Spontaneous retroclival subdural hematoma in association with anticoagulation: a case report

Posted By Alysse Sever
Spontaneous retroclival subdural hematoma in association with anticoagulation: a case report

Case Report Our patient, a 72 year old female with a past history of a right frontoparietal stroke and residual left hemiparesis, presented to the emergency room with a one day history of headache and confusion. One month previously she had been diagnosed with a deep venous thrombosis in her leg and had been started on lovenox and Coumadin. There was no reported history of antecedent trauma. Review of systems, other than the residual deficits from her previous infarct, was noncontributory. A noncontrast head CT (Computed tomography) was subsequently performed and demonstrated an area of extra-axial hyperdensity marginating the clivus and extending from the most inferiorly visualized aspect of the anterior foramen magnum cephalad towards the left and right cerebellopontine angle cisterns. (figs 1, 2). A subdural hemorrhage was suspected. Less likely considerations included an extra –axial hypercellular mass such as a meningioma, lymphoma, or plasmacytoma. A CT angiogram of the head and neck was performed next to exclude any regional vascular anomalies such as an occult arteriovenous malformation or dissection as well as to assess for any abnormal regional enhancement. There was no evidence of an underlying enhancing mass or regional aberrant vessels (figs 2,3). Elevation and dorsal displacement of the distal V4 verterbral artery segements and the basilar artery was observed. Anticoagulation was reversed in the emergency room with fresh frozen plasma and vitamin K was begun; the patient was subsequently admitted for supportive care and observation. An MRI (Magnetic resonance imaging ) of the brain and cervical spine, ordered to ensure a bland nature of the hemorrhage and to completely exclude any underlying mass, demonstrated the hematoma to have predominantly low signal on T2 FSE (Fast spin echo) images and high signal on T1, consistent with intracellular methemoglobin. There was dissection from the superior aspect of the clivus distally through the anterior foramen magnum into the ventral spinal canal. The hematoma 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. (figs 5,6) As a final step in the workup, a four vessel cerebral angiogram, not shown, was done to exclude any small contributory distal vertebral aneurysms and proved negative in this regard. After an uneventful 10 day hospital course during which temporal evolution and progressive resolution of the hemorrhage was observed on a follow up CT exam, the patient was discharged back to a skilled nursing care facility. Deep venous thrombosis prophylaxis was reinitiated with subcutaneous heparin and a return appointment as an outpatient with the neurosurgery clinic was scheduled. Discussion Retroclival hematoma is an uncommon finding, typically occurring in the epidural space in pediatric patients following significant blunt trauma. There

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  • Roland Talanow 2015-11-15 14:47:00

    Dr. Sever,

    First, to comment on your last post: on the case upload page, there is a description how the process works.



    Second, please do not copy and paste the entire manuscript - that causes reader fatigue, just pertinent information and why you think this is case report worthy (e.g. extremely rare



    I am looking forward to receiving the above information to make a final decision.

    Thank you.

    Reply

  • Roland Talanow 2015-10-16 12:40:37

    Dr. Sever,

    The JRCR describes the process in the author guidelines and you should have received a notification how it works in case you already submitted the paper to the JRCR.



    Please do not submit the entire manuscript at this stage and location.



    Just a concise synopsis of your case and explain why it should be published. Uncommon findings are in general not case report worthy.

    Please explain why you think it the audience might benefit from such a case and not already reported elsewhere.

    Thank you.

    Reply

  • Alysse Sever 2015-10-06 21:55:40

    I'm going to be honest, I have no idea how this site works. How do I get invited? This is literally the most confusing submission process I have ever seen.

    Reply