Hematomyelia¶

Definition¶

Hematomyelia is hemorrhage within the substance of the spinal cord. It can result from trauma, vascular malformations, tumors, coagulopathy, or spontaneously. The hemorrhage disrupts neural pathways and causes acute neurological deficit.

Etiology¶

Trauma — Most common cause; cord hemorrhage complicating spinal cord injury
Vascular malformations — Cavernous malformations, AVMs
Tumors — Hemorrhagic intramedullary tumors (ependymoma, hemangioblastoma)
Coagulopathy — Anticoagulation therapy, thrombocytopenia
Spontaneous — Rare

Imaging Findings¶

MRI¶

Signal characteristics follow the standard evolution of hemorrhage:

Hyperacute (<24 hours) — Oxyhemoglobin: T1 iso/low, T2 bright
Acute (1–3 days) — Deoxyhemoglobin: T1 iso/low, T2 dark
Early subacute (3–7 days) — Intracellular methemoglobin: T1 bright, T2 dark
Late subacute (1–4 weeks) — Extracellular methemoglobin: T1 bright, T2 bright
Chronic (>4 weeks) — Hemosiderin: T1 dark, T2 dark

The cord is expanded at the level of hemorrhage. Surrounding edema (T2 hyperintensity) is common. GRE/SWI sequences are most sensitive for detecting hemorrhage products (hemosiderin).

Clinical Pearl

When hematomyelia is identified, always search for an underlying cause — particularly a cavernous malformation or vascular tumor. Cavernous malformations show a characteristic "popcorn" or mixed-signal appearance with a complete hemosiderin rim on T2/GRE. Ependymomas and hemangioblastomas may show an enhancing nodule adjacent to the hemorrhage.

Key Points¶

Hemorrhage within the spinal cord parenchyma
MRI signal characteristics follow the standard hemorrhage evolution
Trauma is the most common cause; cavernous malformations and tumors are important considerations
GRE/SWI is the most sensitive sequence for hemosiderin detection
Always evaluate for an underlying vascular malformation or tumor

References¶

Haematomyelia. Radiopaedia.org. https://radiopaedia.org/articles/haematomyelia
Pierce JL, Donahue JH, Nacey NC, et al. Spinal hematomas: what a radiologist needs to know. RadioGraphics. 2018;38(5):1516-1535. https://pubmed.ncbi.nlm.nih.gov/30207937/
Moriarty HK, O'Cearbhaill R, Moriarty PD, Stanley E, Lawler LP, Kavanagh EC. MR imaging of spinal haematoma: a pictorial review. Br J Radiol. 2018;92(1095):20180532. https://pmc.ncbi.nlm.nih.gov/articles/PMC6541191/
Leep Hunderfund AN, Wijdicks EFM. Intramedullary spinal cord hemorrhage (hematomyelia). Rev Neurol Dis. 2009;6(2):E54-E61. https://pubmed.ncbi.nlm.nih.gov/19587631/
Shaban A, Moritani T, Al Kasab S, Sheharyar A, Limaye KS, Adams HP Jr. Spinal cord hemorrhage. J Stroke Cerebrovasc Dis. 2018;27(6):1435-1446. https://pubmed.ncbi.nlm.nih.gov/29555403/
Panda A, Diehn FE, Kim DK, et al. Spinal cord cavernous malformations: MRI commonly shows adjacent intramedullary hemorrhage. J Neuroimaging. 2020;30(5):690-696. https://pubmed.ncbi.nlm.nih.gov/32462668/