Abstract:Spontaneous spinal epidural hematomas (SSEHs) are neurological emergencies complicated by a wide array of presentations. In this study, we report a case of a patient who presented with neck pain and was diagnosed with an SSEH with computed tomography (CT) angiography with subsequent confirmation by magnetic resonance imaging (MRI). The high-risk location and size of the lesion guided management and surgical intervention. In a stable patient presenting to the emergency department without focal neurological defi… Show more
“…SCEH has a time‐sensitive prognosis, with delayed diagnosis potentially leading to permanent neurological sequelae and death. 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 …”
Key Clinical MessageA woman with a history of psychiatric hospitalization was misdiagnosed with conversion paralysis despite lower extremity paralysis due to a thoracic epidural hematoma, leaving her with severe neurological deficits. Conversion paralysis is a diagnosis of exclusion and should never be made unless all possible organic causes have been ruled out.
“…SCEH has a time‐sensitive prognosis, with delayed diagnosis potentially leading to permanent neurological sequelae and death. 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 …”
Key Clinical MessageA woman with a history of psychiatric hospitalization was misdiagnosed with conversion paralysis despite lower extremity paralysis due to a thoracic epidural hematoma, leaving her with severe neurological deficits. Conversion paralysis is a diagnosis of exclusion and should never be made unless all possible organic causes have been ruled out.
“…It has also been suggested that CT angiogram can be utilized to rapidly monitor patients who have worsening pathology. However, the clinician must bear in mind that the CT findings may be subtle and smaller hematomas can be missed [ 20 ]. Fig.…”
Background
This case report presents the case of a man with no known coagulopathy or preceding trauma, who spontaneously developed a spinal epidural hematoma (SEH). This is an uncommon condition which can have variable presentations including hemiparesis mimicking stroke, resulting in the potential for misdiagnosis and inappropriate treatment.
Case presentation
A 28-year-old Chinese male with no past medical history presented with sudden onset neck pain associated with bilateral upper limbs and right lower limb subjective numbness but intact motor function. He was discharged after adequate pain relief but re-attended the emergency department with right hemiparesis. A magnetic resonance imaging of his spine revealed an acute cervical spinal epidural hematoma at C5 and C6. While admitted, he had spontaneous improvement of his neurological function and was eventually managed conservatively.
Conclusions
SEH, although uncommon, can be a mimic of stroke and it is important to avoid misdiagnosis as it is a time critical diagnosis, and administration of thrombolysis or antiplatelets can lead to unfavourable outcomes. Having a high clinical suspicion can help to guide us in the choice of imaging and interpretation of subtle signs to reach the correct diagnosis in a timely manner. Further research is required to better understand the factors that would favour a conservative approach as opposed to surgical treatment.
“…Radiologic differential diagnosis might include lymphoma as well as abscess. Younger patients may present after exertion and during pregnancy 19,20 …”
Section: Discussionmentioning
confidence: 99%
“…Younger patients may present after exertion and during pregnancy. 19,20 Sensory and motor deficit progression are associated with prognosis. Interval of onset and severity of deficits have demonstrated those with partially preserved function before intervention are more likely to show complete recovery.…”
We report a rare case of spontaneous spinal epidural hematoma. Various presentations may occur, most commonly including neck pain, interscapular pain, radicular pain, and paralysis. This condition is frequently associated with paralysis and long‐term disability. This case is unique because it presented with right hand cyanosis, in addition to pain. A 69‐year‐old Caucasian female presented with cyanosis of the right hand, and severe right upper extremity pain which awakened her approximately 11 hours earlier. The pain was exacerbated on extending her head. The patient further reported bilateral shoulder pain and interscapular pain. She reported no motor weakness or paralysis. She denied any history of trauma. The patient was taking aspirin 81 mg/d for the past 2 months. Physical examination revealed cyanosis of the digits of the right hand as well as mildly diminished right biceps reflex and right grip strength. No edema or rashes were noted. Skin was warm and dry. Pulses were +2 in all extremities. Vital signs were within normal limits. The remainder of the physical examination was unremarkable. Magnetic resonance imaging of the cervical/thoracic spine revealed a right posterior–lateral epidural hematoma extending from the 3rd cervical level to the 1st thoracic level of the spinal cord. There was also evidence of cord compression at the 4th‐5th and 5th‐6th cervical levels. Given the potential for significant complications, clinicians should maintain a high index of suspicion for spinal epidural hematoma, particularly in those patients taking anticoagulation. Symptoms, including extremity cyanosis, pain, and paralysis all are suggestive of the diagnosis.
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