Case Report

Acute hemiparesis
A rare presentation of spontaneous spinal epidural hematoma mimicking
acute stroke
Da-Wei Huang, MD, Jui-Ming Sun, MD, Yu-Hao Chen, MD, Kuo-Chang Huang, MD.

ABSTRACT

‫يعد الشلل النصفي احلاد عرض نادر للغاية للورم الدموي فوق‬
‫ والذي قد يساء تشخيصه على أنه‬،‫اجلافية في العمود الفقري‬
‫سكتة إقفارية حادة ويعالج بشكل غير صحيح بعامل جتلط‬
‫ تستعرض في هذا التقرير حالة امرأة تبلغ من‬.‫الدم في الوريد‬
‫ عا ًما تعاني من آالم حادة في الرقبة وضعف في اجلانب‬54 ‫العمر‬
‫ كان يشتبه في البداية أنها مصابة بسكتة إقفارية وبالتالي‬.‫األمين‬
‫ فقد طورت‬،‫ ومع ذلك‬.‫مت عالجها بعامل جتلط الدم في الوريد‬
‫ وأكدت صور الرنني املغناطيسي الالحقة‬،‫عملية الترقع التدريجي‬
.‫ورم دموي فوق اجلافية الفقري العنقي‬
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.
Neurosciences 2020; Vol. 25 (4): 316-319
doi: 10.17712/nsj.2020.4.20200027
Section of Neurosurgery (Huang, Sun, Chen, Huang), Department
of Surgery; from the Chung-Jen Junior College of Nursing, Health
Sciences and Management (Chen), Chia-Yi Christian Hospital,
Chia-Yi; from the Department of Neurological Surgery (Sun), TriService General Hospital, National Defense Medical Center, Taipei;
and from the Department of Biotechnology (Sun), Asia University,
Taichung, Taiwan.
Received 2nd March 2020. Accepted 14th June 2020.
Address correspondence and reprint request to: Dr. Kuo-Chang Huang,
Section of Neurosurgery, Department of Surgery, Chia-Yi Christian
Hospital, Chiayi, Taiwan. E-mail: man58.tw@yahoo.com.tw
ORCID ID: https://orcid.org/0000-0003-2698-5103

316 Neurosciences 2020; Vol. 25 (4)

S

troke is a leading cause of mortality and morbidity
in Taiwan.1 Acute hemiparesis is one of the most
indicative manifestations of acute stroke. Administration
of recombinant tissue plasminogen activator (rtPA), a
thrombolytic agent, within 3 to 4.5 hours of symptom
onset is the standard treatment for acute ischemic
stroke.2 However, various diseases such as slipped
cervical discs, epilepsy, and spinal epidural hematoma
may present along with acute hemiparesis, mimicking
acute stroke, and thus be inappropriately treated with
rtPA.3 Spontaneous spinal epidural hematoma (SSEH)
is a rare condition of unknown etiology and requires
urgent surgical intervention.3-5 The characteristic
manifestation of SSEH is sudden-onset neck pain
following by motor paralysis or tetraparesis.4 However,
SSEH presenting with acute hemiparesis has been rarely
reported in the literature. Therefore, we reported a case
of SSEH with acute hemiparesis wrongly treated with
rtPA in the emergency department (ED).
Case Report. Patient information. The informed
consent was obtained from the patient for the case
report. The timeline for this case report was summarized
in Table 1. A 54-year-old woman experienced suddenonset neck pain, right facial numbness, and right-sided

Disclosure. The all authors certify that they have NO
affiliations with or involvement in any organization or
entity with any financial interest (such as honoraria;
educational grants; participation in speakers’ bureaus;
membership, employment, consultancies, stock
ownership, or other equity interest; and expert testimony
or patent-licensing arrangements), or non-financial
interest (such as personal or professional relationships,
affiliations, knowledge or beliefs) in the subject matter
or materials discussed in this manuscript.

OPEN ACCESS

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Spontaneous spinal epidural hematoma … Huang et al
Table 1 - The timeline for the presented case.
Dates

Relevant past medical history and interventions
She denied a history of hypertension, taking anticoagulant/antiplatelet medication, or trauma events.

2020/1/3

Summaries from initial and follow-up visits

Diagnostic testing (including dates)

Interventions

• Sudden-onset neck pain, right facial
numbness, and right-sided weakness

• Hemoglobin level of 10.8 mg/dL
and platelet count of 263,000/μL.
(2020/1/3)
• A coagulation test produced
normal results. (2020/1/3)
• A computed tomography (CT)
scan of the brain revealed no
intracranial hemorrhage. CT
angiography revealed no evidence
of major vessel occlusion or artery
dissection. (2020/1/3)

• Intravenous recombinant tissue plasminogen
activator (rtPA) was administrated within 4.5
hours of symptom onset. (2020/1/3)

• Subsequent magnetic resonance
images of the brain and cervical spine
revealed a mass in the right dorsal
portion of the cervical canal above
the C3 level that was compressing
the spinal cord (2020/1/3)

• Emergent laminectomy with hematoma
removal 12 hours after symptom onset.
(2020/1/3)

• Visiting our ER 2 hours later after the onset
of symptoms

2020/1/3

Left-side weakness developed 3 hours later
rtPA injection

2020/1/8

The motor strength of the left extremities
recovered to grade 4

2020/1/21

Discharge with right extremities recovered to
grade 3

2020/2/5

She could walk with walker

weakness. After these symptoms had persisted for
2 hours, she visited our ED. She denied a history
of hypertension, taking anticoagulant/antiplatelet
medication, or trauma events.
Clinical findings. On arrival, she was alert and
cognizant. Her vital signs were as follows: blood pressure
of 113/73 mm Hg (normal range: 90/60mmHg to
120/80mmHg), heart rate of 74 beats per minute
(normal range: 60 to 100 beats per minute), respiratory
rate of 20 breaths per minute (normal range: 12 to 16
breaths per minute), and body temperature of 36.1°C
(normal range: 36.1 to 37.2). Neurological examination
revealed Grade 2 (of 5) muscle power in the right
extremities, normal deep tendon reflexes, and a right
Babinski sign. Cranial nerve function was normal,
except for decreased sensation on the right side of the
face. Laboratory examination revealed a hemoglobin
level of 10.8 mg/dL (normal range: 12-15.5mg/dl) and
platelet count of 263,000/μL (normal range: 150,000
to 450,000/uL). A coagulation test produced normal
results. An emergency computed tomography (CT)
scan of the brain revealed no intracranial hemorrhage.
CT angiography revealed no evidence of major vessel
occlusion or artery dissection. Her National institutes

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of health stroke scale was 11 (normal range: 0 to 42).
As acute ischemic stroke is highly suspected with right
hemiparesis, intravenous rtPA was administrated within
4.5 hours of symptom onset.
Diagnostic assessment. However, the right side
progressively weakened after rtPA administration, and
left-side weakness developed 3 hours later. The patient
remained alert and oriented. Grade 2 (of 5) muscle
power was found in the left extremities. Subsequent
magnetic resonance (MR) images of the brain and
cervical spine revealed a mass in the right dorsal
portion of the cervical canal above the C3 level that
was compressing the spinal cord (Figure 1A). The mass
was isointense on T1-weighted images (Figure 1B) and
hyperintense on T2-weighted images (Figure 1C).
Therapeutic intervention. With a diagnosis of
cervical SSEH, the patient underwent emergent
laminectomy with hematoma removal 12 hours after
symptom onset. The hematoma was located primarily
on the dorsal aspect of the right spinal canal above the
C3 level and was severely compressing the spinal cord
(Figure 2). Pathological examination confirmed the
diagnosis of hematoma without vascular abnormality.
The intraoperative blood loss was 50 mL.

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Spontaneous spinal epidural hematoma … Huang et al

Figure 1 - Magnetic resonance images of the cervical spine showing A) Axial T2-weighted image shows a mass (white arrow) in the right dorsal portion
of the cervical canal above the C3 level, compressing the spinal cord. B) Sagittal T1-weighted image shows mass isointensity (white arrow).
C) Sagittal T2-weighted image shows high mass intensity (white arrow).

Figure 2 - Intraoperative view following laminectomy; hematoma (white
arrow) mainly located on the right dorsal aspect of the C3
region.

Follow-up and outcomes. Postoperatively, her
neurological deficits decreased gradually. On the
fifth postoperative day, the motor strength of the left
extremities recovered to grade 4. The motor strength of
the right extremities recovered to grade 3 at discharge.
She could walk with the walker one month after the
surgery.
Discussion. Spontaneous spinal epidural hematoma
is a rare etiology of acute hemiparesis that can cause
spinal cord compression. The annual incidence of
SSEH is approximately 0.1 per 100,000, and most
cases are observed in men aged between 50 and 80
years.4 Spontaneous spinal epidural hematoma is caused

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by many factors, such as hypertension, coagulopathy,
anticoagulant/antiplatelet
therapy,
neoplasm,
hemodialysis, vascular abnormality, and idiopathic
causes.3,5 Although the pathophysiological mechanism
is unclear, bleeding in SSEH has been hypothesized
to be associated with activities resulting in a sudden
increase in posterior epidural venous pressure, such as
cough, sneezing, twisting, lifting, and straining.3-6
Patients with cervical SSEH commonly present
with sudden-onset neck pain and subsequent rapid
motor paralysis or sensory dysfunction.7 However,
acute hemiparesis has been reported to be an extremely
rare presentation of SSEH.5,8,9 Such cases may be
initially misdiagnosed as acute ischemic stroke, which
commonly presents with acute hemiparesis and is
treated with intravenous thrombolytic agents in the
ED.5,8,10 Kim et al3 showed that 2 (22.2%) of 9 patients
initially misdiagnosed with ischemic stroke and treated
with intravenous rtPA actually had SSEH. Clinical
manifestations such as Horner syndrome, BrownSequard syndrome, and the absence of cranial nerve
palsies in acute hemiparesis indicate SSEH rather than
stroke; after observing such manifestations, Patel et al9
showed that 13 patients suspected of having stroke and
treated with heparin, rtPA, or warfarin actually had
SSEH. Furthermore, Matsumoto et al8 concluded that
initial symptoms of neck pain and the Lhermitte sign
are the most crucial for distinguishing SSEH from acute
ischemic stroke.
The soft tissue window of a CT scan may enable
physicians to rule out cerebrovascular or cardiovascular
disease and identify SSEH.11 Magnetic resonance
imaging is the standard method for diagnosing SSEH and
can help determine the location, contours, and severity

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Spontaneous spinal epidural hematoma … Huang et al

of cord compression.4 In the acute stage, hematoma
commonly appears as an isosignal on T1-weighted MR
images and a high signal on T2-weighted MR images.4,7
Enhanced MR imaging or MR angiography may be
helpful in differentiating SSEH from other disorders
presenting with hemiparesis, including ischemic stroke,
prolapsed cervical discs, epidural abscesses, neoplasms,
or transverse myelitis.9
Although few cases (mainly from pediatric patients)
with spontaneous resolution following conservative
treatment have been described,12-14 decompressive
laminectomy with hematoma evacuation is the standard
care procedure for patients with SSEH presenting with
neurological deficitis.4,9,11 The outcome is correlated
with the delay from symptom onset until surgical
intervention.9 Surgical decompression after more than
12 hours of profound deficits may cause permanent
neurological disability.15 However, the effects of rtPA
on the surgical outcome and intraoperative bleeding
tendency are unclear because few SSEH patients
are treated with intravenous rtPA.10 In our case, the
operation was performed 8 hours after intravenous rtPA
treatment, and the intraoperative blood loss was only
50 mL. Thus, the effect of one-time intravenous rtPA
administration on surgical intervention is negligible. In
patient’s perspective, cervical SSEH must be considered
when sudden onset of neck pain following by motor
weakness occurs, without obvious cranial nerve
abnormalities such as facial palsy or tongue deviation.
In conclusion, although acute hemiparesis is the
main presentation of acute stroke in the ED, cervical
SSEH must be considered when a patient presents with
neck pain but no obvious cranial nerve abnormalities,
such as facial palsy or tongue deviation. Improper use
of rtPA may cause cervical SSEH to progress, delay
surgical intervention, and worsen the surgical outcome.
Acknowledgement. We would like to thank Dr. Cheng-Ta
Hsieh (Sijhih Cathay General Hospital, New Taipei, Taiwan) for
providing assistance in the preparation of the manuscript.

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