Spontaneous spinal epidural hematoma mimicking transient ischemic attack

Abstract

Rationale:Spontaneous spinal epidural hematoma (SSEH) is a rare but highly disabling neurological emergency. The initial presentations are variable. Most patients of SSEH present with paraplegia or tetraplegia clinically, but recurrent hemiparesis with complete spontaneous recovery, mimicking transient ischemic attack (TIA), is a very rare initial presentation of SSEH.Patient concerns:A 71-year-old female presented to the emergency department with 2 episodes of transient right hemiparesis in 5 hours. Two days later, above symptom reappeared and progressed to quadriplegia, dyspnea, and uroschesis quickly. The neurological examination showed tetraplegia and hypalgesia below the C2 level, but neither facial palsy nor aphasia was found.Diagnosis:The patient was initially misdiagnosed as TIA and treated with antiplatelet therapy. But during the hospital day, the cervical magnetic resonance imaging showed a dorsal epidural hematoma extending from C2 to C6 level and she was diagnosed as SSEH.Interventions:She underwent surgical decompression and hematoma removal 1 week later.Outcomes:One week after operation, the sensory deficit above C6 level improved, but there was no improvement in her muscle strength and dyspnea. Unfortunately, she died 1 month later.Lessons:Our case highlights recurrent hemiparesis with complete spontaneous recovery mimicking TIA is a rare initial presentation of SSEH. It is important to perform careful clinical assessments and neuroimaging investigations for correct diagnosis. Neck pain and hemiparesis sparing cranial nerve are important signs for distinction of SSEH from acute ischemic cerebrovascular diseases.

A brief review of literature of spontaneous spinal epidural hematoma in the context of an idiopathic spinal epidural hematoma

“…In the case series by Liao et al, 54% of patients reported a straining-associated event during the initial attack, supporting the venous theory [1]. This is especially true in the older patients [2]. They have slow progression of neurological deficits.…”

“…The venous theory will not be applicable in the cervical region [1,2]. The venous pressure is lower than the intrathecal pressure [1,2]. Secondly, the cervical epidural hematoma usually produces rapid deterioration.…”

“…It may be a consequence of trauma or abrupt movements. The rapid development of spinal cord compression is better explained by arterial bleeding [2,3]. The high mobility of the C6-C7 cervical spine also is a factor [3,5].…”

“…There is a debate over the origin of bleeding. Literature describes both venous and arterial origins, although the most widely accepted theory is of the venous origin [1,2]. There is a lack of consensus on treatment also.…”

Spontaneous cervical epidural hematoma mimicking a transient ischemic attack

“…However, if misdiagnosed as TIA and antiplatelet therapy is initiated, cervical epidural hematoma could deteriorate, which might require emergency decompressive laminectomy and result in permanent sequela or death. 4,5 Therefore, spontaneous cervical epidural hematoma should always be considered as an important differential diagnosis in patients with neck pain and transient hemiparesis mimicking TIA. In patients with transient hemiparesis mimicking TIA, neurological examination is not helpful because of improvement of neurological abnormalities.…”