Thunderclap headache as a presentation of spontaneous spinal epidural hematoma with spontaneous recovery

Abstract

Background

Spontaneous spinal epidural hematoma (SSEH) is a rare spinal cord compression disorder. Thunderclap headache mimicking subarachnoid hemorrhage as an initial manifestation of this disorder has been scarcely reported. Moreover, the neurological outcome of conservative treatment is satisfactory only in some clinical settings. The unusual presentation and mechanisms for spontaneous recovery of SSEH are discussed.

Objective

To report a case of SSEH that presented with acute severe headache that mimicked subarachnoid hemorrhage. After a period of neurological deficit, spontaneous improvement was seen, which progressed to full recovery without neurosurgical intervention.

Findings

A 62-year-old man presented with acute occipital headache and neck stiffness for which subarachnoid hemorrhage was initially suspected. An emergency computed tomographic brain scan and cerebrospinal fluid analysis excluded subarachnoid hemorrhage. Later, he developed acute paraparesis, hypoesthesia up to the fourth thoracic dermatomal level (T4) as well as bowel and bladder dysfunction. The magnetic resonance imaging eventually revealed spinal epidural hematoma, located anterior to C7 through T4 spinal level. He had no previous history of spinal injury, systemic, and hematological disorders. The neurological recovery began 20 hours after the onset and continued until complete recovery, 4 months after the onset without neurosurgical intervention.

Conclusion

SSEH could sometimes imitate subarachnoid hemorrhages when it located in the cervical region. Spontaneous recovery of SSEH without surgical intervention might be possible in cases with continuing neurological recovery, although the recovery began much later in the clinical course.

Keywords:

• Headache
• Spontaneous spinal epidural hematoma
• Subarachnoid hemorrhage
• Paraparesis

Acknowledgement

The authors thank Prof. Dr Siriporn Hirunpat, Dr Kittipong Riabroi, Dr Nuttha Sanghan, and Sakrai Thongchuea, Department of Radiology, Faculty of Medicine, Prince of Songkla University for their assistance in reviewing the MRIs and formatting the image files. The authors also thank David Brown and David Leather, International Affairs Unit, Faculty of Medicine, Prince of Songkla University for editing the manuscript.