Cervical epidural haematomas should be considered in any patient presenting with neck pain and suspected stroke particularly if taking antiplatelets.
Case Report
This eighty-year-old gentleman presented to accident and emergency with right arm weakness. The patient reported a sudden onset of right neck pain at rest radiating to his right shoulder and back, leading to immediate numbness and tingling down his right arm and associated heaviness. There was no report of any preceding trauma or headache. He had a past history of hypertension, tablet controlled diabetes mellitus, previous transient ischaemic attacks, bilateral carotid endarterectomies and peripheral vascular disease. His medications included aspirin 75 mg once a day and dipyridamol sustained release 200 mg twice a day.Neurological examination revealed 3/5 power in his right upper limb with reduced sensation throughout. He had pain on right lateral neck movement but no stiffness. Cranial nerves and lower limbs were normal. He was haemodynamically stable with a systolic blood pressure of 140 mmHg. Electrocardiogram showed sinus rhythm with no acute features. Blood results were unremarkable. The main differential diagnoses were cerebral stroke, aortic dissection and cervical myelopathy. An urgent Computed Tomography (CT) aortic angiogram was normal. Cervical spine x-ray showed no fracture. CT head scan did not reveal any infarct or haemorrhage and his dual antiplatelets were continued. A non-urgent Magnet Resonance Imaging (MRI) of his cervical spine was arranged.The patient underwent rehabilitation therapy. Symptom resolution occurred within 24 hrs of presentation. On day 6 of admission he was fit to be discharged home with follow-up in one month. The MRI neck report was still outstanding but as the patient was well, we did not wish to delay discharge. On review of the MRI the next day, it showed ‘a right sided shallow fluid collection projecting into the spinal canal from the posterolateral aspect of the canal between C4 and C7. Cause uncertain but includes haematoma or abscess’ (Figure 1). There was also spondylosis with potential nerve impingement at C6/C7 bilaterally. The patient was contacted and advised to stop the dipyridamole. The images were linked to our nearest neurosurgical centre and discussed with the doctor on duty. It was agreed that due to his symptom resolution, conservative management was appropriate.
Figure 1
MRI Cervical Spine Showing Epidural Haematoma
MRI Cervical Spine Showing Epidural HaematomaA repeat MRI after a further 3 weeks showed the epidural haematoma to have resolved.
Discussion
Literature review has revealed other reported cases of spontaneous cervical haematoma mimicking stroke.[1-3] The patients have presented with sudden onset of acute neck pain and commonly quadriplegia with loss of sensation and bowel/bladder dysfunction.[4] Unilateral weakness is uncommon and could explain why these patients are initially misdiagnosed. Pathogenesis has been attributed to hypertension, increased intra-abdominal pressure and the use of anticoagulants. Other case reports have shown patients to be on higher doses of aspirin or Low Molecular Weight Heparin.[2,5] MRI cervical spine is the preferred imaging method. In the majority of the cases the patients have required emergency decompression with surgical removal of the haematoma. However, there are reported cases of full recovery with conservative management.[5-7] It is felt that surgical intervention is not required in patients who show early neurological improvement. In these cases symptom resolution could be attributed to the spreading of the haematoma through the epidural space.This report highlights the importance of considering a spontaneous epidural haematoma in any patient presenting with neck pain and limb weakness. We must pay particular attention to any antiplatelet medication as this may put the patient at higher risk. Misdiagnosis includes aortic dissection, myocardial infarction, vasculitis and in particular cerebral infarction which could lead to inappropriate anticoagulation or thrombolysis. Although conservative management has a role patients may need neurosurgical intervention. Without prompt diagnosis and neurosurgical input patients can be left disabled from an otherwise reversible condition.[8]
DECLARATIONS
Competing interests
None declared
Funding
No funding or sponsorship to declare
Ethical approval
Written informed consent was obtained from the patient or next of kin where necessary
Guarantor
JG
Contributorship
All authors participated in the preparation of the manuscript. RS was the lead consultant in charge of the patient's care with JG being the junior doctor in his team. The MRI was reported by J Reynolds Radiologist at Heartlands Hospital, Birmingham. Advice was sought from the Queen Elizabeth Hospital neurosurgical department regarding the MRI results and how best to manage the patient
Figure 1