Cervical Hemangioblastoma Masquerading as Ischemic Stroke: The Hidden Risk of Thrombolysis
Background:
Hemangioblastomas of the cervical spinal cord are rare, typically presenting with slowly progressive myelopathic symptoms rather than acute focal deficits. However, when lesions extend to the cervicomedullary junction, they may produce cranial nerve findings that closely resemble anterior circulation stroke. Stroke mimics account for up to 30% of patients treated with intravenous tissue plasminogen activator (tPA). Current guidelines list no contraindication to thrombolysis in patients with known spinal lesions, yet this case highlights how treatment can be inadvertently harmful when the underlying pathology is non-ischemic
Results:
An 81-year-old man with hypertension, hyperlipidemia, and a C2-T2 hemangioblastoma, however at time of presentation patient reported it to be C1-C2. He presented with sudden onset right facial droop, right arm and leg weakness, and hemisensory loss while seated at his desk. CT head and CTA neck were negative for infarct or occlusion. With an NIHSS of 5 and no contraindications, IV tPA was administered for presumed ischemic stroke. Over the next hour, the patient developed severe headache, quadriplegia, and respiratory failure requiring intubation. MRI cervical spine revealed extensive intramedullary hemorrhage from C2–T2 with edema extending into the medulla, consistent with hemorrhagic conversion of a hemangioblastoma. MRI brain was negative for infarct. Despite supportive management, the patient experienced progressive decline and ultimately passed away while on hospice 2 weeks after presentation.
Conclusions:
This case illustrates a rare stroke mimic in which a cervical hemangioblastoma presented as acute facial droop and hemiparesis. Although no formal tPA contraindication exists, thrombolysis precipitated catastrophic hemorrhage. Clinicians should consider spinal pathology in patients with atypical presentations, neck pain, or known spinal lesions prior to thrombolysis. Broader awareness of spinal stroke mimics may guide safer acute stroke evaluation and future refinement of treatment guidelines.
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