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Spontaneous spinal epidural hematoma mimicking transient ischemic attack

Spontaneous spinal epidural hematoma mimicking transient ischemic attack Rationale: Spontaneous spinal epidural hematoma (SSEH) is a rare but highly disabling neurological emergency. The initial presentations are variable. Most patients of SSEH present with paraplegia or tetraplegia clinically, but recurrent hemiparesis with complete spontaneous recovery, mimicking transient ischemic attack (TIA), is a very rare initial presentation of SSEH. Patientconcerns: A 71-year-old female presented to the emergency department with 2 episodes of transient right hemiparesis in 5hours. Two days later, above symptom reappeared and progressed to quadriplegia, dyspnea, and uroschesis quickly. The neurological examination showed tetraplegia and hypalgesia below the C2 level, but neither facial palsy nor aphasia was found. Diagnosis: The patient was initially misdiagnosed as TIA and treated with antiplatelet therapy. But during the hospital day, the cervical magnetic resonance imaging showed a dorsal epidural hematoma extending from C2 to C6 level and she was diagnosed as SSEH. Interventions: She underwent surgical decompression and hematoma removal 1 week later. Outcomes: One week after operation, the sensory deficit above C6 level improved, but there was no improvement in her muscle strength and dyspnea. Unfortunately, she died 1 month later. Lessons: Our case highlights recurrent hemiparesis with complete spontaneous recovery mimicking TIA is a rare initial presentation of SSEH. It is important to perform careful clinical assessments and neuroimaging investigations for correct diagnosis. Neck pain and hemiparesis sparing cranial nerve are important signs for distinction of SSEH from acute ischemic cerebrovascular diseases. Abbreviations: MRI = magnetic resonance imaging, SSEH = spontaneous spinal epidural hematoma, TIA = transient ischemic attack. Keywords: hemiparesis, spontaneous spinal epidural hematoma, transient ischemic attack 1. Introduction the “spontaneous” refers to atraumatic etiology and lack of iatrogenic procedure. Its etiology is related to vascular malforma- Spontaneous spinal epidural hematoma (SSEH) is a rare but highly tion, coagulopathy, anticoagulants, tumor, hypertension, and disabling neurological emergency, which accounts for <1% of all pregnancy. The classic manifestations of SSEH are sudden onset of [1,2] spinal epidural space-occupying lesions. The annual incidence back or neck pain followed by rapidly progressive spinal cord [3] of SSEH was estimated to be 0.1 per 100,000 patients. In SSEH, compression syndrome. But the initial presentations of SSEH are often miscellaneous and atypical. Recurrent hemiparesis with complete spontaneous recovery, mimicking transient ischemic Editor: Elena Cecilia Rosca. attack (TIA), is a very rare initial presentation of SSEH. Here, we CL and RH contributed equally to this work. report a rare case of SSEH who initially presented with recurrent The authors report no conflicts of interest. hemiparesis and was misdiagnosed as TIA. Department of Neurology, The Affiliated Guangzhou Red Cross Hospital, Jinan University, Guangzhou, Department of Neurology, Xiaolan Hospital of Southern Medical University, Zhongshan, Department of Neurology, Shenzhen Hospital, 2. Case report Southern Medical University, Shenzhen, Guangdong, China. A 71-year-old woman presented with sudden neck pain and Correspondence: Fangming Li, Department of Neurology, Shenzhen Hospital, Southern Medical University, N0.1333 Xinhu Road, Shenzhen, Guangdong weakness in her right upper and lower limbs while she was having 518110, China (e-mail: lifly050413@163.com). a bath at home. Her symptoms resolved spontaneously within Copyright © 2017 the Author(s). Published by Wolters Kluwer Health, Inc. 10 minutes. After half past 4hours later, she had the same onset This is an open access article distributed under the terms of the Creative of right hemiparesis and had full recovery within 15 minutes, and Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is then was immediately admitted to our emergency department. permissible to download, share, remix, transform, and buildup the work provided The patient had a 30 years history of hypertension without well- it is properly cited. The work cannot be used commercially without permission from the journal. control. She had no previous history of taking any antiplatelet or anticoagulant drugs. There was no recent history of head and Medicine (2017) 96:49(e9007) spinal trauma or surgery. Received: 9 August 2017 / Received in final form: 8 November 2017 / Accepted: 9 November 2017 The initial blood pressure was 210/90mm Hg. On neurological examination, the patient had a normal cranial nervous system http://dx.doi.org/10.1097/MD.0000000000009007 1 Li et al. Medicine (2017) 96:49 Medicine Figure 1. Cervical magnetic resonance imaging (MRI; sagittal) showed a longitudinal dorsal epidural hematoma (A: T2-weighted, B: T1-weighted) extending from C2 to C6 level. and sensory system. Her muscle strength was grade 5/5 in One week after operation, the sensory deficit above C6 level bilateral upper and lower limbs, but the right knee reflex was improved, but there was no improvement in her muscle strength hyperactive and Hoffman’s sign was positive. Laboratory and dyspnea. Unfortunately, she died 1 month later. investigations showed that a complete blood cell count, prothrombin time, and partial thromboplastin time were within 3. Discussion normal limits. An emergency brain computed tomography and SSEH is a rare clinical emergency which was first described by cervical x-ray scans were unremarkable. A clinical diagnosis of [4] [3] Jackson in 1869. Holtas et al reported that the annual TIA was considered. Then the patient was hospitalized in the incidence of SSEH was approximately 0.1 patient per 100,000 neurological wards and treated with antiplatelet therapy (100mg patients. But in the last years, the number of diagnosed and aspirin and 75mg clopidogrel, once daily). She did not complain reported cases of SSEH has been increased due to the progress of any other symptoms except a mild neck pain in the following 2 neuroradiological investigations and neurosurgery. Patients with days after admission. SSEH usuallypresent with sudden onset of severe backor neck pain On the third hospital day, the brain magnetic resonance followed by rapidly progressive symptoms and signs of nerve root imaging (MRI) and cervical MRI were performed. The brain MRI or spinal cord compression. The clinical symptom severity is showed no signs of acute cerebral infarction. The cervical MRI significantly correlated with the rate of bleeding, the extent of revealed a spinal epidural hematoma located in the posterior hematoma, and the length of time of onset. However, the initial spinal epidural space extending from the C2 to C6 spinal manifestations of SSEH are sometimes atypical, even mimicking vertebral level. The hematoma was isointense on T1-weighted an onset of ischemic stroke. Among the initial presentations of images and hyperintense on T2-weighted images (Fig. 1). Just patients with SSEH, hemiparesis is a less common symptom after returning to the wards, the patient recurred the right compared with other motor deficits such as paraplegia or hemiplegia (muscle strength was grade 3/5 in right upper and [5,6] tetraplegia. But with the rapid development of MRI technolo- lower limbs), and developed rapidly progressive quadriplegia, gy, there are increasing cases of SSEH who presented with loss of pain and temperature sensation, dyspnea, and uroschesis. hemiparesis initially have been reported in the last years. In clinical Neurological examination revealed tetraplegia (the muscle practice, when patients of SSEH presented with sudden onset of strength was grade 2/5 in left limbs and 1/5 in right limbs) hemiparesis, even they complained of back pain or neck pain, they and loss of pain below the C2 level bilaterally. She had neither are often been suspected to have an acute cerebral infarction during aphasia nor abnormal cranial nerve signs. Given her progressive [7] the initial assessment. Moreover, hemiparesis with complete symptoms and imaging findings, the diagnosis of spinal cord spontaneous recovery, mimicking TIA, is a rare initial symptom of compression was considered. The patient was transferred to the SSEH. Only a few patients with complete spontaneous recovery intensive care unit immediately and treated with trachea cannula [8,9] due to SSEH have been reported in the last decades. For and ventilator-assisted ventilation. Her family members did not [8] example, Hernandez et al reported that a patient had 3 relapsing consent to emergency surgical decompression and the patient paraplegia and complete spontaneous recovery in 5hours, and became worse in the following days. After a week later, her family myelography and computed tomography confirmed a posterior members finally consented to the surgical decompression. The epidural hematoma extending from T11 to T12 level. The initial findings of operation confirmed a hematoma arising on the dorsal presentation of our patient was 2 episodes of right hemiparesis with spinal epidural surface and extended from the C2 to C6 spinal complete spontaneous recovery within 5hours.The present patient vertebral level, and the right was more serious. 2 Li et al. Medicine (2017) 96:49 www.md-journal.com was an old woman with a previous history of uncontrolled treated with the antiplatelet drugs due to her initial manifestation hypertension, so she is easy to be misdiagnosed as having a TIA at mimicking TIA, which may result in the rapid development of the early stage and consequently administrated with antiplatelet hematoma and poor outcome. In clinical practice, physicians drugs. This patient did complain of neck pain on admission, but tend to consider TIA as the first diagnosis for patients with acute- this symptom did not be attached great importance by physicians episodic neurological disorders. If the patient complained of due to the findings of cervical x-ray scans was unremarkable. persistent neck or back pain and recurred or fluctuating Similar to the previous reported cases of SSEH with complete hemiparesis, neck or back pain should not be overlooked as spontaneous recovery, the length of spinal epidural hematomas an important sign for the diagnosis of SSEH, especially in the was not long in our patient. In addition, the cervical MRI of our patients without cranial nerve signs. patient showed that the shape of spinal epidural hematomas was Spinal MRI is the preferred diagnostic tool for SSEH. Spinal cylindrical, which might have less pressure on the spinal cord. MRI can show the segmental and range of epidural hematoma, These may be the reasons why our patient presented with less and the extent of spinal cord compression. However, the super severely neurological deficits and had complete spontaneous acute or acute hemorrhage has atypical MR manifestations. The recovery at the early stage. In addition, we think that at the hematoma shows isointense on T1-weighted and hyperintense on beginning of the stage, the hematoma may spread along spinal T2-weighted images. It should combine the onset time to analyze epidural space containing fat, areolar tissue, and vascular network, the MR signs of hematoma. If physicians’ lack of the realization which would result in the subsequent decompression of internal of early imaging changes, it can easily lead to a misdiagnosis. For pressure. Hence, our patient had the manifestation of recurrent subactue hemorrhage, it shows characteristic hyperintense on T1- hemiparesis with complete spontaneous recovery mimicking TIA. weighted and low signal intensity on T2-weighted images. In our We emphasize that it is important to collect a comprehensive case patient, the findings of spinal MRI were consistent with the signs history and perform neurological examination in the course of of acute hemorrhage. diagnosis. Radicular pain should not be ignored as an important Emergency surgical spinal decompression is the main treatment sign of SSEH. When patients have sudden neck pain with of SSEH, which should be performed within 12hours and not [12,21] neurological deficits, it is highly suggestive of a possible cervical later than 36hours for a favorable outcome. Conservative spinal cord hemorrhagic disease, and SSEH should be considered management can also be considered in those SSEH patients with as a common stroke mimic. minimal neurological deficits or who have rapidly improving [22] So far, the actual source of bleeding has not been well defined in neurological function. Delayed surgical decompression was patients with SSEH. Most authors support the venous origin performed in our patients, and her condition deteriorated due to hypothesis due to the anatomical characteristics of the posterior hematoma expansion. internal vertebral venous plexus and the most common location Although our patient presented with mild and recurrent [1,10,11] was the posterior of the thoracic region in the spinal canal. hemiparesis with complete spontaneous recovery at the initial They believed that it is prone to resulting in veins rupture and stage, she developed rapidly progressive neurological deficits within bleeding when patients had a suddenly increasing pressure effect a short time after admission. We considered that the causes of her from the thoracic or abdominal cavity, especially in the older rapid exacerbation were multifactorial, including old age, uncon- patients or the patients with slow progression of neurological trolled hypertension, the location of hematoma in the cervical area, decline. The present patient had the onset when she was having a the antiplatelet therapy, and delayed surgical spinal decompression. bath, whereas many patients of SSEH have been reported to be Among above factors, the use of antiplatelet agent may be the major initially triggered by actions that suddenly increase venous cause of hematoma expansion and poor outcome. [12,13] pressure. On the contrary, some authors support the arterial In conclusion, our case highlights recurrent hemiparesis with origin of bleeding, especially when the hematomas was located in complete spontaneous recovery mimicking TIA is a rare initial [14] the cervical region. They think that the intrathecal pressure is presentation of SSEH. It is important to perform careful clinical higher than the venous pressure at the cervical level, which would assessments and neuroimaging investigations for diagnosis. Neck prevent bleeding from veins in the epidural space. Considering pain and hemiparesis sparing cranial nerve are important signs for that the hematoma of our patient was located at the cervical distinction of SSEH from acute ischemic cerebrovascular diseases. region, our patient had rapidly deteriorating neurological deficit after admission, as well as she had an uncontrolled hypertensive condition, we speculated that the hematoma may be of arterial References origin in the present patient. [1] Groen RJ, Ponssen H. The spontaneous spinal epidural hematoma. A The precise etiology remains unclear. Increasing age, hyper- study of the etiology. J Neurol Sci 1990;98:121–38. [2] Alexiadou-Rudolf C, Ernestus RI, Nanassis K, et al. Acute nontraumatic tension, anticoagulants, thrombolytics, antiplatelet agents, spinal epidural hematomas: an important differential diagnosis in spinal vascular malformation, and systemic diseases have been consid- emergencies. Spine (Phila Pa 1976) 1998;23:1810–3. ered as possible predisposing factors in some patients with [3] Holtas S, Heiling M, Lonntoft M. Spontaneous spinal epidural [1,12,15–18] SSEH. However, there are 40% to 60% of cases could hematoma: findings at MR imaging and clinical correlation. Radiology [19,20] not find any underlying cause. SSEH could occur at any age, 1996;199:409–13. [4] Jackson R. Case of spinal apoplexy. Lancet 1869;2:5–6. but most of the patients are in their fourth or fifth decades of life. [5] Liao CC, Lee ST, Hsu WC, et al. Experience in the surgical management A recent individual patient data meta-analysis revealed the of spontaneous spinal epidural hematoma. J Neurosurg 2004;100(1 [16] median age is 58 years. Hypertension has been observed in a suppl Spine):38–45. range from 3% to 21.4% of patients with SSEH, but whether [6] Marinella MA, Barsan WG. Spontaneously resolving cervical epidural hematoma presenting with hemiparesis. Ann Emerg Med 1996;27:514–7. hypertension is a risk factor of SSEH or not is still controver- [1,16] [7] Liu Z, Jiao Q, Xu J, et al. Spontaneous spinal epidural hematoma: sial. Evidences from current meta-analysis could not suggest analysis of 23 cases. Surg Neurol 2008;69:253–60. the relationship between hypertension and the development of [8] Hernandez D, Vinuela F, Feasby TE. Recurrent paraplegia with total [16] SSEH. We thought that old age and uncontrolled hypertension recovery from spontaneous spinal epidural hematoma. Ann Neurol may be risk factors of our case. Moreover, this patient was 1982;11:623–4. 3 Li et al. Medicine (2017) 96:49 Medicine [9] Harik SI, Raichle ME, Reis DJ. Spontaneously remitting spinal epidural [16] Bakker NA, Veeger NJ, Vergeer RA, et al. Prognosis after spinal cord and haematoma in a patient on anticoagulants. N Engl J Med 1971;284: cauda compression in spontaneous spinal epidural hematomas. 1355–7. Neurology 2015;84:1894–903. [10] Thiele RH, Hage ZA, Surdell DL, et al. Spontaneous spinal epidural [17] Spengos K, Tsivgoulis G, Zakopoulos N. Could high blood pressure be hematoma of unknown etiology: case report and literature review. the cause of acute spontaneous spinal epidural hematoma? Eur J Emerg Neurocrit Care 2008;9:242–6. Med 2007;14:59. [11] Huang M, Barber SM, Moisi M, et al. Cervical epidural hematoma after [18] Van Schaeybroeck P, Van Calenberg F, Van De Werf F, et al. chiropractic spinal manipulation therapy in a patient with an Spontaneous spinal epidural hematoma associated with thrombolysis undiagnosed cervical spinal arteriovenous malformation. Cureus and anticoagulation therapy: report of three cases. Clin Neurol 2015;7:e307. Neurosurg 1998;100:283–7. [12] Liao CC, Lee ST, Hsu WC, et al. Experience in the surgical management [19] Dziedzic T, Kunert P, Krych P, et al. Management and neurological of spontaneous spinal epidural hematoma. J Neurosurg 2004;100: outcome of spontaneous spinal epidural hematoma. J Clin Neurosci 38–45. 2015;22:726–9. [13] Kato Y, Takeda H, Furuya D, et al. Spontaneous spinal epidural [20] Zhong W, Chen H, You C, et al. Spontaneous spinal epidural hematoma. hematoma with unusual hemiparesis alternating from one side to the J Clin Neurosci 2011;18:1490–4. other side. Intern Med 2009;48:1703–5. [21] Liao CC, Hsieh PC, Lin TK, et al. Surgical treatment of spontaneous [14] Beatty RM, Winston KR. Spontaneous cervical epidural hematoma. A spinal epidural hematoma: a 5-year experience. J Neurosurg Spine consideration of etiology. J Neurosurg 1984;61:143–8. 2009;11:480–6. [15] Groen RJ, Van Alphen HA. Operative treatment of spontaneous spinal [22] Huh J, Kwak HY, Chung YN, et al. Acute cervical spontaneous spinal epidural hematomas: a study of the factors determining postoperative epidural hematoma presenting with minimal neurological deficits: a case outcome. Neurosurgery 1996;39:494–508. report. Anesth Pain Med 2016;6:e40067. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Medicine Pubmed Central

Spontaneous spinal epidural hematoma mimicking transient ischemic attack

Medicine , Volume 96 (49) – Dec 8, 2017

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Copyright © 2017 the Author(s). Published by Wolters Kluwer Health, Inc.
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Abstract

Rationale: Spontaneous spinal epidural hematoma (SSEH) is a rare but highly disabling neurological emergency. The initial presentations are variable. Most patients of SSEH present with paraplegia or tetraplegia clinically, but recurrent hemiparesis with complete spontaneous recovery, mimicking transient ischemic attack (TIA), is a very rare initial presentation of SSEH. Patientconcerns: A 71-year-old female presented to the emergency department with 2 episodes of transient right hemiparesis in 5hours. Two days later, above symptom reappeared and progressed to quadriplegia, dyspnea, and uroschesis quickly. The neurological examination showed tetraplegia and hypalgesia below the C2 level, but neither facial palsy nor aphasia was found. Diagnosis: The patient was initially misdiagnosed as TIA and treated with antiplatelet therapy. But during the hospital day, the cervical magnetic resonance imaging showed a dorsal epidural hematoma extending from C2 to C6 level and she was diagnosed as SSEH. Interventions: She underwent surgical decompression and hematoma removal 1 week later. Outcomes: One week after operation, the sensory deficit above C6 level improved, but there was no improvement in her muscle strength and dyspnea. Unfortunately, she died 1 month later. Lessons: Our case highlights recurrent hemiparesis with complete spontaneous recovery mimicking TIA is a rare initial presentation of SSEH. It is important to perform careful clinical assessments and neuroimaging investigations for correct diagnosis. Neck pain and hemiparesis sparing cranial nerve are important signs for distinction of SSEH from acute ischemic cerebrovascular diseases. Abbreviations: MRI = magnetic resonance imaging, SSEH = spontaneous spinal epidural hematoma, TIA = transient ischemic attack. Keywords: hemiparesis, spontaneous spinal epidural hematoma, transient ischemic attack 1. Introduction the “spontaneous” refers to atraumatic etiology and lack of iatrogenic procedure. Its etiology is related to vascular malforma- Spontaneous spinal epidural hematoma (SSEH) is a rare but highly tion, coagulopathy, anticoagulants, tumor, hypertension, and disabling neurological emergency, which accounts for <1% of all pregnancy. The classic manifestations of SSEH are sudden onset of [1,2] spinal epidural space-occupying lesions. The annual incidence back or neck pain followed by rapidly progressive spinal cord [3] of SSEH was estimated to be 0.1 per 100,000 patients. In SSEH, compression syndrome. But the initial presentations of SSEH are often miscellaneous and atypical. Recurrent hemiparesis with complete spontaneous recovery, mimicking transient ischemic Editor: Elena Cecilia Rosca. attack (TIA), is a very rare initial presentation of SSEH. Here, we CL and RH contributed equally to this work. report a rare case of SSEH who initially presented with recurrent The authors report no conflicts of interest. hemiparesis and was misdiagnosed as TIA. Department of Neurology, The Affiliated Guangzhou Red Cross Hospital, Jinan University, Guangzhou, Department of Neurology, Xiaolan Hospital of Southern Medical University, Zhongshan, Department of Neurology, Shenzhen Hospital, 2. Case report Southern Medical University, Shenzhen, Guangdong, China. A 71-year-old woman presented with sudden neck pain and Correspondence: Fangming Li, Department of Neurology, Shenzhen Hospital, Southern Medical University, N0.1333 Xinhu Road, Shenzhen, Guangdong weakness in her right upper and lower limbs while she was having 518110, China (e-mail: lifly050413@163.com). a bath at home. Her symptoms resolved spontaneously within Copyright © 2017 the Author(s). Published by Wolters Kluwer Health, Inc. 10 minutes. After half past 4hours later, she had the same onset This is an open access article distributed under the terms of the Creative of right hemiparesis and had full recovery within 15 minutes, and Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is then was immediately admitted to our emergency department. permissible to download, share, remix, transform, and buildup the work provided The patient had a 30 years history of hypertension without well- it is properly cited. The work cannot be used commercially without permission from the journal. control. She had no previous history of taking any antiplatelet or anticoagulant drugs. There was no recent history of head and Medicine (2017) 96:49(e9007) spinal trauma or surgery. Received: 9 August 2017 / Received in final form: 8 November 2017 / Accepted: 9 November 2017 The initial blood pressure was 210/90mm Hg. On neurological examination, the patient had a normal cranial nervous system http://dx.doi.org/10.1097/MD.0000000000009007 1 Li et al. Medicine (2017) 96:49 Medicine Figure 1. Cervical magnetic resonance imaging (MRI; sagittal) showed a longitudinal dorsal epidural hematoma (A: T2-weighted, B: T1-weighted) extending from C2 to C6 level. and sensory system. Her muscle strength was grade 5/5 in One week after operation, the sensory deficit above C6 level bilateral upper and lower limbs, but the right knee reflex was improved, but there was no improvement in her muscle strength hyperactive and Hoffman’s sign was positive. Laboratory and dyspnea. Unfortunately, she died 1 month later. investigations showed that a complete blood cell count, prothrombin time, and partial thromboplastin time were within 3. Discussion normal limits. An emergency brain computed tomography and SSEH is a rare clinical emergency which was first described by cervical x-ray scans were unremarkable. A clinical diagnosis of [4] [3] Jackson in 1869. Holtas et al reported that the annual TIA was considered. Then the patient was hospitalized in the incidence of SSEH was approximately 0.1 patient per 100,000 neurological wards and treated with antiplatelet therapy (100mg patients. But in the last years, the number of diagnosed and aspirin and 75mg clopidogrel, once daily). She did not complain reported cases of SSEH has been increased due to the progress of any other symptoms except a mild neck pain in the following 2 neuroradiological investigations and neurosurgery. Patients with days after admission. SSEH usuallypresent with sudden onset of severe backor neck pain On the third hospital day, the brain magnetic resonance followed by rapidly progressive symptoms and signs of nerve root imaging (MRI) and cervical MRI were performed. The brain MRI or spinal cord compression. The clinical symptom severity is showed no signs of acute cerebral infarction. The cervical MRI significantly correlated with the rate of bleeding, the extent of revealed a spinal epidural hematoma located in the posterior hematoma, and the length of time of onset. However, the initial spinal epidural space extending from the C2 to C6 spinal manifestations of SSEH are sometimes atypical, even mimicking vertebral level. The hematoma was isointense on T1-weighted an onset of ischemic stroke. Among the initial presentations of images and hyperintense on T2-weighted images (Fig. 1). Just patients with SSEH, hemiparesis is a less common symptom after returning to the wards, the patient recurred the right compared with other motor deficits such as paraplegia or hemiplegia (muscle strength was grade 3/5 in right upper and [5,6] tetraplegia. But with the rapid development of MRI technolo- lower limbs), and developed rapidly progressive quadriplegia, gy, there are increasing cases of SSEH who presented with loss of pain and temperature sensation, dyspnea, and uroschesis. hemiparesis initially have been reported in the last years. In clinical Neurological examination revealed tetraplegia (the muscle practice, when patients of SSEH presented with sudden onset of strength was grade 2/5 in left limbs and 1/5 in right limbs) hemiparesis, even they complained of back pain or neck pain, they and loss of pain below the C2 level bilaterally. She had neither are often been suspected to have an acute cerebral infarction during aphasia nor abnormal cranial nerve signs. Given her progressive [7] the initial assessment. Moreover, hemiparesis with complete symptoms and imaging findings, the diagnosis of spinal cord spontaneous recovery, mimicking TIA, is a rare initial symptom of compression was considered. The patient was transferred to the SSEH. Only a few patients with complete spontaneous recovery intensive care unit immediately and treated with trachea cannula [8,9] due to SSEH have been reported in the last decades. For and ventilator-assisted ventilation. Her family members did not [8] example, Hernandez et al reported that a patient had 3 relapsing consent to emergency surgical decompression and the patient paraplegia and complete spontaneous recovery in 5hours, and became worse in the following days. After a week later, her family myelography and computed tomography confirmed a posterior members finally consented to the surgical decompression. The epidural hematoma extending from T11 to T12 level. The initial findings of operation confirmed a hematoma arising on the dorsal presentation of our patient was 2 episodes of right hemiparesis with spinal epidural surface and extended from the C2 to C6 spinal complete spontaneous recovery within 5hours.The present patient vertebral level, and the right was more serious. 2 Li et al. Medicine (2017) 96:49 www.md-journal.com was an old woman with a previous history of uncontrolled treated with the antiplatelet drugs due to her initial manifestation hypertension, so she is easy to be misdiagnosed as having a TIA at mimicking TIA, which may result in the rapid development of the early stage and consequently administrated with antiplatelet hematoma and poor outcome. In clinical practice, physicians drugs. This patient did complain of neck pain on admission, but tend to consider TIA as the first diagnosis for patients with acute- this symptom did not be attached great importance by physicians episodic neurological disorders. If the patient complained of due to the findings of cervical x-ray scans was unremarkable. persistent neck or back pain and recurred or fluctuating Similar to the previous reported cases of SSEH with complete hemiparesis, neck or back pain should not be overlooked as spontaneous recovery, the length of spinal epidural hematomas an important sign for the diagnosis of SSEH, especially in the was not long in our patient. In addition, the cervical MRI of our patients without cranial nerve signs. patient showed that the shape of spinal epidural hematomas was Spinal MRI is the preferred diagnostic tool for SSEH. Spinal cylindrical, which might have less pressure on the spinal cord. MRI can show the segmental and range of epidural hematoma, These may be the reasons why our patient presented with less and the extent of spinal cord compression. However, the super severely neurological deficits and had complete spontaneous acute or acute hemorrhage has atypical MR manifestations. The recovery at the early stage. In addition, we think that at the hematoma shows isointense on T1-weighted and hyperintense on beginning of the stage, the hematoma may spread along spinal T2-weighted images. It should combine the onset time to analyze epidural space containing fat, areolar tissue, and vascular network, the MR signs of hematoma. If physicians’ lack of the realization which would result in the subsequent decompression of internal of early imaging changes, it can easily lead to a misdiagnosis. For pressure. Hence, our patient had the manifestation of recurrent subactue hemorrhage, it shows characteristic hyperintense on T1- hemiparesis with complete spontaneous recovery mimicking TIA. weighted and low signal intensity on T2-weighted images. In our We emphasize that it is important to collect a comprehensive case patient, the findings of spinal MRI were consistent with the signs history and perform neurological examination in the course of of acute hemorrhage. diagnosis. Radicular pain should not be ignored as an important Emergency surgical spinal decompression is the main treatment sign of SSEH. When patients have sudden neck pain with of SSEH, which should be performed within 12hours and not [12,21] neurological deficits, it is highly suggestive of a possible cervical later than 36hours for a favorable outcome. Conservative spinal cord hemorrhagic disease, and SSEH should be considered management can also be considered in those SSEH patients with as a common stroke mimic. minimal neurological deficits or who have rapidly improving [22] So far, the actual source of bleeding has not been well defined in neurological function. Delayed surgical decompression was patients with SSEH. Most authors support the venous origin performed in our patients, and her condition deteriorated due to hypothesis due to the anatomical characteristics of the posterior hematoma expansion. internal vertebral venous plexus and the most common location Although our patient presented with mild and recurrent [1,10,11] was the posterior of the thoracic region in the spinal canal. hemiparesis with complete spontaneous recovery at the initial They believed that it is prone to resulting in veins rupture and stage, she developed rapidly progressive neurological deficits within bleeding when patients had a suddenly increasing pressure effect a short time after admission. We considered that the causes of her from the thoracic or abdominal cavity, especially in the older rapid exacerbation were multifactorial, including old age, uncon- patients or the patients with slow progression of neurological trolled hypertension, the location of hematoma in the cervical area, decline. The present patient had the onset when she was having a the antiplatelet therapy, and delayed surgical spinal decompression. bath, whereas many patients of SSEH have been reported to be Among above factors, the use of antiplatelet agent may be the major initially triggered by actions that suddenly increase venous cause of hematoma expansion and poor outcome. [12,13] pressure. On the contrary, some authors support the arterial In conclusion, our case highlights recurrent hemiparesis with origin of bleeding, especially when the hematomas was located in complete spontaneous recovery mimicking TIA is a rare initial [14] the cervical region. They think that the intrathecal pressure is presentation of SSEH. It is important to perform careful clinical higher than the venous pressure at the cervical level, which would assessments and neuroimaging investigations for diagnosis. Neck prevent bleeding from veins in the epidural space. Considering pain and hemiparesis sparing cranial nerve are important signs for that the hematoma of our patient was located at the cervical distinction of SSEH from acute ischemic cerebrovascular diseases. region, our patient had rapidly deteriorating neurological deficit after admission, as well as she had an uncontrolled hypertensive condition, we speculated that the hematoma may be of arterial References origin in the present patient. [1] Groen RJ, Ponssen H. The spontaneous spinal epidural hematoma. A The precise etiology remains unclear. Increasing age, hyper- study of the etiology. J Neurol Sci 1990;98:121–38. [2] Alexiadou-Rudolf C, Ernestus RI, Nanassis K, et al. Acute nontraumatic tension, anticoagulants, thrombolytics, antiplatelet agents, spinal epidural hematomas: an important differential diagnosis in spinal vascular malformation, and systemic diseases have been consid- emergencies. Spine (Phila Pa 1976) 1998;23:1810–3. ered as possible predisposing factors in some patients with [3] Holtas S, Heiling M, Lonntoft M. Spontaneous spinal epidural [1,12,15–18] SSEH. However, there are 40% to 60% of cases could hematoma: findings at MR imaging and clinical correlation. Radiology [19,20] not find any underlying cause. SSEH could occur at any age, 1996;199:409–13. [4] Jackson R. Case of spinal apoplexy. Lancet 1869;2:5–6. but most of the patients are in their fourth or fifth decades of life. [5] Liao CC, Lee ST, Hsu WC, et al. Experience in the surgical management A recent individual patient data meta-analysis revealed the of spontaneous spinal epidural hematoma. J Neurosurg 2004;100(1 [16] median age is 58 years. Hypertension has been observed in a suppl Spine):38–45. range from 3% to 21.4% of patients with SSEH, but whether [6] Marinella MA, Barsan WG. Spontaneously resolving cervical epidural hematoma presenting with hemiparesis. Ann Emerg Med 1996;27:514–7. hypertension is a risk factor of SSEH or not is still controver- [1,16] [7] Liu Z, Jiao Q, Xu J, et al. Spontaneous spinal epidural hematoma: sial. Evidences from current meta-analysis could not suggest analysis of 23 cases. Surg Neurol 2008;69:253–60. the relationship between hypertension and the development of [8] Hernandez D, Vinuela F, Feasby TE. Recurrent paraplegia with total [16] SSEH. We thought that old age and uncontrolled hypertension recovery from spontaneous spinal epidural hematoma. Ann Neurol may be risk factors of our case. Moreover, this patient was 1982;11:623–4. 3 Li et al. Medicine (2017) 96:49 Medicine [9] Harik SI, Raichle ME, Reis DJ. Spontaneously remitting spinal epidural [16] Bakker NA, Veeger NJ, Vergeer RA, et al. Prognosis after spinal cord and haematoma in a patient on anticoagulants. N Engl J Med 1971;284: cauda compression in spontaneous spinal epidural hematomas. 1355–7. Neurology 2015;84:1894–903. [10] Thiele RH, Hage ZA, Surdell DL, et al. Spontaneous spinal epidural [17] Spengos K, Tsivgoulis G, Zakopoulos N. Could high blood pressure be hematoma of unknown etiology: case report and literature review. the cause of acute spontaneous spinal epidural hematoma? Eur J Emerg Neurocrit Care 2008;9:242–6. Med 2007;14:59. [11] Huang M, Barber SM, Moisi M, et al. Cervical epidural hematoma after [18] Van Schaeybroeck P, Van Calenberg F, Van De Werf F, et al. chiropractic spinal manipulation therapy in a patient with an Spontaneous spinal epidural hematoma associated with thrombolysis undiagnosed cervical spinal arteriovenous malformation. Cureus and anticoagulation therapy: report of three cases. Clin Neurol 2015;7:e307. Neurosurg 1998;100:283–7. [12] Liao CC, Lee ST, Hsu WC, et al. Experience in the surgical management [19] Dziedzic T, Kunert P, Krych P, et al. Management and neurological of spontaneous spinal epidural hematoma. J Neurosurg 2004;100: outcome of spontaneous spinal epidural hematoma. J Clin Neurosci 38–45. 2015;22:726–9. [13] Kato Y, Takeda H, Furuya D, et al. Spontaneous spinal epidural [20] Zhong W, Chen H, You C, et al. Spontaneous spinal epidural hematoma. hematoma with unusual hemiparesis alternating from one side to the J Clin Neurosci 2011;18:1490–4. other side. Intern Med 2009;48:1703–5. [21] Liao CC, Hsieh PC, Lin TK, et al. Surgical treatment of spontaneous [14] Beatty RM, Winston KR. Spontaneous cervical epidural hematoma. A spinal epidural hematoma: a 5-year experience. J Neurosurg Spine consideration of etiology. J Neurosurg 1984;61:143–8. 2009;11:480–6. [15] Groen RJ, Van Alphen HA. Operative treatment of spontaneous spinal [22] Huh J, Kwak HY, Chung YN, et al. Acute cervical spontaneous spinal epidural hematomas: a study of the factors determining postoperative epidural hematoma presenting with minimal neurological deficits: a case outcome. Neurosurgery 1996;39:494–508. report. Anesth Pain Med 2016;6:e40067.

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MedicinePubmed Central

Published: Dec 8, 2017

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