Case Report

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American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

Ischemic stroke differential diagnose: spontaneous spinal epidural hematoma can be fatal

Spontaneous Spinal epidural hematoma is rarely seen, and it is the important reason for the Spinal cord compression. Patients generally visit a doctor due to the acute pain in the neck and interscapular area. A 58-year-old male patient was admitted to the emergency service of our hospital with a sudden-onset neck pain followed by rapid progres- sive right hemiparesis. He arrived at our hospital 120 minutes after the onset of her symptoms with suspected acute stroke. We assessed for acute stroke performed clinical examinations necessary for intravenous thrombolytic treatment with alteplase. No abnormality was observed in his brain tomography and diffusion magnetic resonance imaging. We suspected about spinal cord pathology, and cervical magnetic resonance imaging demonstrated an epidural hematoma causing compression of the spinal cord. Spontaneous spinal epidural hematoma is a rare but an urgent condition and should be diagnosed and treated fast. It can mimic such conditions such as stroke. When the patient who was ad- mitted to the hospital with hemiparesis (for instance, patient with right-side paralysis), if there was no hemispheric or cranial finding, spontaneous spinal epidural hematoma should be kept in mind in the differential diagnosis.

Spontaneous spinal epidural hematoma (SSEH) is rarely seen, and it is the important reason for the spinal cord compression [1]. The incidence of this Rare condition is predicted as 0.1/100000 [2]. Patients generally visit a doctor due to the acute pain in the neck and interscapular area. There can be motor and sensory loss due to the spinal cord compression [3]. early diagnosis and treatment are very important for prognosis. In our study, we included SSEH cases who visited the doctor with stroke symptoms.

A 58-year-old male patient was admitted to the emergency service of our hospital with a sudden-onset neck pain followed by rapid progressive right hemiparesis. He arrived at our hospital 120 minutes after the onset of her symptoms with suspected acute stroke. The patient did not have trauma history and systemic disease as well as the routine use of drugs, but his blood pressure was 180/110 mm Hg when he was examined in the emergency service. The right upper and lower extremity muscle strength was evaluated as 3/5 according to his neurologic examination. However, his general and sensory examination had normal results. Urea, creatinine, liver enzyme values, activated par- tial thromboplastin time, and international normalized ratio values were also normal according to the results of laboratory tests. We assessed for acute stroke-performed clinical examinations necessary for intravenous thrombolytic treatment with alteplase. No abnormality was observed in his brain tomography and diffusion magnetic reso- nance imaging (MRI). brain MRI and MRI angiography were negative for signs of Ischemic infarction. Computed tomography arteriography

was normal (Fig. 1). We suspected about spinal cord pathology, and cer- vical MRI demonstrated an epidural hematoma causing compression of the spinal cord (Fig. 2).

We planned an operation after consulting the brain surgery. Howev- er, we did not operate the patient because the clinicals complaints were rapidly recovered upon the antiedema treatment. His blood pressure was controlled with Antihypertensive therapy. He was recruited to the hospital for further examination after 1 month, and the strength of his muscles was nearly normal. It was observed that the bleeding was spontaneously resorbed.

Spinal epidural hematomas can be divided into 2 groups, spontaneous and traumatic. The incidence of the SSEH is 0.1/100000, and it requires immediate intervention [2]. Characteristic symptoms were pains radiating neck and back, paraparesis, and sensory deficits. The most common cause of hemiparesisis is a cerebrovascular incident such as cerebral infarction. Spinal cord disorders, although rare, can lead to hemiparesis depending on the unilateral corticoSpinal injury [4]. Cervical MRI is the imaging method of choice in the diagnosis of SSEH. Magnetic resonance imaging supplies the most reliable data in the duration of the hemorrhage, hematoma localization, spinal cord edema, and the determination of the degree of spinal cord compression. Spontaneous spinal epidural hematoma is characterized with isointense on T₁-weighted images within the first 24 hours after hemorrhage and the hyperintense signal changes between 24 and 36 hours [2]. Sponta- neous spinal epidural hematoma is an urgent surgical condition, and the most effective treatment is decompressive laminectomy and draining the hematoma quickly [5]. conservative therapy can be applied to patients with declining neurologic deficits and high surgical risk [6]. An important factor in the prognosis of the disease in SSEH was the time between the onset of the symptoms (complaints) and surgery [7]. According to studies, the Neurologic recovery rates were detected as very high in the patients who were operated on in 12 hours upon neurologic deficit [8].

Recently, intravenous thrombolytic treatment with alteplase

initiated within 3 hours of symptom onset has been approved in most countries for treatment of acute ischemic stroke. Alteplase administra- tion in the person with SSEH can be fatal [9]. Because of the severe acute neck pain, presence of hemiparesis without cranial nerve finding and the normal diffusion MRI directed us to cervical pathology. As a result, SSEH is a rare but an urgent condition, and it should be diagnosed and treated fast. It can mimic such conditions such as stroke. When the patient who was admitted to the hospital with hemiparesis (for instance, a patient with right-side paralysis), if there was no hemispheric or cranial finding, SSEH should be kept in mind in the differential diagnosis.

0735-6757/(C) 2015

Fig. 1. Computed tomography arteriography was normal.

Fig. 2. Cervical MRI demonstrated an epidural hematoma causing compression of the spinal cord.

Huseyin Buyukgol, MD Department of Neurology, Aksaray State Hospital, Aksaray, Turkey Corresponding author. Tel.: + 90 05336142789

E-mail address: [email protected]

M. Kemal Ilik

Mevlana University Department of neurosurgery, Konya, Turkey

Faik Ilik

Mevlana University Department of Neurology, Konya, Turkey

http://dx.doi.org/10.1016/j.ajem.2015.01.018

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