Spontaneous spinal epidural hematoma leading to acute paraplegia: a case report.

BACKGROUND: Spontaneous spinal epidural hematoma is an infrequent yet potentially debilitating condition characterized by blood accumulation in the epidural space, with only 300 documented cases globally. Although the exact etiology of spontaneous spinal epidural hematoma remains poorly understood, theories suggest arteriovenous malformations, rupture of epidural vessels, or epidural veins as possible causes. CASE PRESENTATION: This study presents a 58-year-old Malay woman patient from Singapore with well-controlled hypertension, hyperlipidemia, type II diabetes mellitus, and microscopic hematuria. Despite a prior cystoscopy revealing no abnormalities, she presented to the emergency department with sudden-onset back pain, weakness, and numbness in both lower limbs. Rapidly progressing symptoms prompted imaging, leading to the diagnosis of a spinal epidural hematoma from thoracic (T) 9 to lumbar (L) 1. Prompt decompressive surgery was performed, and the patient is currently undergoing postoperative rehabilitation for paralysis. CONCLUSION: This case emphasizes the severity and life-altering consequences of spontaneous spinal epidural hematomas. Despite various proposed causative factors, a definitive consensus remains elusive in current literature. Consequently, maintaining a low threshold of suspicion for patients with similar presentations is crucial. The findings underscore the urgent need for swift evaluation and surgical intervention in cases of acute paraplegia.

Progressive unilateral leg weakness after lumbar decompression due to ischemic monomelic neuropathy misdiagnosed as epidural hematoma: A CARE-compliant case report.

RATIONALE: Ischemic monomelic neuropathy (IMN) is a disease that occurs after acute arterial occlusion or steal phenomenon in an extremity that results in single or multiple axonal mononeuropathies in the distal limb without the classical features of limb ischemia, including a skin color change, limb swelling, and ischemic claudication. IMN can easily be misdiagnosed as any other neuropathic disorder. Here we present a case of IMN that was misdiagnosed as spinal epidural hematoma. PATIENT CONCERNS: A 77-year-old man presented with sudden motor weakness and pain in his left foot and calf 5 days after a bilateral L4 to 5 posterior decompression for lumbar spinal stenosis. His symptoms progressed over the next 5 days. The strengths of the left ankle dorsiflexors, first toe extensors, and ankle plantar flexors were Medical Research Council 0. On brain and whole-spine magnetic resonance imaging, no specific abnormalities correlated with his symptoms were observed. Computed tomography angiography of the lower extremities revealed segmental occlusion of the left common femoral artery and multifocal severe stenoses in the bilateral anterior and posterior tibial arteries of the left leg. No skin color change or swelling was observed in the left lower extremity. DIAGNOSIS: Based on his clinical features and imaging findings, he was diagnosed with IMN. INTERVENTION: The patient underwent thrombectomy of the left femoral artery. OUTCOMES: After the treatment, his pain almost completely disappeared. LESSONS: When patients exhibit acute-onset pain in the unilateral limb with or without motor weakness but no correlated abnormality on spinal magnetic resonance imaging or computed tomography, clinicians should consider the possibility of IMN.

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

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.

Evacuation of a spontaneous massive spinal epidural hematoma by a minimally invasive surgical technique: a case report.

Spontaneous spinal epidural hematomas are a rare consequence of long-term anticoagulant therapy. Their physiopathology remains poorly understood. This pathology carries a significant risk of morbidity. The purpose of this article is to report a case of a massive spontaneous spinal epidural hematoma extending on multiple levels, detailing the surgical technique used in its evacuation described for the first time in literature. This is a case report of an 80-year-old patient on anticoagulant therapy with a thoracolumbar spontaneous spinal epidural hematoma extending from T1 to L1 vertebrae. We share the clinical and radiological presentations, the surgical treatment, outcome and follow-up. The diagnosis of spontaneous spinal epidural hematoma has to be considered in patients with acute brutal onset radiculo-medullary compression. Medullary magnetic resonance imaging (MRI) remains the exam of choice. Medical and surgical treatment must be started immediately after the diagnosis is confirmed. The prognosis remains poor despite a proper management, with debilitating complications.

Spontaneous cervical epidural haematoma mimicking stroke: a case report and literature review.

Spontaneous spinal epidural haematoma (SSEH) is a rare disease that requires emergency decompression or haematoma evacuation to prevent permanent neurological deficits. Hemiparesis is an extremely rare presentation of SSEH, commonly misdiagnosed as stroke. With the help of case studies and references, this paper comprehensively discusses the effective methods to distinguish SSEH from stroke and provides theoretical support and ideas for rapid and accurate identification of SSEH. Herein, we report on the case of a 51-year-old man with SSEH who presented with acute hemiparesis and posterior neck pain. Cervical computed tomography (CT) revealed cervical degeneration. A carotid CT angiogram revealed a high-density mass in the C2-C5 right posterolateral epidural region. Cervical spine magnetic resonance imaging showed SSEH. The patient was conservatively treated and discharged following a full recovery. Rapid identification of SSEH continues to present a great challenge for neurologists. A soft tissue CT scan can be used to quickly and accurately identify SSEH; however, in the absence of cranial signs, Brown-Sequard syndrome, Lhermitte's sign and Horner syndrome should be used to differentiate SSEH from stroke.

[Neck pain: when is it ominous?] / Nekpijn: wanneer omineus?

Three patients with acute severe neck pain, presented with and without neurological deficits. One patient had severe neck pain followed by autonomic dysfunction, aphagia and dysarthria. She had an vertebrobasilar infarction due to the etiology of a dissection of both vertebral arteries. In one patient with a subarachnoidal bleeding, were the complaints mainly started with severe neck pain. There was no aneurysma found. One patient presented with severe pain in the right side of the neck, shoulders and her right arm. She had a hemiparesis. Because of the suspicion of a cerebral infarction, additional anticoagulation was started. She developed a paraparalysis. Her diagnosis was an acute spontaneous cervical epidural hematoma In a few cases, the presence of solely per-acute neck pain is found as symptom of a subarachnoid hemorrhage. In cases of acute neck pain with alarm symptoms, the patient should be referred to the emergency department.

Postoperative Epidural Hematoma.

Symptomatic postoperative epidural hematomas are rare, with an incidence of 0.10% to 0.69%. Risk factors have varied in the literature, but multiple studies have reported advanced age, preoperative or postoperative coagulopathy, and multilevel laminectomy as risk factors for hematoma. The role of pharmacologic anticoagulation after spine surgery remains unclear, but multiple studies suggest it can be done safely with a low risk of epidural hematoma. Prophylactic suction drains have not been found to lower hematoma incidence. Most symptomatic postoperative epidural hematomas present within the first 24 to 48 hours after surgery but can present later. Diagnosis of a symptomatic hematoma requires correlation of clinical signs and symptoms with a compressive hematoma on MRI. Patients will usually first complain of a marked increase in axial pain, followed by radicular symptoms in the extremities, followed by motor weakness and sphincter dysfunction. An MRI should be obtained emergently, and if it confirms a compressive hematoma, surgical evacuation should be carried out as quickly as possible. The prognosis for neurologic improvement after evacuation depends on the time delay and the degree of neurologic impairment before evacuation.

Evaluation and Management of Cauda Equina Syndrome.

Cauda equina syndrome is a potentially devastating spinal condition. The diagnosis of cauda equina syndrome lacks sensitivity and specificity, sometimes occurring after irreparable neurological damage has happened. Timely diagnosis and treatment is imperative for optimal outcomes and for avoiding medicolegal ramifications. Cauda equina syndrome results from conditions that compress the nerves in the lumbosacral spinal canal. Although no consensus definition exists, it generally presents with varying degrees of sensory loss, motor weakness, and bowel and bladder dysfunction (the latter of which is required to definitively establish the diagnosis). A thorough history and physical exam is imperative, followed by magnetic resonance or computed tomography imaging myelogram to aid in diagnosis and treatment. Once suspected, emergent spinal surgery referral is indicated, along with urgent decompression. Even with expeditious surgery, improvements remain inconsistent. However, early intervention has been shown to portend greater chance of neurologic recovery. All providers in clinical practice must understand the severity of this condition. Providers can optimize long-term patient outcomes and minimize the risk of litigation by open communication, good clinical practice, thorough documentation, and expeditious care.

Extruded disc causes acute cervical epidural hematoma and cord compression: a case report.

INTRODUCTION: Cervical spontaneous epidural hematoma is a serious neurosurgical pathology that often requires prompt surgical intervention. While a variety of causes may contribute, the authors present the first case in the literature of cervical disc extrusion provoking epidural hemorrhage and acute neurological deterioration. CASE PRESENTATION: A 65 year old male presented with six months of worsening signs and symptoms of cervical myelopathy. He had progressive deterioration over the course of two weeks leading to ambulatory dysfunction requiring a cane for assistance. While undergoing his medical workup in the emergency department, the patient became acutely plegic in the right lower extremity prompting emergent surgical decompression and stabilization. DISCUSSION: Based on imaging, pathology, and intraoperative findings, it was concluded that the patient had an extruded disc segment that may have precipitated venous bleeding in the epidural space and findings of acute cervical cord compression. Cervical disc extrusion may lead to venous damage, epidural hematoma, and spinal cord compression. If this unique presentation is recognized and addressed in a timely manner, patient outcomes may still be largely positive as this case demonstrates.

Therapeutic strategy for acute spinal cord paralysis by epidural hematoma derived from the application of non-operative observation and the optimal timing to convert to surgical intervention.

Some cases of acute spinal cord paralysis by epidural hematoma have made complete recovery through natural progression. This group cannot be ignored in choosing a therapy. We have considered the applications of non-operative observation and the optimal timing to convert to surgical intervention. Of the 454 cases reported, cases that were of trauma/post-operative, undergone epidural block, lumbosacral level, paralysis-free, were excluded. 10 clinical items were identified as factors related to the outcome of therapy, and a total of 142 cases (73 surgical and 69 non-surgical/observation cases) which included all items in its record, were extracted for this study. 104 cases that made complete recovery from spinal paralysis (CR) includes 65 cases without surgical intervention (NOP-CR). Using "paralysis recovery start time (PRST)", ROC analysis was conducted to show the diagnostic time needed to detect the cases of CR and NOP-CR. Clinical characteristics of CR and NOP-CR were identified using multiple logistics regression analysis. CR probability were higher at PRST < 15 h from the onset and NOP-CR was even higher at < 11 h. Three clinical items: incomplete motor paralysis, no use of anti-coagulant therapy, and PRST within 15 h were found to be the characteristics of CR and NOP-CR. The case with all 3 items; especially PRST within 11 h from onset, is applicable to non-operative observation. Immediate surgical intervention at 6-hours is recommended in cases that presented with unchanged complete motor paralysis. Observation treatment is discontinued and converted to surgery if motor usefulness is not regained at 15-hours.

[Cervical Spinal Epidural Hematoma].

A woman in her 60s was admitted to our hospital because of sudden-onset right hemiparesis, paresthesia, and neck pain. At first, a head CT scan was performed to rule out stroke, which did not detect any abnormalities. Subsequently, a neck CT scan was performed, which revealed a mild high-density structure compressing the dural sac within the cervical spinal canal. She was suspected to have a spinal hematoma. A MRI scan revealed a spindle-shaped structure with a heterogeneous high signal on T2-weighted and a mild high signal on T1-weighted sagittal images, which led to the diagnosis of a spontaneous spinal epidural hematoma. The patient was treated with conservative therapy upon which her symptoms improved. She was discharged seven days after admission. Spontaneous cervical spinal epidural hematoma often causes neck pain followed by unilateral spinal cord compression symptoms(such as hemiparesis and paresthesia)and can be misdiagnosed as a stroke. In cases of hemiparesis with sudden-onset neck pain, cervical lesions should be considered in the differential diagnoses in addition to stroke.

Atraumatic Spinal Epidural Hematoma as Initial Presentation of Hemophilia A in an Infant.

ABSTRACT: Hemophilia A is characterized by deficiency of factor VIII. We present a unique, illustrative case of an infant with a short history of neck pain and irritability without neurological deficits who was found to have a spinal epidural hematoma. The subsequent investigation for the etiology, including workup for nonaccidental trauma, led to a diagnosis of severe hemophilia A.

Acute hemiparesis. A rare presentation of spontaneous spinal epidural hematoma mimicking acute stroke.

Acute hemiparesis is an extremely rare presentation of spontaneous spinal epidural hematoma, which may be misdiagnosed as acute ischemic stroke and improperly treated with an intravenous thrombolytic agent. Here, we report a case of a 54-year-old woman who presented with acute neck pain and right-sided weakness. She was initially suspected of having ischemic stroke and therefore treated with an intravenous thrombolytic agent. However, she developed progressive tetraparesis, and subsequent magnetic resonance images confirmed cervical spontaneous spinal epidural hematoma.

Spontaneous Epidural Hematoma of the Cervical Spine in an Elderly Woman with Recent COVID-19 Infection: A Case Report.

BACKGROUND This report presents the case of a woman with no known coagulopathy, use of anticoagulants, or history of trauma who spontaneously developed an epidural hematoma of the spine. This is an uncommon condition, with the potential for missed diagnosis and potential harm to the patient. CASE REPORT The patient was an elderly woman with a history of Type 2 diabetes mellitus and hyperlipidemia. Of note, she had recently recovered from COVID-19. Because the woman presented with right-sided weakness and pain in the back of her neck, the stroke team was activated. A computed tomography (CT) scan of her neck revealed a very subtle hyperdensity, which on further investigation was found to be an acute epidural hematoma at C2-C3 space through the C6 vertebra. While awaiting surgery, the patient had spontaneous improvement of her right-sided weakness and her condition eventually was managed conservatively. CONCLUSIONS Spontaneous spinal epidural hematoma is an uncommon condition, and a high index of suspicion is required to accurately diagnose and appropriately manage it. In the case presented here, the hematoma was subtle on the CT scan, and the patient's weakness easily could have been misdiagnosed as an ischemic stroke. That may have resulted in administration of thrombolytics, potentially causing significant harm. In addition, the patient had recently recovered from COVID-19 disease, which may or may not be incidental. Further observation will be required to determine if there is a spike in similar cases, which may be temporally associated with the novel coronavirus.

Fast-Growing Cervical Juxtafacet Cyst Mimicking Epidural Hematoma: A Case Report.

CASE: A 75-year-old man, who was a carpenter, experienced neck pain and numbness in the upper and lower extremities while hammering a nail and later developed a gait disturbance. Initial magnetic resonance imaging (MRI) revealed a tumor-like mass at the C5 epidural space compressing the spinal cord. The first diagnosis was cervical epidural hematoma. The following day, the patient's symptom deteriorated. A second MRI revealed an increase in the size of the mass, and surgery was performed. Operative findings included a juxtafacet cyst. CONCLUSION: Repeated job-related load on the facet joint in this patient caused rapid progression of facet cysts, causing myelopathy similar to an epidural hematoma.

Spinal epidural hematoma as a stroke mimic.

PURPOSE: Spinal epidural hematoma is a rare but important disease as it can be a stroke mimic. Our aim was to investigate the clinical characteristics of patients with an activated stroke code and spinal epidural hematoma. METHODS: Patients with an activated stroke code were examined retrospectively. Patients with spinal epidural hematoma were evaluated with further neurological examinations and neuroimaging. RESULTS: Of 2866 patients with an activated stroke code, spinal epidural hematoma was detected in 5 (0.2%, 63-79 years, 2 men). In all 5 cases, hematoma was located in the unilateral dorsal region of the spinal canal and spread to 5-9 vertebral segments at the C1-T3 level. None of the patients had a medical history of head or neck injury, coagulopathy, or use of anti-thrombotic agents. All of the patients had occipital, neck, and/or back pain, and their hemiparesis occurred simultaneously or within 1 h after the onset of pain. Hyperalgesia ipsilateral to the hematoma was observed in 1 patient, hypoalgesia contralateral to the hematoma was observed in 1, and quadriparesis and bilateral hypoalgesia were observed in 1. The hematomas spontaneously decreased in size in 4 patients, and cervical laminectomy was performed in the other patient. In the 1860 patients with an activated stroke code and spontaneous eye opening, the sensitivity of pain as a predictor of spinal epidural hematoma was 100%, with a specificity of 88.7%, and positive predictive value of 2.3%. CONCLUSION: Patients with spinal epidural hematoma could present with clinical characteristics mimicking ischemic stroke. Spinal epidural hematoma should be differentiated in patients treated under stroke code activation.

A Case Report: An Acute Spinal Epidural Hematoma after Acupuncture Mimicking Stroke.

BACKGROUND: Spinal epidural hematoma (SEH) after acupuncture is rare and may present with acute or subacute onset and varied symptoms, making it difficult to diagnose. This condition can mimic acute stroke, so it is vital to establish a clear diagnosis before considering thrombolytic therapy, which could be disastrous if applied inappropriately. CASE REPORT: We describe a 52-year-old man who presented to our emergency department (ED) with acute onset of unilateral weakness of the limbs for 3.5 h immediately after receiving acupuncture at the bilateral neck and back. The acute stroke team was activated. In the ED, computer tomography angiography from the aortic arch to the head revealed spinal epidural hematoma. The patient was admitted to the ward for conservative treatment and was discharged with subtle residual symptoms of arm soreness 5 days later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acute spinal epidural hematoma rarely presents with unilateral weakness of the limbs, mimicking a stroke. Because inappropriate thrombolysis can lead to devastating symptoms, spinal epidural hematoma should be excluded when evaluating an acute stroke patient with a history of acupuncture who is a possible candidate for thrombolytic therapy.

Safety guideline: neurological monitoring associated with obstetric neuraxial block 2020: A joint guideline by the Association of Anaesthetists and the Obstetric Anaesthetists' Association.

Serious neurological lesions such as vertebral canal haematoma are rare after obstetric regional analgesia/anaesthesia, but early detection may be crucial to avoid permanent damage. This may be hampered by the variable and sometimes prolonged recovery following 'normal' neuraxial block, such that an underlying lesion may easily be missed. These guidelines make recommendations for the monitoring of recovery from obstetric neuraxial block, and escalation should recovery be delayed or new symptoms develop, with the aim of preventing serious neurological morbidity.