Spontaneous cervical epidural hematoma mimicking a transient ischemic attack

Dear Editor,

Spontaneous cervical epidural hematoma, resulting from spontaneous bleeding into the cervical epidural space, causes sudden neck pain and cervical spinal cord compression, which generally requires emergency decompressive laminectomy. However, it occasionally subsides without surgical intervention.1 Although cervical epidural hematoma patients typically present with tetraparesis or paraparesis, 24% of the cases present with hemiparesis, thereby mimicking stroke.2 Neurological examination is crucial in differentiating cervical epidural hematoma from stroke (Table S1). Particularly, cervical epidural hematomas have three prominent features on neurological examination: hemiparesis spares the face, cranial nerve deficits are absent, and a circumferential boundary below which there is impairment of sensation is observed. Deep tendon reflexes and other findings are not useful in the differentiation. However, we found that if the neurological symptoms rapidly improve before arrival at the emergency department, neurological examination is not informative and differentiating between spontaneous cervical epidural hematoma and transient ischemic attack (TIA) could be challenging.

A 67‐year‐old man with no relevant medical history suddenly experienced neck and left shoulder pain after skiing, although he neither injured his head nor neck during skiing. Shortly thereafter, he could not move his left arm, and he had reduced sensation in his left hand. He could not stand up because of the weakness in his left leg. However, his symptoms rapidly improved en route to the emergency department. On admission, his neck and left shoulder pain had nearly resolved, and he neither exhibited hemiparesis nor any sensory disturbance on neurological examination. We performed a brain computed tomography scan to exclude hemorrhagic stroke, which revealed no abnormalities.

The patient and emergency medical personnel reported that he could move his face bilaterally at the scene. It was uncertain whether the patient had dysphagia and dysarthria or not. Therefore, we suspected either a lower brainstem lesion, such as TIA in the medial medulla caused by vertebral artery dissection, or a cervical spinal cord lesion, because the patient seemed to have hemiparesis sparing the face, which generally indicates a lesion below where the pyramidal tract gives off fibers to contralateral facial nucleus in the pons. We performed brain and cervical magnetic resonance imaging (MRI). Although brain MRI revealed no abnormalities, cervical MRI revealed an epidural mass lesion at the C2–C6 levels that demonstrated isointensity on T1‐weighted imaging and hyperintensity on T2‐weighted imaging (Fig. 1). Therefore, we diagnosed the patient as having spontaneous cervical epidural hematoma. He was admitted to the hospital, but his neck and left shoulder pain and his neurological symptoms were not recurrent during hospitalization. On day 4, we repeated cervical MRI and confirmed that the hematoma had decreased. He was discharged on day 7.

Figure 1.

Sagittal view of cervical magnetic resonance imaging of a 67‐year‐old man with spontaneous cervical epidural hematoma. The images show a cervical epidural mass lesion at the C2–C6 levels that exhibited isointensity on T1‐weighted imaging (A, red arrows) and hyperintensity on T2‐weighted imaging (B, blue arrows).

Spontaneous cervical epidural hematoma is very rare with an incidence of approximately 0.1 per 100,000 patients annually,3 and is not generally considered as an important differential diagnosis of TIA. However, if misdiagnosed as TIA and antiplatelet therapy is initiated, cervical epidural hematoma could deteriorate, which might require emergency decompressive laminectomy and result in permanent sequela or death.4, 5 Therefore, spontaneous cervical epidural hematoma should always be considered as an important differential diagnosis in patients with neck pain and transient hemiparesis mimicking TIA. In patients with transient hemiparesis mimicking TIA, neurological examination is not helpful because of improvement of neurological abnormalities. Therefore, history taking focusing on the distribution of weakness, dysphagia, dysarthria and the area of impaired sensation, should be performed to reveal the presence of characteristic neurological symptoms of cervical epidural hematoma.

Disclosure

Approval of the research protocol: N/A.

Informed consent: Informed consent was obtained from the patient.

Registry and the registration no. of the study/trial: N/A.

Animal studies: N/A.

Conflict of interest: None declared.

Supporting information

Table S1. Neurological features of cervical epidural hematoma.