J, Caplan LR. Spinal stroke syndromes. In: Barth A, Caplan LR, eds. Stroke Syndromes. New York: Cambridge University;1995:395-402.
- Geldmacher DS, Bowen BC. Spinal cord vascular disease. In: Bradley WG, Daroff RB, Fenichel GM, Marsden CD, eds. Neurology in Clinical Practice Principles of Diagnosis and Management. 4th ed. Philadelphia, Pa:. Butterworth-Heimann;2004: 1313-22.
- Karavelis A, Foroglou G, Petsanas A, Zarampoukas T. Spinal cord dysfunction caused by non-traumatic hematomyelia. Spinal Cord. May 1996;34(5):268-71. [Medline].
- Russell NA, Benoit BG. Spinal subdural hematoma. A review. Surg Neurol. Aug 1983;20(2):133-7. [Medline].
- Toole JF. Spinal cord vascular anatomy and diseases. In: Toole JF, ed. Cerebrovascular Disorders. 4th ed. Baltimore, Md: Lippincott Williams & Wilkins; 1990:. 519-34.
- Weisberg LA. Vascular diseases of the spinal cord. In: Rowland LP, ed. Merritt's Textbook of Neurology. 10th ed. Baltimore, Md: Lippincott Williams & Wilkins; 2001:. 271.
Spinal Cord Hemorrhage excerpt Article Last Updated: Sep 12, 2006
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