Spontaneous thoracic subdural hematoma associated with warfarin therapy: Case report with serial MRI

BACKGROUND: Spontaneous acute spinal subdural hematoma (SASSDH) is a rare but serious condition. We present diagnostic challenges and serial magnetic resonance imaging (MRI) findings of a patient who developed warfarin-associated thoracic SASSDH that was managed surgically. CASE DESCRIPTION: A 68-year-old male presented with sudden onset left-sided chest and back pain, left leg weakness, and bilateral loss of sensations below T4 level. His symptoms developed after strenuous physical activity. He was taking warfarin for atrial fibrillation. His admission international normalized ratio was 4.25. Deterioration of neurological status 3 days after admission prompted spinal computed tomography (CT) scan that demonstrated nonhomogenous hyperdense intradural mass lesion in the thoracic spine. MRI demonstrated heterogeneous mass lesion on the left side of the spinal canal and thoracic myelopathy. The patient underwent urgent surgical evacuation of subacute subdural hematoma extending from T3 to T6 levels. MRI scan following the surgery showed no signs of the hematoma and thoracic myelopathy. MRI at 3 months follow-up demonstrated myelopathy extending from T3 to T6 levels with deviation of the spinal cord. The patient's motor strength and sensations improved but he retained left leg weakness with sensory deficit below T8 level. CONCLUSIONS: Spinal subdural hematoma should be suspected in patients presenting with acute onset back pain and myelopathy in the absence of trauma history. Coagulopathy should raise the suspicion for SASSDH. MRI is a valuable imaging modality for initial diagnosis to rule-out other lesions, and to assess postoperative re-bleeding and residual lesions.