Spontaneous cervical epidural hematoma associated with thunderclap headache

Case reportAn 80-year-old woman abruptly developed an explosive,severe headache in the bilateral occipital and frontalregions associated with neck pain/stiffness while sitting onher couch watching television. There was no associatedloss of consciousness or awareness, nausea, vomiting,autonomic symptoms, photophobia or phonophobia. Shedenied any preceding neck pain or history of head or necktrauma.Prior to this event, she rarely experienced mild, infre-quent episodic headaches lasting a few hours only whichwere relieved by aspirin. Her medical history includeddiabetes, hypertension, coronary artery disease, prior cer-ebellar infarcts, glaucoma, and deep venous thrombosis forwhich she was receiving anticoagulation. Her medicationsincluded warfarin, aspirin, clopidogrel, simvastatin, val-sartan, and carvedilol. She was a heavy smoker, but deniedalcohol or drug use.In the emergency department she was afebrile and hadmild neck stiffness, particularly on neck ﬂexion. Bloodpressure was 168/89 mm Hg with a heart rate of 85 beatsper minute. Neurological examination did not revealpapilledema or any focal, long tract, or lateralizing signs.Cranial computed tomography (CT) was negative forintracranial hemorrhage. Blood work revealed a markedlyelevated INR (6.0), but CBC, electrolytes, ESR (26 mm/h),urinalysis, and serum glucose (138 mg/dL) were normal.The patient was administered 4 U of fresh frozen plasma toreverse her coagulopathy to perform an emergent lumbarpuncture; during this time she underwent magnetic reso-nance imaging (MRI) and angiography (MRA) of the brainand neck (time-of-ﬂight with fat-suppression), which wereremarkable only for evidence of prior bilateral cerebellarand small deep left middle cerebral artery territory infarcts.Although magnetic resonance venography (MRV) was notperformed, contrast-enhanced MRI revealed patency andnormal enhancement of the venous sinuses.Cerebrospinal ﬂuid (CSF) examination demonstratedsubarachnoid hemorrhage (SAH) as well as a neutrophilicpleocytosis (540 red blood cells and 8 white blood cells perhigh power ﬁeld intube 1,2,100red blood cells and15 whiteblood cells per high power ﬁeld in tube 4, 96 % polymor-phonuclear leukocytes, glucose 100 mg/dL), with elevatedCSF protein levels (72 mg/dL). Gram stain and subsequentCSF cultures revealed no causative organism. Chest X-raydid not demonstrate any inﬁltrate. Given the possibility of acentral nervous system (CNS) infectious process, the patientwas empirically treated with intravenous antibiotics(vancomycin, ceftriaxone, ampicillin) and acyclovir.Because of the persistence of head and neck pain, herhistory of diabetes, and warfarin combined with dual anti-platelet agent use, a cervical epidural etiology (infectious orhemorrhagic) was suspected. Gadolinium-enhanced MRI ofthe cervical and thoracic spine demonstrated a heteroge-neous cervical epidural collection spanning from mid-C2through T1/T2 vertebral level, with a thin rim of contrastenhancement extending from the upper cervical cord tothe anterior pons (Fig. 1). Gradient-echo sequences (notshown) revealed few areas of hypointensity, suggestive of acervical epidural hematoma with acute elements.The headache and neck pain resolved several days afterwithholding anticoagulation and treating with empiricintravenous antibiotics (vancomycin and ceftriaxone).