Reactions 1704, p151 - 2 Jun 2018 Spontaneous retroclival subdural haematoma: case report A 72-year-old woman developed spontaneous retroclival subdural hematoma during treatment with enoxaparin sodium [Lovenox] and warfarin [Coumadin; routes and dosages not stated] for deep vein thrombosis (DVT) in the leg. The woman, who had a history of residual left hemiparesis and right frontoparietal stroke, presented to the emergency department with one-day history of confusion and headache. One month prior to the presentation, she was diagnosed with DVT in the leg and had been started on enoxaparin sodium and warfarin. On presentation, an axial noncontrast CT scan of head was subsequently performed and revealed an area of of extra-axial hyperdensity marginating the clivus and extending from the most inferiorly visualised aspect of the anterior foramen magnum cephalad towards the left and right cerebellopontine angle cisterns. A suspected diagnosis of spontaneous retroclival subdural haematoma was made. An extra-axial hypercellular mass, like plasmacytoma, lymphoma or meningioma was less likely considered. Thereafter, a CT angiogram of the neck and head was performed to rule out any regional vascular anomalies, such as an occult arteriovenous malformation or dissection, as well as to assess for any abnormal regional enhancement. The CT angiogram revealed no evidence of an underlying enhancing mass or regional aberrant vessels. Elevation and dorsal displacement of the distal V4 vertebral artery segments and the basilar artery was observed. The woman was started on anticoagulation reversal therapy with vitamin K and fresh frozen plasma in the emergency department. Subsequently, she was admitted for observation and supportive care. At that time, an MRI of the cervical spine and brain revealed the hematoma to have predominantly low signal on T2 FSE images and high signal on T1. These findings were consistent with intracellular methaemoglobin. There was dissection from the superior aspect of the clivus distally through the anterior foramen magnum into the ventral spinal canal. The haematoma was noted to overlay an intact, otherwise unremarkable tectorial membrane and to extend distal to the membrane attachment at the dorsal mid C2 vertebral body, consistent with a subdural location. Finally, a four vessel cerebral angiogram was performed to rule out any small contributory distal vertebral aneurysms and was found negative. During 10-day hospitalisation, temporal evolution and progressive resolution of haemorrhage was noted upon a follow-up CT scan. Ten days after uneventful hospital course, she was shifted back to the skilled nursing care facility. She was started on SC heparin for DVT prophylaxis. She was scheduled for an outpatient appointment with the neurosurgery clinic. Author comment: "Retroclival subdural hematomas are overall less common than epidural hemorrhage at this location and occur more often in the adult population. Overall they represent only 0.3% of acute subdurals. Though trauma may be an inciting factor, other etiologies reported have included hemophilia or iatrogenic anticoagulation, pituitary apoplexy, ruptured AVM, and decompressive craniectomy." Sever A, et al. Spontaneous retroclival subdural hematoma associated with anticoagulation. Applied Radiology 46: 38-41, No. 3, Mar 2017 - USA 803323002 0114-9954/18/1704-0001/$14.95 Adis © 2018 Springer International Publishing AG. All rights reserved Reactions 2 Jun 2018 No. 1704
Reactions Weekly – Springer Journals
Published: Jun 2, 2018
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