Objective:

To describe a case of spontaneous spinal epidural hematoma (SSEH) mimicking acute ischemic stroke (AIS) and its outcome post intravenous thrombolysis.

Background:

SSEH is an exceedingly rare condition with a prevalence of 1:1000000. It may manifest with hemiparesis mimicking AIS. The diagnosis of SSEH is often made after clinically worsening due to IV thrombolysis.

Design/Methods:

N/A

Results:

81-year-old male with history of hypertension, hyperlipidemia, type 2 diabetes mellitus presented with sudden onset left arm and leg weakness upon awakening 6 hours after his last known well. NIHSS was 4 (left face, arm, leg paresis and left hypoesthesia). He received intravenous thrombolysis as the 24-hour late presenter thrombolysis protocol of our institution and clinically his left hemiparesis improved.  He was admitted to the neurosciences intensive care unit and 3 hours later was symptomatically improved but complaining of neck pain. 8 hours later, the patient developed acute weakness of the right side contralateral to initial stroke symptoms. Emergent MRI brain showed no acute infarct but the MRI cervical spine revealed a heterogenous T2 hyperintense extramedullary lesion, extending from C4 through the thoracic spine mostly consistent with epidural hemorrhage, with significant mass effect on the spinal cord, resulting in severe spinal canal narrowing. Patient underwent emergent surgical spinal decompression after reversal of IV tPA with cryoprecipitate and intraoperative tranexamic acid during the evacuation of the epidural hematoma. Clinically he improved postoperatively and was discharged to rehab. Only 12 stroke mimic cases of SSEH have been reported in which IV tPA was administered.

Conclusions:

Diagnosis of SSEH is challenging as it can present with hemiparesis, mimicking AIS. Neck pain should raise suspicion of SSEH. Careful imaging evaluation of the cord including standard-of-care CTA neck angiography may lead to a faster diagnosis.