Spinal Cord Hemorrhage Workup

Updated: Jul 21, 2021
  • Author: Morteza Sadeh, MD, PhD, MS; Chief Editor: Helmi L Lutsep, MD  more...
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Laboratory Studies

The following laboratory studies may aid in diagnosis:

  • CBC with platelets
  • Prothrombin time (PT)/INR and activated partial thromboplastin time (aPTT) – to exclude coagulopathy
  • CSF studies (cell count, glucose, protein, oligoclonal bands, etc.) are helpful if infectious, inflammatory or demyelinating etiologies are expected
  • CSF xanthochromia

Imaging Studies

Spinal MRI

Cervical, thoracic, or lumbar spinal MRI is the preferred test to confirm presence and delineate location of hemorrhage. This may indicate the underlying pathology, for instance, with enhancement.

CT myelography

An alternative when clinical suspicion is high and MRI is not available, or the patient who is not able to tolerate MRI. CT myelogram shows fluid collections (such as EDH, SDH) and is also useful for CSF leak detection. In general, CT is not as sensitive as MRI for non-boney structures. CT alone may or may not show acute hematomyelia.



Lumbar puncture

If hemorrhage extends into the cerebrospinal fluid (CSF), the CSF sample is usually bloody appearing or xanthochromic, and protein content is increased. Xanthochromia is the yellowish discoloration of CSF due to the presence of bilirubin, which is the result of RBC lysis and subsequent heme breakdown occurring over time. An initial “bloody tap” (in the absence of a preceding hemorrhagic event) should clear and not be xanthochromic.

Xanthochromia may be present as early as 4 hours post hemorrhage, but usually takes about 12 hours to occur, after the appearance of blood within the subarachnoid space.  It may persist up to four days after the original hemorrhage. Detection of xanthochromia is done by visual inspection pre- and post CSF centrifugation, which eliminates red blood cells.  Mass spectroscopy of CSF may also be useful, for detection of bilirubin and to rule out other possible causes of xanthochromia (such as high protein content, or melanin). This is especially useful when the suspicion for SAH is high and the imaging findings are negative due to the time elapsed since the hemorrhage, or with smaller amounts of blood. [23]

Spinal angiography

This may be helpful in delineating the size, location, configuration, and blood flow of a spinal vascular malformation, such as AVM or AVF.