Spontaneous Spinal Subarachnoid Hemorrhage After Severe Coughing

A Case Report

Yutaka Oji; Kazuyuki Noda; Joji Tokugawa; Kazuo Yamashiro; Nobutaka Hattori; Yasuyuki Okuma


J Med Case Reports. 2013;7(274) 

In This Article

Case Presentation

We here describe the case of a 66-year-old Japanese woman with a history of hypertension who presented with SSH after severe coughing of unusual spontaneous origin. She suddenly developed a severe headache accompanied by vomiting after severe coughing. Her headache was alleviated within approximately minutes, but severe back pain suddenly developed. She visited the orthopedic department of our hospital, and analgesic drugs were prescribed. Improvement of her back pain with analgesic drugs was temporary, and her headache with nausea exacerbated and became progressively worse. She visited the neurology department 6 days after the onset. Computed tomography of her brain showed no abnormal findings, but a lumbar puncture revealed bloody cerebrospinal fluid (CSF). She was immediately admitted to the neurology department of our hospital with the diagnosis of subarachnoid hemorrhage. She had no history of trauma and had not been prescribed anticoagulation agents. Her blood pressure on admission was 149/67mmHg. No neurological deficits were found except for meningism. There were no clinical features suggesting BD, including a positive pathergy test result or the presence of typical genital or ocular lesions. Hematological and coagulation function test results were normal. The test results of antinuclear antibodies and anti-double-stranded deoxyribonucleic acid were negative. Magnetic resonance (MR) images of her lumbar spine taken on day 1 were reviewed retrospectively. A sagittal T1-weighted MR image showed a diffuse isosignal intensity in the subarachnoid space; therefore, no normal-appearing thecal sac or nerve roots were observed (Figure 1A). Sagittal and axial T2-weighted MR images showed a high signal intensity, which was slightly lower than the signal intensity of CSF per se, from L1 to L2, in the ventrolateral subarachnoid space (Figure 1B and 1C). These findings were indicative of acute hemorrhage. Digital subtraction angiography on day 7 disclosed no abnormal findings. MR images of the lumbar spine on day 8 showed high signal intensity on T1-weighted images, and a low signal intensity on T2-weighted images from L1 to L3, which was indicative of early subacute hemorrhage (Figure 2). No MR imaging evidence of vascular abnormalities was detected in her entire spine. MR images of her entire spine on day 8 showed no tumor-like staining by gadolinium on T1-weighted images. Although the patient was advised to undergo spinal angiography, she did not consent to it. The patient was discharged 25 days after admission without any neurological deficits. Spinal angiography was performed with her consent 2 months after the onset, which disclosed no abnormal findings. The diagnosis of spontaneous SSH was confirmed. Repeated MR imaging showed no recurrence, and no signal change within the spinal cord. She was healthy at the 2-year follow-up examination.

Figure 1.

Initial magnetic resonance imaging. A sagittal T1-weighted image shows diffuse isosignal intensity in the subarachnoid space. No normal-appearing thecal sac or nerve roots are observed (A). Sagittal T2-weighted (B) and axial T2-weighted (C) images show a high signal intensity from L1 to L2 (arrowheads).

Figure 2.

Magnetic resonance imaging 8 days after onset. Sagittal T1-weighted (A) and sagittal T2-weighted (B) images show subarachnoid hemorrhage extending from L1 to L3 ventrally to the spinal cord (arrowheads). There is no severe compression of the cord. The axial T1-weighted (C) and axial T2-weighted (D) images are at L1.