Spontaneous Thoracic Spinal Subarachnoid Hemorrhage
Tohoku J. Exp. Med., 2013, 231, 139-144139

Spontaneous Thoracic Spinal Subarachnoid Hemorrhage
Diagnosed with Brain Computed Tomography
Tatsuro Sasaji,1 Kiyotsugu Shinagawa1 and Shigetsune Matsuya1
1

Department of Orthopedic Surgery, Iwate Prefectural Central Hospital, Morioka, Iwate, Japan

Spontaneous thoracic spinal subarachnoid hemorrhage is rare, and thus no useful radiological findings forpreoperative diagnosis have been reported. We experienced a patient with spontaneous thoracic spinal
subarachnoid hemorrhage. A 37-year-old female presented with sudden-onset paraplegia and numbness
in the trunk and bilateral lower extremities. The patient had no past history of trauma, lumbar puncture andbleeding disorder. T2-weighted sagittal magnetic resonance imaging (MRI) of the cervical and thoracic
spines showed a mass occupied in the ventral space of spinal cord that was dorsally shifted. The mass
extended from C6 to Th6 levels, with its largest size at Th2 level. Thoracic spine T2-weighted sagittal andaxial MRI showed that the mass compressed spinal cord and was located in the intradural space. Therewas no spinal cord tumor and no spinal vascular malformation around the mass. Brain computed
tomography (CT) showed a high-density area in the subarachnoid space, indicating the possibility ofsubarachnoid hemorrhage. Brain MRI showed no ruptured aneurysm. The patient was diagnosed as aspontaneous thoracic spinal subarachnoid hemorrhage and emergency surgery was selected. We
performed right-side hemilaminectomy at Th1-Th6 and opened dura mater and arachnoid membrane.
Hematoma was found in the ventral space of spinal cord and was removed. One year after surgery,
numbness in the trunk and bilateral lower extremities had disappeared but paraplegia remained unchanged.
Thoracic spine T2-weighted MRI confirmed no hematoma but showed a newly formed intradural cyst.
Preoperative combination of brain CT and thoracic MRI is useful to diagnose thoracic spinal subarachnoid
hemorrhage.
Keywords: paraplegia; spinal canal; spinal cord; subarachnoid hemorrhage; thoracic vertebrae
Tohoku J. Exp. Med., 2013 October, 231 (2), 139-144. © 2013 Tohoku University Medical Press
We experienced a patient with spontaneous thoracic
spinal subarachnoid hemorrhage and present specific radiological findings and the treatment course. The patient provided consent for her data to be published.

Introduction
Intraspinal hematoma causing neurological symptom
is an emergency disease and sometimes encountered. Incase of intraspinal hematoma, early diagnosis is necessary.
Intraspinal hematoma is divided into extradural hematoma,
subdural hematoma, subarachnoid hemorrhage and hematomyelia, depending on the location (Hoshimaru 2005).
Spinal extradural hematoma is the most frequent entity ofspinal bleeding (Sarubbo et al. 2009). However, spinal subarachnoid hemorrhage is rare.
For useful radiological findings of spinal subarachnoid
hemorrhage, Domenicucci et al. (2005) reported one patient
whose hematoma was surrounded by cerebrospinal fluid.
Their patient underwent a conservative treatment, and thus
the diagnosis was not confirmed as subarachnoid hemorrhage. To the best of our knowledge, there have been nostudies for specific radiological findings of spinal subarachnoid hemorrhage. Accordingly, preoperative diagnosis ofspinal subarachnoid hemorrhage is difficult.

Clinical Report
A 37-year-old female presented to our hospital withsudden-onset back pain, numbness in the trunk and bilaterallower extremities, and paraplegia. There was no history oftrauma, lumbar puncture, blood disorders, or anticoagulant
therapy. The patient complained of headache for several
months ago; however, no neurological symptoms or backpain were observed. On brain magnetic resonance images(MRI), there were no tumor and hematoma. And so, toinvestigate spinal cord, cervical and thoracic spine MRI
was obtained at another department one month before theonset of paraplegia. On cervical and thoracic spine
T2-weighted MRI, there were no spinal tumor and no vessel malformation (Fig. 1A and B).

Received July 23, 2013; revised and accepted September 26, 2013. Published online October 17, 2013; doi: 10.1620/tjem.231.139.
Correspondence: Tatsuro Sasaji, Department of Orthopedic Surgery, Iwate Prefectural Central Hospital, 1-4-1, Ueda, Morioka, Iwate
020-0066, Japan.
e-mail: taturosasaji@hotmail.com

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Fig. 1. Magnetic resonance images of the cervical and thoracic spine (one month before onset of symptom).
A: Sagittal plane on T2-weighted image. B: Axial plane at Th2 level on T2-weighted image.
Sagittal plane (A) and axial plane at the Th2-Th3 level (B) T2-weighted images showing no spinal tumor and no vessel
malformation.

Neurological Examination
On neurological examination at the initial visit to ourdepartment, muscle power was zero in bilateral lower
extremities and the patellar tendon, Achilles tendon, andbulbocavernous reflexes could not be elicited. Sensory disturbance was detected in the trunk and bilateral lower
extremities. The patient had no upper extremity complaints
and was diagnosed as having a thoracic spinal cord injury.
The patient was considered at Grade A (Complete) of theFrankel scale (Frankel et al. 1969). All laboratory findings
were within normal limits.
Radiological Findings
Preoperative cervical and thoracic spine T2-weighted
sagittal MRI showed that the mass was located in the duramater and extended from C6 to Th6, and the spinal cord
had been dorsally shifted (Fig. 2A). PreoperativeT2-weighted axial MRI showed a mass of high-intensity
signal, which was located in the right ventral space of thespinal cord, and this mass maximally compressed spinal
cord at Th2 level (Fig. 2B). The dura mater was deformed
into an oval shape from the inner side by the intradural
mass. The reported signs of intradural-extra-arachnoid
hematoma on MRI included a “black line,” which is a linein the dura mater on T2-weighted axial image, but it could
not be observed in the present case (Shimada et al. 1996).
Brain computed tomography (CT) showed a high-density
area in the subarachnoid space that appeared to be a subarachnoid hemorrhage (Fig. 3). Brain MRI showed no rup-tured aneurysm (Fig. 4). On the basis of the history of nobleeding tendency and radiological findings of no tumor orno vessel malformation, the patient was diagnosed withspontaneous thoracic spinal subarachnoid hemorrhage.
Therefore, we performed the emergency surgery.
Operation
The right-side thoracic spine was explored through astraight posterior midline approach. Right-side hemilaminectomy at Th1-Th6 revealed no hematoma in the extradural space. The dura mater and arachnoid membrane wereexposed and the spinal cord was centrally retracted reveal
to a hematoma in the ventral space of the spinal cord atTh1-Th6. We scraped out and removed the hematoma (Fig.
5A). After removal of the hematoma, the spinal cord wasdecompressed (Fig. 5B). The bleeding point was unclear,but bleeding spontaneously stopped.
Postoperative Course
Numbness in the patient’s trunk and lower extremities
disappeared after surgery. One year later, the patient had nocomplaints of numbness. However, paraplegia and neurogenic bladder did not resolve. The patient was consideredat Grade B (Sensory only) of the Frankel scale (Frankel etal. 1969). The patient has returned to a daily life and uses awheel chair.
Follow-up cervical and thoracic spine T2-weighted
MRI on postoperative day 10 showed no indications of thehematoma, and the spinal cord was decompressed (Fig. 6A

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Fig. 2. Preoperative magnetic resonance images of the cervical and thoracic spine.
A: Sagittal plane on T2-weighted image. B: Axial plane at Th2 level on T2-weighted image.
A: Sagittal plane on T2-weighted image showing a mass in the right ventral space of the spinal cord. The mass extended from C6 to Th6 level (arrow heads). Compression of the spinal cord was maximal at Th2 level. B: Axial plane at theTh2 -Th3 level on T2-weighted image showing that the spinal cord was compressed and deformed by the intradural
mass (arrows).

Fig. 4. Preoperative magnetic resonance image of the brain.
There was no ruptured aneurysm.

Fig. 3. Preoperative computed tomographic image of thebrain.
There was a high-density area in the subarachnoid space(arrows).

and B). Follow-up thoracic spine T2-weighted MRI 1 year
after surgery showed that a new intradural cyst in the ventral left side had appeared and was compressing the spinalcord (Fig. 7A and B). However, because the patient’s
symptoms had not worsened, we thought that the cyst had
not evoked any new spinal cord symptoms. We did not perform revision surgery, but we continued the patient followup.

Discussion
Spinal subarachnoid hemorrhage accounts for < 1% of
all cases of subarachnoid hemorrhage (Walton 1953). In

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Fig. 5. Intraoperative photographs.
A: Opening of the dura mater and arachnoid membrane. B: After removal of the hematoma.
A: Opening of the dura mater and arachnoid membrane revealed that the hematoma surrounded the spinal cord. B: Thespinal cord was decompressed after removal of the hematoma.

Fig. 6. Postoperative magnetic resonance images of the cervical and thoracic spine (10 days after surgery).
A: Sagittal plane on T2-weighted image. B: Axial plane at Th2 level on T2-weighted image.
Sagittal plane (A) and axial plane at the Th2-Th3 level (B) T2-weighted images showing decompressed spinal cord andintraspinal high-intensity area.

addition, according to a review of spinal subarachnoid hemorrhage, 12 of the 69 cases (17.3%) were spontaneous cases(Domenicucci et al. 2005). The rate of secondary cases washigher than that of spontaneous cases. The reported causes
were coagulopathy, hematological pathology, alcoholic
hepatitis, lumbar puncture, spinal trauma, previous spinal

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Fig. 7. Postoperative magnetic resonance images of the thoracic spine (1 year after surgery).
A: Sagittal plane on T2-weighted image. B: Axial plane at Th2 level on T2-weighted image.
Sagittal plane (A) and axial plane at the Th2-Th3 level (B) T2-weighted images showing newly formed intradural cyst
(arrow heads) in the left ventral space and the spreading intraspinal high-intensity area (arrows).

surgery and arteriovenous malformation (Russell andBenoit 1983; Domenicucci et al. 2005). About spontaneous
spinal subarachnoid hemorrhage, Plotkin et al. firstly
reported in 1966 and there have been some subsequent
reports (Plotkin et al. 1966; Owaki et al. 1975; Russell andBenoit 1983; Swann et al. 1984; Hiyama et al. 1990;
Langmayr et al. 1995; Sunada et al. 1995; Komiyama et al.
1997; Ruelle et al. 2001; Domenicucci et al. 2005; Kim andLee 2009). Spontaneous spinal subarachnoid hemorrhage
is a rare disease.
The reported preoperative diagnosis of spinal subarachnoid hemorrhage was unclear by myelography(Plotkin et al. 1966), intraspinal tumor by myelography(Owaki et al. 1975), subarachnoid hematoma by lumbar
puncture (Swann et al. 1984), intradural hematoma by MRI(Hiyama et al. 1990), and spinal hematoma by MRI (Sunadaet al. 1995). Swann et al. (1984) reported that xanthochromic cerebrospinal fluid was useful for diagnosis. Except inone study (Swann et al. 1984), the diagnosis was intraoperatively confirmed. Preoperative diagnosis is difficult
because there have been no specific radiological findings
regarding spinal subarachnoid hemorrhage. Domenicucci
et al. (2005) reported that MRI and CT are not usually diagnostic. In the present patient, the hematoma was located in
the dura mater based on MRI. However, we could not
determine whether hematoma was located in the intraduralextra-arachnoid space or subarachnoid space. Reported
specific radiological findings of intradural-extra-arachnoid
hematoma have included the “black line” (Shimada et al.

1996). In the present patient, a “black line” was notobserved on MRI. We thought that the hematoma may havebeen located in the subarachnoid space. However, theextra-arachnoid and subarachnoid spaces were so close that
we could not confirm the diagnosis only by the MRI.
There have been a few reports regarding radiologicalfindings of brain CT in spinal subarachnoid hemorrhage
case (Hiyama et al. 1990; Ruelle et al. 2001; Kim and Lee2009). Subarachnoid hemorrhage on brain CT could not befound in cases of lumbar spine subarachnoid hemorrhage(Ruelle et al. 2001; Kim and Lee 2009). It was identified incase of thoracic spine subarachnoid hemorrhage (Hiyama etal. 1990). However, the authors did not describe the interpretation of brain CT. In the present case, the radiologicalfindings of subarachnoid hemorrhage on brain CT were
useful for diagnosis. Because the upper thoracic spine wasso close to the brain, blood spread from the upper thoracic
spine to the brain through the subarachnoid space. To thebest of our knowledge, this is the first report to describe theusefulness of brain CT for spinal subarachnoid hemorrhage,and we believe that brain CT may be useful for diagnosis inpatients with upper thoracic subarachnoid hemorrhage.
The reported treatments for spinal subarachnoid hemorrhage included surgery, needle aspiration, and conservative treatment (Plotkin et al. 1966; Owaki et al. 1975;
Russell and Benoit 1983; Swann et al. 1984; Hiyama et al.
1990; Langmayr et al. 1995; Sunada et al. 1995; Komiyamaet al. 1997; Ruelle et al. 2001; Domenicucci et al. 2005;
Kim and Lee 2009). In paralysis cases, surgery has been

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performed (Owaki et al. 1975; Russell and Benoit 1983;
Hiyama et al. 1990; Langmayr et al. 1995; Domenicucci etal. 2005). Prognosis has been influenced by preoperative
neurological status, duration between the onset of symptoms and operation, and rapidity of symptom progression(Sunada et al. 1995). We thought that the poor preoperative
neurological function (Frankel A) and acute-onset paraplegia were the causes of poor neurological recovery in thepresent case.
No reports have described newly formed intraduralcyst following spinal subarachnoid hemorrhage. In thepresent patient, we thought that the hematoma had damaged
the arachnoid membrane and caused cyst formation.

Conflict of Interest
The authors declare no conflict of interest.

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