Good outcomes after the delayed removal of an epidural hematoma: A case report

Medicine (Baltimore). 2018 Apr;97(14):e0341. doi: 10.1097/MD.0000000000010341.

Abstract

Rationale: Epidural hematomas can develop following intrathecal puncture, spinal vascular malformation, or spontaneous hemorrhage. Prompt recognition of symptoms and referral to neurosurgical services are crucial for recovery. We report a rare case of delayed removal of an epidural hematoma that resulted in good patient outcomes.

Patient concerns: A 69-year-old woman weighing 58 kg presented with back pain that had persisted for 12 years. Her medical history was notable for hypertension. Cervical computed tomography angiography indicated a giant abdominal aortic aneurysm measuring 11.58 × 17.34 × 13.00 cm in her abdominal cavity. Stent graft implantation was scheduled by the interventional therapy group to treat her abdominal aortic aneurysm under single-dose spinal anesthesia. Postoperatively, the patient complained of numbness and swelling of her lower extremities, with progressive paralysis developing in both legs accompanied with sensory disturbances.

Diagnoses: Delayed magnetic resonance imaging detected an epidural hematoma.

Interventions: Eighty hours after the onset of sensorimotor symptoms, lumbar decompression and removal of the hematoma were performed via laminectomy under general anesthesia.

Outcomes: The patient was discharged 2 months after the operation with a 3/5 score on the Muscle Strength Grading System.

Lessons: Laminectomy may be effective in achieving a good prognosis despite a considerable delay in diagnosis.

Publication types

  • Case Reports

MeSH terms

  • Aged
  • Anesthesia, Spinal / adverse effects*
  • Delayed Diagnosis
  • Female
  • Hematoma, Epidural, Spinal / chemically induced
  • Hematoma, Epidural, Spinal / diagnosis
  • Hematoma, Epidural, Spinal / surgery*
  • Humans
  • Laminectomy / methods*
  • Lumbar Vertebrae / surgery
  • Paralysis / chemically induced
  • Paralysis / surgery
  • Time-to-Treatment