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


The symptoms of this patient were sudden-onset severe headache and back pain. Although the sudden onset of severe back pain is a characteristic symptom of SSH, it is difficult to distinguish between epidural, subdural, and subarachnoid spinal hemorrhage.[3–6] It has been estimated that 80% of patients with SSH have concomitant intracranial symptoms such as headache (70%) and mental changes (22%).[7] The headache of this patient was associated with meningism, and spinal tapping revealed bloody CSF. These findings strongly suggested that the origin of her hemorrhage was in the subarachnoid space.

Spontaneous SSH is rare. To the best of our knowledge, only 20 individual cases of spontaneous SSH, including our patient without any apparent source of bleeding, have been reported.[1–6,8–15] The paroxysmal onset of severe back pain and headache is observed in 11 of 20 spontaneous SSH cases, including our patient.[2–4,6,8–10,12,14,15] Consciousness disturbance was observed in three of the 20 cases.[3,10] The circumstances at the time of onset of symptoms include eating, bending the head, scuba diving, having sexual intercourse, defecating, receiving the recoil of a shotgun, and jumping into the sea.[1–3,5,10,12,13,15] To the best of our knowledge, there have been no reported cases of SSH that developed after severe coughing. With regard to the pathogenesis of the condition, it is considered that a forgotten effort or minor trauma increases intrathoracic and intra-abdominal pressure, and the intraluminal pressure of spinal vessels, particularly the valveless radiculomedullary veins crossing the subarachnoid space, which results in subsequent tearing of vessels within the subarachnoid space.[2] On the basis of this mechanism, we considered that the vessels within the subarachnoid space of the lumbar spine ruptured, which resulted in SSH because of a sudden increase in intra-abdominal pressure after the severe coughing in our patient.

Acute spontaneous SSH is a potentially dangerous condition and may have disastrous consequences; thus, urgent decompressive surgery should be performed when the neurological state progressively deteriorates, unlike in our patient.[3,4,10–13] When bleeding occurs in the subarachnoid space, the CSF may dilute the subarachnoid hemorrhage, and defibrination by pulsation of the spinal cord reduces the likelihood of subarachnoid hematoma formation.[1,2] In this patient, it is considered that these mechanisms effectively worked owing to the absence of mechanical obstacles within the spinal column such as spondylosis, disk herniation, and thickening of the yellow ligament. Komiyama et al. postulated that the ventral-type SSH causes acute back pain and minimal neurological deficits, and could be treated conservatively. Conversely, the dorsal type may require surgical intervention.[2] According to this theory, this patient had ventral SSH without neurological deficits, and could be managed conservatively. However, Ruelle et al. reported that in their patients the hemorrhage was located dorsally and ventrally, but they recovered without surgical decompression.[9] Therefore, the location of the hemorrhage does not seem to be the only factor deciding the treatment. It is considered that the decision to perform surgical decompression in SSH does not necessarily depend on the hemorrhage location, but on the neurological status of the patient.[1]