Letter to the Editor
Response to “Spontaneous acute epidural haematoma of the cervical spine with an atypical onset resembling ictal symptom”
Respuesta a «Hematoma epidural agudo cervical espontáneo de inicio atípico simulando cuadro ictal»
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Martinez-Perez, N. Rayo" "autores" => array:2 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Martinez-Perez" "email" => array:2 [ 0 => "rafa11safin@hotmail.com" 1 => "rafa11safn@hotmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "N." "apellidos" => "Rayo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Neurocirugía. Hospital 12 de Octubre. Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "División de Neurocirugía. Instituto de Ciencias Neurológicas. Universidad Austral de Chile, Valdivia, Chile" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Wester University, London, Ontario, Canada" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author:" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Respuesta a «Hematoma epidural agudo cervical espontáneo de inicio atípico simulando cuadro ictal»" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the letter to the editor by Arévalo et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> entitled “Spontaneous acute epidural haematoma of the cervical spine with an atypical onset resembling ictal symptom.” We would like to thank the authors for the valuable clarifications on the management of these patients. Most of the conclusions and information on this type of disease are from a small number of case reports with an inherent selection bias, or small series that lack detailed statistical analysis. However, we would like to clarify some points based on our experience and on the only Spanish multicentre study, conducted by members of our working group, which included 29 patients with surgically treated spontaneous epidural spinal haematoma.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We agree with Arévalo et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> that treatment of this type of lesions is essentially surgical. Furthermore, in patients presenting spontaneous improvement or whose health condition contraindicates surgery, a conservative approach should be adopted. Spontaneous improvement is more frequent than we may expect<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>; in our series, we excluded 2 patients who presented excellent progression, eventually recovering, despite not having received surgical treatment. The usefulness of corticosteroids in patients ineligible for surgical treatment has not been clearly demonstrated in the case of spinal haematoma<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>; all the available conclusions and recommendations are from the NACIS multicentre study.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Our study on prognostic factors in patients with surgically treated spontaneous spinal haematomas<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> showed that late surgery was associated with poor prognosis and absence of neurological improvement. However, up to 43% of the patients undergoing surgery in the first 24 hours showed some degree of objective neurological improvement. Likewise, contrary to the results of studies into spinal cord trauma,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> the degree of neurological involvement before surgery was not significantly associated with prognosis. In view of these 2 findings, we may conclude that although neurological recovery is multifactorial, surgical decompression is a relatively safe technique that should be performed as early as possible in patients with neurological involvement. However, persistence of symptoms beyond 24 hours or presence of complete spinal cord lesion should not be considered contraindications for surgical treatment in patients with compression due to spinal haematoma.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The study by Arévalo et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> introduces several elements into the description of the radiological image that, despite being interesting from a descriptive point of view, are of little prognostic value. The most relevant radiological images include an increased length of the intra-axial lesion shown by an increased intra-axial signal in T2-weighted sagittal MRI sequences of the spinal cord, which is the only radiological prognostic factor found to date.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The length of the extra-axial haematoma and the percentage of occupation of the spinal canal are not as relevant as the latter radiological finding. The benefit of having radiological variables that may help predict prognosis with some degree of certainty becomes especially relevant in circumstances in which proper neurological examination is not possible: patients under sedation or who are uncooperative.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> We should mention that the extension of the lesion is a time-dependent variable: it is thought to increase in length by approximately 10 mm per day.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Therefore, the prognostic value of MRI becomes significant when it is performed in the first 48-72 hours after symptom onset.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Arévalo et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> report that the patient was surgically treated after diagnosis by CT scan and that MRI was performed after the procedure. It would be interesting to analyse the motives leading to that decision.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Based on the above, we recommend performing a spinal MRI scan and prescribing surgical treatment as early as possible in patients with spinal cord compression. Creation of a radiological protocol including sagittal T2-weighted sequences as the main diagnostic study would help to save time in the management of these patients, who require urgent treatment. Adding the length of the intramedullary lesion to the radiological description would provide a better idea of recovery expectations in these patients. In those cases in which performing an MRI scan would delay surgical treatment beyond 48 hours, it would be appropriate to prioritise emergency surgical treatment over the prognostic value of MRI.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0030" class="elsevierStylePara elsevierViewall">This study has received no external funding.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-10-12" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martinez-Perez R and Rayo N. Respuesta a «Hematoma epidural agudo cervical espontáneo de inicio atípico simulando cuadro ictal». Neurología. 2020;35:507–508.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spontaneous acute epidural haematoma of the cervical spine with an atypical onset resembling ictal symptom" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Arevalo" 1 => "M. Navas" 2 => "P. Pulido" 3 => "R. Garcia de Sola" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Neurol." 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| 2024 April | 12 | 3 | 15 |
| 2024 March | 19 | 5 | 24 |
| 2024 February | 7 | 4 | 11 |
| 2024 January | 20 | 3 | 23 |
| 2023 December | 19 | 9 | 28 |
| 2023 November | 14 | 2 | 16 |
| 2023 October | 21 | 10 | 31 |
| 2023 September | 15 | 8 | 23 |
| 2023 August | 13 | 3 | 16 |
| 2023 July | 16 | 4 | 20 |
| 2023 June | 18 | 4 | 22 |
| 2023 May | 31 | 4 | 35 |
| 2023 April | 30 | 1 | 31 |
| 2023 March | 14 | 3 | 17 |
| 2023 February | 14 | 0 | 14 |
| 2023 January | 11 | 1 | 12 |
| 2022 December | 23 | 4 | 27 |
| 2022 November | 25 | 7 | 32 |
| 2022 October | 13 | 7 | 20 |
| 2022 September | 16 | 5 | 21 |
| 2022 August | 20 | 5 | 25 |
| 2022 July | 14 | 8 | 22 |
| 2022 June | 15 | 4 | 19 |
| 2022 May | 15 | 6 | 21 |
| 2022 April | 12 | 7 | 19 |
| 2022 March | 31 | 4 | 35 |
| 2022 February | 12 | 6 | 18 |
| 2022 January | 33 | 3 | 36 |
| 2021 December | 39 | 8 | 47 |
| 2021 November | 15 | 8 | 23 |
| 2021 October | 12 | 11 | 23 |
| 2021 September | 12 | 11 | 23 |
| 2021 August | 12 | 8 | 20 |
| 2021 July | 9 | 7 | 16 |
| 2021 June | 17 | 14 | 31 |
| 2021 May | 19 | 3 | 22 |
| 2021 April | 27 | 16 | 43 |
| 2021 March | 20 | 10 | 30 |
| 2021 February | 10 | 5 | 15 |
| 2021 January | 13 | 9 | 22 |
| 2020 December | 11 | 8 | 19 |
| 2020 November | 8 | 6 | 14 |
| 2020 October | 10 | 7 | 17 |
| 2020 September | 14 | 6 | 20 |
| 2020 August | 19 | 9 | 28 |
Show all
