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Título

Spontaneous Spinal Epidural Hematoma as a stroke mimic in time window for thrombolysis

RESUMO

Case report: A 73-year-old woman presented to the Emergency Department with right hemiparesis and ipsilateral neck pain with sudden onset three hours before arrival. Her past medical history included hypertension and diabetes, but no remarkable history of neurological disease. Code Stroke was activated. At admission, her blood pressure was 220/105 mmHg and her blood glucose level was 213 mg/dL. Her National Institutes of Health Stroke Scale score was 8 due to a right-sided hemiplegia; there was no facial palsy. CT scan showed no signs of recent ischemic infarction or intracranial hemorrhage. CT angiography showed no sign of arterial occlusion, critical stenosis or dissection. As the patient was taken back to the emergency room, her motor deficit improved substantially spontaneously, but then got worse again. The team decided to proceed with thrombolytic therapy, but the time window ran out due to poor blood pressure control despite increasing doses of intravenous vasodilator drug. The patient was then started on antiplatelet therapy for secondary prophylaxis. 24 hour follow-up CT scan showed no changes from the initial exam. The patient performed an MR angiography for persisting neck pain, which revealed a posterolateral right-sided cervical epidural hematoma. Because her motor deficit had remained stable over the last day, a conservative approach was chosen.
Discussion: Spontaneous Spinal Epidural Hematoma (SSEH) represents a rare cause of spinal cord compression and neurological emergency. Paraplegia or tetraplegia are the most common presentation, while hemiparesis is considered to be a rare feature, more commonly associated with cervical epidural hematoma. In these rare stroke mimicking presentations, thrombolytic therapy, anticoagulation or treatment with an antiplatelet agent can lead to hematoma expansion and need for a prompt surgical evacuation. Although clinical presentation may be similar to a stroke, previous studies have reported persistent neck or back pain and absence of facial weakness as a high index of suspicion of SSEH, and may help to distinguish from cerebral etiologies.
Final Commentaries: This case represents a rare stroke mimic with potential harm associated with thrombolytic therapy, so SSEH should be always suspected as a differential diagnosis of ischemic stroke to avoid fatal outcomes.

Palavras Chave

Stroke mimic; Spinal Epidural Hematoma;