产后自发性椎管内硬膜外血肿

Bang

25岁女性，顺产后8小时，突发下肢无力，小便失禁，乳头水平以下感觉异常。

Spontaneous Spinal Epidural Hematoma (SSEH)

in the Postpartum Period

产后自发性椎管内硬膜外血肿

背景：

Among the recognized conditions that could predispose one to SSEH, pregnancy accounts for 1%, and others include anticoagulant therapy, vascular malformations, hemophilia, and vasculitis.

根据影像资料，考虑诊断为自发性椎管内硬膜外血肿（SSEH）。1%左右的患者由妊娠诱发发病，其他原因包括抗凝治疗、血管畸形、血友病、血管炎症等。

SSEH in pregnancy or the postpartum period is believed to be associated with rupture of primitive valveless epidural veins owing to elevated thoracic, abdominal, and pelvic pressure during or after pregnancy. Hyperdynamic circulation after uterine contraction, hormonal effects on vessels, and hypercoagulable state are also among the proposed factors.

妊娠或产后胸腔、腹腔、盆腔内压力增高引起硬膜外无瓣膜的静脉丛破裂，是妊娠或产后SSEH的主要发病原因。另外，子宫收缩引起的循环血量增加、激素刺激血管、血液易凝状态等也是可能的致病因素。

临床表现：

Sudden-onset pain in the chest-back region, limb weakness and sensation disturbance, paraplegia, urinary retention, or Brown-Sequard syndrome

SSEH的临床症状包括：胸背部突发疼痛、下肢无力、感觉异常、截瘫、尿潴留、脊髓半切综合征等。

影像诊断要点：

CT: Crescentic high-intensity mass within the spinal epidural space

CT:椎管内硬膜外可见新月形高密度肿块

MRI: Acute stage — isointensity on T1WI and slight hyperintensity on T2WI with heterogeneous patchy hypointensity. Hyperintensity on both T1WI and TWI2 can be seen in the subacute stage. Peripheral enhancement of the hematoma is thought to be related to peripheral blood supply and hyperemia. The absence of flow-voids within or surrounding the lesion may help to exclude an underlying arteriovenous malformation, which can be further confirmed by angiography.

MRI：急性期T1WI呈等信号；T2WI呈不均匀稍高信号，内可见斑片状低信号。亚急性期，T1WI和T2WI均呈高信号。增强扫描的周边强化可能与病灶周边血供及充血有关。病灶内或病灶周围未见流空血管影，可以排除血管畸形的可能性，这也可以通过血管造影进一步检查证实。

鉴别诊断：

Spinal arteriovenous malformation

椎管内动静脉畸形

Spinal subdural hematoma

椎管内硬膜下血肿

Epidural abscess

硬膜外脓肿

Metastases or lymphoma

转移瘤或淋巴瘤

治疗

A decompressive laminectomy and evacuation of hematoma is crucial for SSEH in the presence of neurologic deficit or acute-onset severe symptoms and signs.

当SSEH出现神经功能异常或突发严重的症状体征时，去椎板减压术和血肿清除至关重要。