Conservative management of an acute spontaneous holocord epidural hemorrhage in a hemophiliac infant

Case report

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Central nervous system hemorrhages are an uncommon but severe complication of hemophilia, occurring in only 2–8% of children with hemophilia. Less than 10% of these CNS hemorrhages are intraspinal. The authors report on their care of an infant with hemophilia A who presented with irritability, meningismus, and decreased spontaneous movement. These symptoms prompted imaging studies, which revealed a spinal epidural hematoma (SEH) extending from C-1 through the cauda equina. The boy was treated with factor replacement and close monitoring. Repeat radiographic imaging 14 days later demonstrated complete resolution, and the patient had returned to his normal baseline status.

A literature review in the modern treatment era revealed 24 cases of SEH in children with hemophilia. Of these 24 cases, 11 underwent laminectomy and 13 received conservative treatment. All conservatively treated patients, 5 of whom had presented with weakness, experienced a full recovery. Of the 11 laminectomy patients, 10 presented with weakness and all but 3 experienced full neurological improvement. These 3 patients were notable for having previously undiagnosed hemophilia. An increased index of suspicion facilitates the essential management features of prompt diagnosis and correction of coagulopathies in children who present with SEHs. The authors apply a multidisciplinary approach involving a pediatric hematologist, neurosurgeon, and pediatric intensive care unit to ensure timely correction of the coagulation disorder, maintenance of adequate factor levels, and close hemodynamic and neurological monitoring. Observation with aggressive correction of coagulopathy is a reasonable treatment choice for hemophilic patients presenting with SEH and a stable neurological examination.

Abbreviation used in this paper: SEH = spinal epidural hematoma.

Article Information

Address correspondence to: John A. Jane Jr., M.D., Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia 22908. email:

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Left and Right: Initial T2-weighted MR images of the entire spine demonstrating a large dorsal epidural hematoma extending from C-1 through the cauda equina with significant spinal cord compression at its worst at the cervicothoracic junction.

  • View in gallery

    Sagittal T2-weighted MR image of the entire spine obtained 2 weeks after presentation, demonstrating complete resolution of the hematoma.



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