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Título

Ischemic Myelopathy and Hematomyelia: A Case Report

RESUMO

Case-Report: A 28-year-old woman presented upper thoracic spine pain after supposed
trauma in a soccer game, evolving after 03 days with paresthesia of hands and tongue with
evolution in 40 minutes to tetraparesis, lowered level of consciousness and acute respiratory
failure requiring airway support.The patient underwent a study of the cerebrospinal fluid
(CSF) which showed pleocytosis with lymphocytic and neutrophilic predominance
associated with normal levels of protein and glucose. The diagnostic investigation was
complemented with magnetic resonance imaging (MRI) of the skull and cervical spine, which
presented longitudinally extensive myelopathy in addition to internal hemorrhagic foci and
presence of hematomyelia in the pons and in the anterior portion of the cervical spine. A
hypothesis of acute longitudinally extensive transverse rhomboencephalomyelitis of probable
immune-mediated etiology was raised and pulse therapy was started with 1g
methylprednisolone for 05 days, and, due to an unsatisfactory response, complemented with
05 sessions of plasmapheresis, with imaging improvement afterwards, but without clinical
response. She underwent cervical and thoracic spinal cord angiography that showed
dissection of the left vertebral artery in the V2 cervical segment and failure of opacification of
the anterior spinal artery in the projection of the odontoid process suggestive of occlusion.
We reached the conclusion of an ischemic lesion with hemorrhagic transformation,
secondary to dissection of the left vertebral artery and probable occlusion of the anterior
spinal artery.
Discussion: Hematomyelia is a very rare intraparenchymal spinal cord hemorrhage. The
most common cause is trauma, followed by vascular malformation, coagulopathy, neoplasm,
and iatrogenic procedures. A hemorrhagic transformation after spinal cord infarction can
sometimes occur, caused by mechanisms such as arterial dissection, atherosclerosis and
fibrocartilaginous embolism. Patients may present with acute severe neck or back pain at
onset followed by rapid severe myelopathy deficits The hematomyelia treatment consists of
cervical or thoracic laminectomy followed by durotomy and myelotomy, after which the
hematoma cavity is evacuated and irrigated.
Final Comments: Vascular myelopathies are important clinical entities due to its acute and
progressive course. A quick diagnosis can potentially result in a life-saving therapy and
prevent lasting neurologic damage and death.

Palavras Chave

Spinal Cord Ischemia, Paresis