- Case report
- Open Access
- Open Peer Review
Spontaneous spinal subarachnoid hemorrhage after severe coughing: a case report
© Oji et al.; licensee BioMed Central Ltd. 2013
- Received: 8 May 2013
- Accepted: 1 October 2013
- Published: 23 December 2013
Spinal subarachnoid hemorrhage has many causes including trauma, vascular malformations, aneurysms, spinal cord tumors, coagulation abnormalities, use of anticoagulants, systemic lupus erythematosus, or Behçet’s disease. We report on a rare case of a spontaneous spinal subarachnoid hemorrhage after severe coughing of unknown origin. To the best of our knowledge, this is the first report of spontaneous spinal subarachnoid hemorrhage after severe coughing.
A 66-year-old Japanese woman initially complained of headache with severe back pain after severe coughing. She was referred to our neurology department 6 days after her first visit to our hospital. No neurological deficits were revealed except for meningism. Computed tomography of her head revealed no abnormality. A lumbar puncture showed bloody cerebrospinal fluid with xanthochromia. Cerebral angiography revealed no abnormality. Magnetic resonance imaging of her lumbar spine revealed subarachnoid hemorrhage. Spinal angiography revealed no abnormality. The diagnosis of spontaneous spinal subarachnoid hemorrhage was made. She recovered with conservative treatment and her neurological status was normal 2 years after the onset.
Spontaneous spinal subarachnoid hemorrhage could be caused by rapid changes in intrathoracic and intra-abdominal pressure. Spontaneous subarachnoid hemorrhage should be considered when sudden back pain associated with severe headache develops. Even though emergent surgical decompression is necessary when the neurological state progressively deteriorates, conservative treatment with close monitoring of the symptoms can be recommended for patients with a stable neurological status.
- Back pain
- Spinal cord
- Spinal subarachnoid hemorrhage
Spinal subarachnoid hemorrhage and/or hematoma (SSH) is rare and represents less than 1% of all subarachnoid hemorrhage cases . SSH is usually caused by several well-known predisposing factors, including trauma (often caused by lumbar puncture), coagulopathy, arteriovenous malformation, aneurysm, neoplastic lesions, systemic lupus erythematosus, and Behçet’s disease (BD) . SSH may also occur spontaneously, which is extremely rare.
The symptoms of this patient were sudden-onset severe headache and back pain. Although the sudden onset of severe back pain is a characteristic symptom of SSH, it is difficult to distinguish between epidural, subdural, and subarachnoid spinal hemorrhage [3–6]. It has been estimated that 80% of patients with SSH have concomitant intracranial symptoms such as headache (70%) and mental changes (22%) . The headache of this patient was associated with meningism, and spinal tapping revealed bloody CSF. These findings strongly suggested that the origin of her hemorrhage was in the subarachnoid space.
Spontaneous SSH is rare. To the best of our knowledge, only 20 individual cases of spontaneous SSH, including our patient without any apparent source of bleeding, have been reported [1–6, 8–15]. The paroxysmal onset of severe back pain and headache is observed in 11 of 20 spontaneous SSH cases, including our patient [2–4, 6, 8–10, 12, 14, 15]. Consciousness disturbance was observed in three of the 20 cases [3, 10]. The circumstances at the time of onset of symptoms include eating, bending the head, scuba diving, having sexual intercourse, defecating, receiving the recoil of a shotgun, and jumping into the sea [1–3, 5, 10, 12, 13, 15]. To the best of our knowledge, there have been no reported cases of SSH that developed after severe coughing. With regard to the pathogenesis of the condition, it is considered that a forgotten effort or minor trauma increases intrathoracic and intra-abdominal pressure, and the intraluminal pressure of spinal vessels, particularly the valveless radiculomedullary veins crossing the subarachnoid space, which results in subsequent tearing of vessels within the subarachnoid space . On the basis of this mechanism, we considered that the vessels within the subarachnoid space of the lumbar spine ruptured, which resulted in SSH because of a sudden increase in intra-abdominal pressure after the severe coughing in our patient.
Acute spontaneous SSH is a potentially dangerous condition and may have disastrous consequences; thus, urgent decompressive surgery should be performed when the neurological state progressively deteriorates, unlike in our patient [3, 4, 10–13]. When bleeding occurs in the subarachnoid space, the CSF may dilute the subarachnoid hemorrhage, and defibrination by pulsation of the spinal cord reduces the likelihood of subarachnoid hematoma formation [1, 2]. In this patient, it is considered that these mechanisms effectively worked owing to the absence of mechanical obstacles within the spinal column such as spondylosis, disk herniation, and thickening of the yellow ligament. Komiyama et al. postulated that the ventral-type SSH causes acute back pain and minimal neurological deficits, and could be treated conservatively. Conversely, the dorsal type may require surgical intervention . According to this theory, this patient had ventral SSH without neurological deficits, and could be managed conservatively. However, Ruelle et al. reported that in their patients the hemorrhage was located dorsally and ventrally, but they recovered without surgical decompression . Therefore, the location of the hemorrhage does not seem to be the only factor deciding the treatment. It is considered that the decision to perform surgical decompression in SSH does not necessarily depend on the hemorrhage location, but on the neurological status of the patient .
We suggest that spontaneous SSH should be considered when sudden back pain associated with severe headache develops. Spontaneous SSH may resolve with conservative treatment with close patient monitoring, when the patient has no neurological deficits. However, we should pay close attention to the progression of the neurological symptoms, and appropriate patient triage and timely neurosurgical intervention should be considered.
Written informed consent was obtained from the patient for the publication of this case report and its accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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