How to Avoid Misdiagnosing Spontaneous Cervical Spinal Epidural Hematoma as Ischemic Stroke: 3 Case Reports and Literature Review

Abstract

When spontaneous cervical spinal epidural hematoma (SCEH) presents with hemiparesis, it can be misdiagnosed with ischemic stroke (IS), and the treatment of IS such as thrombolysis may deteriorate the symptoms of patients with SCEH, leading to worse sequelae or even death. We reported 3 SCEH patients who were initially suspected as IS in our center between Jun 2020 and April 2022 and analyzed their clinical characteristics together with 48 patients reported in the literature from Jan 1995 to April 2022. Two of the 3 SCEH patients had neck symptoms, while none of them presented cranial nerve symptoms. Cranial computed tomography (CT) scans were negative; however, abnormal signals in the cervical spinal canal were observed during cranial computed tomography angiography (CTA) and subsequent cervical CT confirmed the diagnosis of SCEH. All of them avoid mistreatment with recombinant tissue plasminogen activator (rt-PA). Subsequently, we analyzed the clinical characteristics of a total of 51 patients. Thirteen of them developed symptoms during activity. Neck pain was an important sign of SCEH because 35 patients had neck pain or neck discomfort. Sensory impairment was reported in a small proportion of patients (11/51), which varied a lot in the patients. Some special manifestations highly suggested spinal cord lesions and provided evidence for the early differential diagnosis of SCEH and stroke, but the incidence of which was quite low: ipsilateral Horner syndrome in 2 patients, Brown-Séquard syndrome in 2 cases, and Lhermitte’s sign in 1 case. Only a minority (8/51) of the patients were correctly diagnosed at the emergency unit using cervical CT. Six patients were correctly diagnosed when performing CTA. A large portion of the cases (21/51) were first misdiagnosed as IS, but no responsible lesions were found on cranial magnetic resonance imaging (MRI), and subsequent cervical MRI confirmed the diagnosis. Sixteen patients were diagnosed with SCEH after the deterioration of symptoms. A total of 13 patients received rt-PA, and 10 of them had symptoms aggravation after thrombolysis. For patients with acute onset of hemiparesis but without cranial nerve symptoms, especially those accompanied by clinical features such as neck pain, ipsilateral Horner syndrome, Brown-Séquard syndrome, and Lhermitte’s sign, SCEH should be highly suspected rather than stroke. Careful differential diagnosis should be performed with a comprehensive medical history and thorough physical examination. Cervical CT scan is a reasonable choice for quick differential diagnosis prior to administering potentially harmful therapy, especially rt-PA.

Thoracic spinal epidural hematoma misdiagnosed as conversion paralysis: A case report

“…The clinical course of spontaneous SCEH often begins with neck or back pain in the case of cervical or thoracic epidural hematoma, respectively, followed by a transition to spinal symptoms 1,9,10,11 . Symptoms of SCEH are more likely to appear with activities and states that increase intravascular pressure can cause bleeding, such as pregnancy, exertion, or straining (i.e., Valsalva maneuver) 10,12,13 . Predisposing factors for SCEH include a history of coagulopathy, use of anticoagulant or antiplatelet medications, hematologic disorders, tumors of the spinal cord, hypertension, and alcoholism 14,15 .…”

“…As a rule, emergency hematoma removal is recommended for patients with severe neurologic dysfunction or clinical deterioration 20,21 . Early hematoma removal within 12–24 h is the key to improving patient outcomes 12,13,22,23 …”

“… 1 , 9 , 10 , 11 Symptoms of SCEH are more likely to appear with activities and states that increase intravascular pressure can cause bleeding, such as pregnancy, exertion, or straining (i.e., Valsalva maneuver). 10 , 12 , 13 Predisposing factors for SCEH include a history of coagulopathy, use of anticoagulant or antiplatelet medications, hematologic disorders, tumors of the spinal cord, hypertension, and alcoholism. 14 , 15 Interestingly, hemorrhagic spinal complications, including SCEH, have been one of the most common spinal cord lesions caused by SARS‐CoV‐2 invasion.…”

“… 20 , 21 Early hematoma removal within 12–24 h is the key to improving patient outcomes. 12 , 13 , 22 , 23 …”

“…20,21 Early hematoma removal within 12-24 h is the key to improving patient outcomes. 12,13,22,23 This patient had a thoracic epidural hematoma that caused sudden-onset motor paralysis of both lower limbs after defecation, followed thereafter by a severe spinal cord injury. Although emergency hematoma removal was warranted, the delay in diagnosis resulted in severe neurological damage.…”