Spinal Hematoma



In 1850, Tellegen appears to have been the first to describe the clinical symptoms of spinal cord hematoma or hematomyelia. The symptoms have not changed significantly with the passage of time and the few that have occurred, change only slightly with varying etiologies.

Spinal cord hematoma or hematomyelia is an infrequently encountered condition that is the result of several unusual disease processes. The causes of spontaneous, nontraumatic spinal cord hematoma include vascular malformations of the spinal cord (the most common), clotting disorders, inflammatory myelitis, spinal cord tumors, abscess, syringomyelia, and unknown etiologies. Traumatic events, such as spinal cord injury (closed or penetrating), and operative procedures involving the spinal cord also can cause a spinal cord hematoma. In addition, several instances of intramedullary spinal cord hematomas have been reported following lumbar or C1-C2 punctures.[1, 2, 3, 4, 5]

Because of the rarity of hematomyelia, its numerous etiologies, and its varied clinical presentations, this article provides a general overview of spinal cord hematomas and briefly discusses each etiology separately. Because hematomyelia is a rare entity, treatment and outcomes, regardless of the cause, are based primarily upon anecdotal evidence and the treating surgeon's philosophy.

Since the original publication of this article, several other case reports have been published that discuss intramedullary spinal cord hematomas. These case reports, while detailing several unusual presentations of patients with intramedullary spinal cord hematomas, add little to the core concepts described in the original article. Patients suffering from intramedullary spinal cord hematomas present with severe spinal pain and significant neurological findings related to the level of spinal cord involvement; MRI with and without gadolinium is still the procedure of choice for early diagnosis; and successful outcomes depend on early diagnosis, aggressive, emergent surgical treatment and drainage of the hematoma. Even when these guidelines are followed, outcome following surgery is highly correlated with the initial neurological status of the patient.



The epidemiology of hematomyelia is based directly upon the underlying pathological process. No general statements can be made with regard to age, incidence, gender, or specificity of symptoms because these depend upon the underlying pathology.


Hematomyelia associated with vascular malformations

A spinal cord hematoma can be associated with an intramedullary vascular malformation. This malformation can be either a true arteriovenous malformation (AVM) or an angioma.[6, 7, 5]

Neurological deficits are related to the location of the malformation and occur emergently, with no change over time. Diagnosis and treatment follow those of any spinal cord AVM—a subject too broad for this article.

Hematomyelia associated with coagulopathies

Both congenital coagulopathies, such as hemophilia and factor XI deficiency, and drug-induced coagulopathies, primarily from Coumadin, have been associated with hematomyelia.

Schenk[8] and Wisoff,[9] in separate reports, detail cases in which patients suffered a spinal cord hematoma secondary to their intrinsic coagulopathies. One case, a cervical clot, was the result of hemophilia, and the other, also a cervical clot, was secondary to factor XI deficiency. Both patients underwent surgery with minimal improvement of their neurological deficits.

Other reports detail intramedullary clots following treatment with Coumadin (warfarin).[4] In these patients, treatment was not only surgical but also involved the correction of the coagulopathy by reversing the effects of Coumadin.

Hematomyelia associated with myelitis/vasculitis

Allen, in 1991, reported a patient who suffered a spinal cord hematoma secondary to a vasculitis/ vasculopathy/myelitis of the cord attributable to radiation treatment.[10, 11]

Evacuation of the patient's thoracic clot provided some improvement in function.

Hematomyelia associated with intramedullary tumors (See the image below.)

View Image

This T1-weighted sagittal MRI is from a 19-year-old man with 4-month history of progressive motor loss and an inability to ambulate. He underwent spin....


Surprisingly, hemorrhage into a spinal cord tumor is a rare event. Cauda equina tumors bleed fairly frequently but usually only produce subarachnoid blood.

Tumors most commonly associated with an intramedullary hematoma include ependymomas, hemangioblastomas, cavernous angiomas, schwannomas, and astrocytomas. Treatment consists of both tumor and clot removal. Outcome is determined primarily by the tumor pathology.

Hematomyelia associated with syringomyelia

Bleeding into a syrinx is a well-recognized phenomenon that Gowers first described in 1886.[12] Since then, several cases of hematomyelia in a syrinx have been reported.

Clinical presentation is usually that of a sudden exacerbation of the symptoms of the syrinx itself, other symptomatology includes an acute worsening of symptoms that subsequently improves or a gradual deterioration of function. Most cases of intrasyringal hemorrhage are associated with either scoliosis or a Chiari I malformation. Some authors believe that the hemorrhage is caused by abnormal blood vessels lining the walls of the cyst cavity, and others believe that an acute dilatation of the syrinx tears existing vessels lining the cavity. Treatment is drainage of the clot and drainage of the syrinx. Most patients improve after surgery.

Hematomyelia of unknown etiology

Several cases of spinal cord hematoma appear to have no underlying cause or pathology.

Both Brandt[13] and Leech[14] reported such cases. Even at autopsy, no underlying cause could be identified. Their patients underwent surgical removal of the clot, but no significant improvement in function was noted.


Regardless of the cause, the almost universal initial symptom of spinal cord hematoma is sudden onset of excruciating back or neck pain. The location of this pain relates directly to the location of the underlying pathology and hematoma.

The neurological deficit caused by the hematoma also directly correlates with the region of hemorrhage. Neurological deficits vary somewhat with the underlying etiology. The deficit associated with a vascular malformation occurs suddenly, along with the pain, and does not usually increase substantially over time. The deficits associated with hematomas from other etiologies may lag the initial onset of pain by several hours. The deficit also may evolve over a period of 2-24 hours, or it may even take days.

Imaging Studies

MRI, with and without gadolinium, is the diagnostic procedure of choice for investigating the possibility of a spinal cord hematoma. Spinal MRI demonstrates both the hematoma and the additional underlying pathology. Moreover, MRI imaging demonstrates other pathology if a spinal cord hematoma is not the cause of the patient's symptoms.[15]

Surgical Therapy


Surgical treatment varies with individual physicians and the underlying pathology. Some surgeons believe that urgent clot evacuation is necessary, while others contest that early exploration damages otherwise viable spinal neurons.

Surgeons who believe in clot evacuation operate immediately upon diagnosing a clot. Their rationale assumes an urgent need to remove mass effect and pressure from the spinal cord.

Less aggressive surgeons believe that the neurologic deficit should plateau before removing the clot to keep from damaging viable tissue.

Regardless of the timing, both groups of surgeons believe that the underlying pathology must be addressed. Any accompanying disorders, such as clotting problems, should be corrected as soon as possible. Intraspinal tumors should be surgically removed using the tenets of individual tumor management, while AVMs are managed by embolization, surgical removal, or a combination of those modalities.

Because of the paucity of cases, empirical data do not exist to clarify which treatment course provides a better outcome.

Outcome and Prognosis

Too few data are available to derive solid outcome and prognosis figures for this disease. As noted above, however, the ultimate outcome of a patient correlates strongly with their initial neurological status; in other words, a patient with minimal findings upon presentation will likely experience a much better outcome than a patient who presents with a significant neurological deficit.

Future and Controversies

Spinal cord hematoma or hematomyelia is a fairly rare entity that is usually caused by some underlying pathology or disease process. These causative diseases include AVMs, coagulopathies, tumors, syringomyelia, and vasculitis. No associated problems occur in a subset of these patients.

Clinical presentation is usually a sudden onset of spinal pain accompanied by neurological deficits correlative with the site of the clot. Treatment is aimed at correcting the underlying pathology or clotting disorder and at removing the clot. Timing of treatment and its results are still controversial.


Rod J Oskouian, Jr, MD, Consulting Physician, Swedish Neuroscience Specialists, Swedish Neuroscience Institute, Seattle

Disclosure: Nothing to disclose.


Charles E Rawlings III, MD, Consulting Surgeon, Department of Neurosurgery, Rawlings Neurosurgical Consulting

Disclosure: Nothing to disclose.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Brian H Kopell, MD, Associate Professor, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from St Jude Neuromodulation for consulting; Received consulting fee from MRI Interventions for consulting.


  1. Pobiel RS, Schellhas KP, Eklund JA, Golden MJ, Johnson BA, Chopra S, et al. Selective cervical nerve root blockade: prospective study of immediate and longer term complications. AJNR Am J Neuroradiol. 2009 Mar. 30(3):507-11. [View Abstract]
  2. Miyakoshi N, Hongo M, Kasukawa Y, Ando S, Shimada Y. Thoracic disk herniation with hematoma--case report. Neurol Med Chir (Tokyo). 2008 Sep. 48(9):414-7. [View Abstract]
  3. Agarwal A, Kanekar S, Thamburaj K, Vijay K. Radiation-induced spinal cord hemorrhage (hematomyelia). Neurol Int. 2014 Oct 23. 6 (4):5553. [View Abstract]
  4. Famularo G, Sajeva MR, Gasbarrone L. Warfarin-associated hematomyelia. Intern Med. 2014. 53 (6):623-6. [View Abstract]
  5. Saliou G, Tej A, Theaudin M, Tardieu M, Ozanne A, Sachet M, et al. Risk factors of hematomyelia recurrence and clinical outcome in children with intradural spinal cord arteriovenous malformations. AJNR Am J Neuroradiol. 2014 Jul. 35 (7):1440-6. [View Abstract]
  6. Matsui T, Taniguchi T, Saitoh T, Kamijoh K, Nakamura T, Yamashita A, et al. Hematomyelia caused by ruptured intramedullary spinal artery aneurysm associated with extramedullary spinal arteriovenous fistula--case report. Neurol Med Chir (Tokyo). 2007 May. 47(5):233-6. [View Abstract]
  7. Che XM, Xu QW, Shou JJ, Gu SX, Zhang MG, Sun B, et al. [The diagnosis and surgical management for intramedullary spinal cord cavernous angioma]. Zhonghua Yi Xue Za Zhi. 2008 May 20. 88(19):1306-8. [View Abstract]
  8. Schenk VWD. Haemorrhages in spinal cord with syringomyelia in a patient with haemophilia. Acta Neuropathol. 1963. 2:306-308.
  9. Wisoff JH, Rovit RL, Ho V. Spontaneous hematomyelia secondary to factor XI deficiency. Case report. J Neurosurg. 1985 Aug. 63(2):293-5. [View Abstract]
  10. Allen JC, Miller DC, Budzilovich GN. Brain and spinal cord hemorrhage in long-term survivors of malignant pediatric brain tumors: a possible late effect of therapy. Neurology. 1991 Jan. 41(1):148-50. [View Abstract]
  11. Cassinotto C, Deramond H, Olindo S, Aveillan M, Smadja D, Cabre P. MRI of the spinal cord in neuromyelitis optica and recurrent longitudinal extensive myelitis. J Neuroradiol. 2009 Feb 13. [View Abstract]
  12. Gowers WR. A Manual of Diseases of the Nervous System. Diseases of the Spinal Cord and Nerves. 1886.
  13. Brandt M. Spontaneous intramedullary haematoma as a complication of anticoagulant therapy. Acta Neurochir (Wien). 1980. 52(1-2):73-7. [View Abstract]
  14. Leech RW, Pitha JV, Brumback RA. Spontaneous haematomyelia: a necropsy study. J Neurol Neurosurg Psychiatry. 1991 Feb. 54(2):172-4. [View Abstract]
  15. Trautner S, Pedersen H, Bendtson I. [Neuromyelitis optica with atypical cerebral lesions demonstrated by magnetic resonance imaging in a 9-year old girl]. Ugeskr Laeger. 2009 Jan 26. 171(5):334-6. [View Abstract]
  16. Banczerowski P, Vajda J, Veres R. [Removal of intraspinal space-occupying lesions through unilateral partial approach, the "hemi-semi laminectomy"]. Ideggyogy Sz. 2008 Mar 30. 61(3-4):114-22. [View Abstract]
  17. Borm W, Mohr K, Hassepass U, Richter HP, Kast E. Spinal hematoma unrelated to previous surgery: analysis of 15 consecutive cases treated in a single institution within a 10-year period. Spine. 2004 Dec 15. 29(24):E555-61. [View Abstract]
  18. Constantini S, Ashkenazi E, Shoshan Y. Thoracic hematomyelia secondary to coumadin anticoagulant therapy: a case report. Eur Neurol. 1992. 32(2):109-11. [View Abstract]
  19. Hamlat A, Adn M, Ben Yahia M, et al. Gowers intrasyringal hemorrhage. Case report and review of the literature. J Neurosurg Spine. 2005 Dec. 3(6):477-81.
  20. Kumar S, Kumar Jaiswal A, Singh H. Spontaneous intramedullary hematoma. A case report. J Neurosurg Sci. 2005 Mar. 49(1):21-3; discussion 23.
  21. Lee DS, Kobrine A. Neurogenic pulmonary edema associated with ruptured spinal cord arteriovenous malformation. Neurosurgery. 1983 Jun. 12(6):691-3. [View Abstract]
  22. McCormick PC, Michelsen WJ, Post KD. Cavernous malformations of the spinal cord. Neurosurgery. 1988 Oct. 23(4):459-63. [View Abstract]
  23. McCormick PC, Torres R, Post KD. Intramedullary ependymoma of the spinal cord. J Neurosurg. 1990 Apr. 72(4):523-32. [View Abstract]
  24. Odom GL, Woodhall B, Margolis G. Spontaneous hematomyelia and angiomas of the spinal cord. J Neurosurg. 1957. 14:192-202.
  25. Onda K, Yoshida Y, Arai H, Terada T. Complex arteriovenous fistulas at C1 causing hematomyelia through aneurysmal rupture of a feeder from the anterior spinal artery. Acta Neurochir (Wien). 2011 Nov 24. [View Abstract]
  26. Oyanagi K, Yamazaki K, Hinokuma K. An autopsy case of intramedullary venous malformation of the spinal cord with spreading hematomyelia. Clin Neuropathol. 1990 May-Jun. 9(3):148-51. [View Abstract]
  27. Perot P, Feindel W, Lloyd-Smith D. Hematomyelia as a complication of syringomyelia: Gowers'' syringal hemorrhage. Case report. J Neurosurg. 1966 Oct. 25(4):447-51. [View Abstract]
  28. Pisani R, Carta F, Guiducci G. Hematomyelia during anticoagulant therapy. Surg Neurol. 1985 Nov. 24(5):578-80. [View Abstract]
  29. Rodesch G, Hurth M, Alvarez H, et al. Spinal cord intradural arteriovenous fistulae: anatomic, clinical, and therapeutic considerations in a series of 32 consecutive patients seen between 1981 and 2000 with emphasis on endovascular therapy. Neurosurgery. 2005 Nov. 57(5):973-83.
  30. Sato K, Kubota T, Ishida M, Handa Y. Spinal tanycytic ependymoma with hematomyelia--case report--. Neurol Med Chir (Tokyo). 2005 Mar. 45(3):168-71.
  31. Thibaud JL, Hidalgo A, Benchekroun G, Fanchon L, Crespeau F, Delisle F, et al. Progressive myelopathy due to a spontaneous intramedullary hematoma in a dog: pre- and postoperative clinical and magnetic resonance imaging follow-up. J Am Anim Hosp Assoc. 2008 Sep-Oct. 44(5):266-75. [View Abstract]
  32. Tubbs RS, Smyth MD, Wellons JC, Oakes WJ. Intramedullary hemorrhage in a neonate after lumbar puncture resulting in paraplegia: a case report. Pediatrics. 2004 May. 113(5):1403-5.
  33. Wisoff HS. Spontaneous intraspinal hemorrhage. In: Wilkins RH, Rengachary SS. eds. Neurosurgery. 2nd ed, Vol. 2. New York: McGraw-Hill. 1996:2559-65.

This T1-weighted sagittal MRI is from a 19-year-old man with 4-month history of progressive motor loss and an inability to ambulate. He underwent spinal biopsy that confirmed an intramedullary glioblastoma.

This T1-weighted sagittal MRI is from a 19-year-old man with 4-month history of progressive motor loss and an inability to ambulate. He underwent spinal biopsy that confirmed an intramedullary glioblastoma.