A case of spontaneous intramedullary hematomyelia mimicking transverse myelitis
Year: 2026
Type: article
Abstract: Introduction: Hematomyelia is a rare condition characterized by sudden and unexpected bleeding into the spinal cord parenchyma. It can usually lead to rapid and irreversible neurological impairment. Its annual incidence is reported to be approximately one in 100,000 people, and it accounts for 0.3–0.9% of all spinal cord lesions. Its main causes include trauma and complications of spinal medical procedures such as lumbar puncture and epidural anesthesia. Other etiological factors may also be involved, such as vascular malformations of the spinal cord, coagulation disorders, inflammatory and infectious myelitis, spinal tumors, and syringomyelia. However, no specific etiological cause may be found in 40–50% of cases, and these are regarded as spontaneous. The lack of studies on the etiology and treatment of spontaneous spinal hematoma underlines the need for more studies and research in this area to increase the scientific evidence on the approach to these patients.Case: A 62-year-old woman had presented to an outside emergency department 3 days before presenting to our hospital with nausea, chest-back pain, and shortness of breath that began 2 hours after consuming clover (yonca) and kızılca herb. Because troponin was elevated on laboratory tests, coronary angiography was performed and showed no pathology. In the evening after the angiography, weakness, numbness, and loss of sensation developed in both feet. A few hours later she could not move either leg. Her pain continued in a diffuse and migratory pattern. Diffusion MRI, brain CT, aorto-pulmonary CT angiography, and abdominal CT obtained at the outside center were reported as normal. Thoracic MRI obtained there drew attention to a suspicious increase in intensity in the spinal cord, starting at the T3 level and extending caudally. She had known hypertension, hyperlipidemia, and atrial fibrillation and was taking apixaban. Neurological examination: she was alert, cooperative, and oriented; pupils were isocoric, light reflex +/+, eye movements were full in all directions, there was no facial asymmetry, speech was fluent, and oral intake was preserved. Motor strength in both upper extremities was full, both lower extremities were plegic, and deep tendon reflexes could not be elicited in the lower extremities. Plantar responses were bilaterally indifferent, and there was a sensory level from T4 downward. There was no urinary or fecal incontinence. A spinal MRI was requested. In light of her examination and the MRI findings, pulse steroid treatment was started. In the meantime, NMO and MOG antibodies were sent and contrast-enhanced spinal imaging was requested again. The patient did not benefit from steroids. On the repeat imaging, hyperintensity on the T1 sequence extending from the upper cervical to the thoracic cord was interpreted as hematomyelia. The patient was transferred to neurosurgery, where no surgical intervention was performed, and she was referred for physical therapy support (Figure 1).Discussion/Conclusion: Spontaneous spinal hemorrhage can be epidural, subdural, subarachnoid, and, very rarely, intramedullary. Warfarin-associated spontaneous hematomyelia has been described in the literature in a few case reports. Our case is the second case of spontaneous intramedullary hemorrhage in the literature that we associate with apixaban use. MRI is a better diagnostic tool than conventional myelography or CT. Spinal angiography can be useful in clarifying a vascular etiology but is not always recommended. The final diagnosis is usually confirmed by microscopy. Early diagnosis and surgical intervention are very important for the hematomyelia cases reported in the literature. Previously reported cases of spontaneous intraspinal intramedullary hematoma have presented with acute, subacute, or chronic myelopathy. Acute hematomyelia usually begins with sudden severe back or neck pain, followed by myelopathy syndromes caused by the compressive effect of fluid and blood on the spinal cord. Hematomyelia usually manifests with sudden onset and rapid neurological deterioration. Once spinal cord compression is diagnosed, prognostic factors are strongly related to the time interval between symptom onset and surgical decompression. In our case, the onset of paraparesis after the plant consumption mentioned in the history led us toward a toxic agent, and the interpretation of the spinal MRIs obtained at the outside center as favoring transverse myelitis somewhat delayed the diagnostic process. It has been reported in the literature in patients presenting with severe chest and back pain that can be confused with the clinical picture of myocardial infarction, and in our case as well, acute coronary syndrome was considered at the first presentation and angiography was performed. There are currently no definitive guidelines for the management of acute hematomyelia, and treatment is usually directed at the underlying cause. Conservative management of acute hematomyelia is not well established; therefore, surgical removal of the hematoma is the preferred treatment for acutely deteriorating hematomyelia. However, there are case reports of patients who were given high-dose steroids and benefited. Therefore, high-dose pulse steroid treatment together with early surgery is recommended in patients presenting with acute hematomyelia. Early diagnosis, accurate diagnosis, and appropriate treatment can reduce morbidity and improve prognosis in patients with acute hematomyelia. After intramedullary T1-hyperintense lesions were seen on the spinal MRI obtained at our center, our patient was diagnosed and transferred to the neurosurgery clinic, but decompression surgery was not performed. Spontaneous intramedullary hemorrhage should be kept in mind in patients taking novel oral anticoagulants who present with acute myelopathy with sudden neck and back pain and no history of trauma, and T1-weighted images should be examined carefully. Our case report aimed to raise awareness on this subject.Keywords:
Authors: Hatun Günöz Çelik, Ömer Çelik
Institutions: Van Yüzüncü Yıl Üniversitesi, Sağlık Bilimleri Üniversitesi
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W7225784133
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