Please cite this article in press as: C. Joubert, S. Gazzola, A. Sellier, et al.. Acute idiopathic spinal subdural hematoma: What to do in an emergency? Neurochirurgie (2019), https://doi.org/10.1016/j.neuchi.2018.10.009 ARTICLE IN PRESS G Model NEUCHI-968; No. of Pages 5 Neurochirurgie xxx (2019) xxx–xxx Disponible en ligne sur ScienceDirect www.sciencedirect.com Short clinical case Acute idiopathic spinal subdural hematoma: What to do in an emergency? C. Joubert a,∗ , S. Gazzola a,b , A. Sellier a , A. Dagain a a Department of neurosurgery, Sainte Anne Military Hospital, France b Department of Interventional Radiology, Sainte Anne Military Hospital, France a r t i c l e i n f o Article history: Received 11 March 2018 Received in revised form 16 August 2018 Accepted 6 October 2018 Available online xxx Keywords: Acute paraparesis Spinal MRI Angiography Idiopathic spinal subdural hematoma a b s t r a c t Acute spinal cord compression usually results from trauma, infection, or cancer. Spinal subdural hematoma is an uncommon cause of spinal cord compression that occurs after spine trauma or spinal invasive procedure, especially in context of coagulopathy. In the following reported case, an 82-year-old woman with a history of rapidly progressive paraparesis after a sudden middle back pain, with no pre- vious trauma or coagulopathy, due to an acute spontaneous spinal subdural hematoma. In fact, the main difficulty was to determine, in an emergency situation, the right strategy to identify both the lesion and its cause to adapt therapeutics. This case not only provides an illustrative unusual condition in an emergency department but also a challenging discussion to choose the right treatment for a sudden neurological impairment. According to a literature review of the idiopathic cases of spinal subdural hematomas with- out coagulopathy, the clinical outcome depends on severity of neurological impairment. MRI is the main examination to perform in an emergency. Thus surgical evacuation should be performed in emergency in patients presenting with severe neurological impairment. © 2019 Elsevier Masson SAS. All rights reserved. 1. Introduction Acute spinal cord compression usually results from trauma, infection, or tumor [1–5]. Classically, spinal hematomas are located in the epidural space, in patients suffering from trauma or hema- tologic diseases[1,6]. They also may follow spinal surgery or anesthesiology procedures [3]. Thus, acute idiopathic spinal sub- dural hematoma remains a rare cause of spinal cord compression, especially in patients without coagulation problems [7,8]. As this condition whose outcome is dependent on judicious intervention we report an uncommon and illustrative case of spontaneous spinal subdural hematoma. Furthermore, we propose a literature review of all the cases of idiopathic spinal subdural hematoma without coagulation disorder published in order to guide diagnosis and treatment in emergency. ∗ Corresponding author. Department of neurosurgery, Sainte Anne Military Hos- pital, 2, boulevard Sainte Anne, 83000 Toulon, France. E-mail addresses: christophe.joubert@neurochirurgie.fr (C. Joubert), sebastien.gazzola@gmail.com (S. Gazzola), aurore.sellier@live.fr (A. Sellier), dr.adagain@gmail.com (A. Dagain). 1.1. Case report An 82- year-old woman presented with a twenty-four hour his- tory of rapidly progressive weakness in both legs after a sudden middle back pain, with no previous trauma. There was no pre- vious history of underlying neoplasm or coagulopathy. Neither antiplatelet treatment nor anticoagulant therapy was reported. Physical examination revealed a symmetric paraparesis sub T12 with average muscle strength of 2/5 and both bowel and bladder dysfunctions, quoted ASIA C, or grade II according to the classifica- tion of Domenicucci et al. [8]. Spinal MRI imaging demonstrated the spinal cord compression due to an acute posterior subdural hematoma extending from T10 to L2, below the conus medullaris, with the major portion at T12- L1, in hyposignal in both T2 (Fig. 1A, C) and T1 (Fig. 1B) weighted sagittal sequences, testifying the acute mechanism, and concordant with the patient’s clinical history. The T1-weighted sequence with gadolinium did not show any associated vascular malformation but still enlightened the heterogeneous degeneration of blood prod- ucts, especially in the middle part of the circumferential clot whose main part was spreading onto the posterior part of the medullar canal. Moreover, spinal selective angiography was performed from L3 to T4, and only demonstrated that the anterior spinal artery arose from the left inter segmental T12 artery, without any underlying vascular malformation. https://doi.org/10.1016/j.neuchi.2018.10.009 0028-3770/© 2019 Elsevier Masson SAS. All rights reserved.