CASE SUMMARY

A 60-year-old woman underwent spinal anesthesia for abdominal surgery. One day later, the patient presented with paresthesia in her lower legs. T2*-weighted and T2-weighted magnetic resonance imaging (MRI) showed intramedullary bleeding in the central portion of the medullary cone (Figures 1 and 2). This was due to an inadvertent puncture during the administration of spinal anesthesia.

FIGURE 1.
FIGURE 1. (A) An axial-section, T2* or gradient-recalled echo sequence shows the serum (arrowhead) and the susceptibility-artifact, which is due to iron-containing hemoglobin (arrow). (B) This T2* or gradient-recalled echo sequence shows a susceptibility artifact due to hemoglobin (arrow).
FIGURE 2.
FIGURE 2. A sagittal section, T2-weighted turbo spin-echo image depicts a bright signal in the central portion of the distal medulla (arrow).

IMAGING FINDINGS

T2*-weighted gradient-recalled echo (GRE) imaging shows the smallest amounts of intramedullary hematoma (Figure 1) in the medullary cone. T2-weighted turbo spin-echo (TSE) imaging yields a high signal of the fluid-equivalent portion (ie, serum) of the hemorrhagic lesion (Figure 2).

DIAGNOSIS

Intramedullary bleeding after inadvertent puncture of the medullary cone

DISCUSSION

Inadvertent puncture of the spinal cord is a rare cause of neurologic deficit following spinal anes-thesia.1 This patient had paresthesia in her lower legs (numbness and tingling). The reason for the patient’s complaints was postpuncture intramedullary bleeding in the medullary cone. MRI, especially T2*-weighted GRE imaging, can be very useful in detecting the smallest amounts of intramedullary bleeding2 because of the paramagnetic effect of iron that is contained in hemoglobin (Figure 1). Furthermore, fluids, such as serum, are depicted as a bright signal on T2-weighted sequences (Figure 2).

CONCLUSION

When there is a suspected hemorrhagic lesion of the medulla, MRI should be the first imaging modality that is used.