Introduction
Intramedullary spinal cord hemorrhage (hematomyelia) is a rare disease, which could cause myelopathy. Trauma is the most common cause of hematomyelia. The most reported cause of atraumatic hematomyelia is a spinal vascular malformation. Spinal cavernoma, anticoagulation therapy, bleeding disorder, spinal tumor, and intrasyringal hemorrhage can cause hematomyelia, however, much rarer. Here, we present a rare case of cervical intramedullary spinal cord hemorrhage with unknown etiology.
Case report
A 34-year-old man visited emergency department complaining of posterior neck pain with radiating right shoulder pain and both upper and lower extremities weakness, which had started after waking up.
An initial neurologic examination revealed grade 0 motor weakness for the right upper and lower extremities, and grade II motor weakness for the left upper and lower extremities. Sensation was decreased below C4 dermatome. His anal tone and sense were absent. Deep tendon reflex in both biceps and quadraceps tendons were normoactive. Barbinski’s reflex, Hoffmann’s reflex, and ankle clonus were absent. A trauma history was denied. He did not take any medication. He had no known disease such as hypertension, bleeding disorders and other central nervous system disorder. Laboratory tests showed no abnormal findings. Cervical spine magnetic resonance imaging with gadolinium injection revealed about 3cm sized, ill-defined enhancing mass in right side of spinal cord at C2-3 level, combined surrounding edema and hemorrhage at C1-5 level. (figure 1)
Mannitol and steroid were injected at initial emergency department. Intramedullary mass removal, C2 total laminectomy and C3-4-5 laminoplasty were performed. On spinal cord inspection, no abnormal findings, such as abnormal vessels, were found. Dark ovoid mass was removed at C2-3 level and sent for histopathological examination. The pathology report confirmed the mass was hematoma. A rehabilitation program including physical and occupational therapy was started after surgery.
On the 5th postoperative week, a neurological examination revealed increased motor strength on all extremities compared to initial examination, grade II to III on right elbow and wrist and grade IV on left upper and both lower extremities. However, grade I was shown in right flexors and abductors of shoulder. Light touch and pinprick sensations were decreased below C2 dermatome. His anal tone and sense were recovered, however, he was unable to void himself after removed the indwelling urinary catheter. Clean intermittent catheterization was performed at the appropriate time intervals.
Discussion
Hematomyelia is rare and usually related to trauma or spinal vascular malformation. We presented a rare case of cervical hematomyelia without any trauma history or underlying disease.
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Figure 1. Cervical MRI images at the day that symptom onset. a. T1 weighted sagittal image, b. T2 weighted sagittal image, c. Enhanced T1 weighted sagittal image, d. T2 weighted axial image. Yellow arrow indicates ill-defined enhancing intramedullary mass, Red arrowheads indicates edema and hemorrhage at C1-C5 level.
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