Acute cervical spinal disc prolapse masquerading as stroke, requiring emergency spinal surgery immediately following thrombolysis.

Sir,

Acute cervical spinal disc prolapse masquerading as stroke is a rare entity. We report a case of acute onset of left-sided weakness, that was initially thrombolysed suspecting stroke and later found to have an acute cervical disc prolapse.

A 46-year-old man presented to the emergency department with complaints of acute onset left-sided weakness (power 0/5) of 3 h duration. He had a history of slip and fall two months ago. There was no local pain or tenderness in the neck. His National Institute of Health Stroke Scale (NIHSS) was 7/42 on arrival and a non-contrast computed tomography brain ruled out a haemorrhage. Acute ischemic stroke protocol was initiated and he was immediately thrombolysed with alteplase 60 mg (Bolus of 6 mg followed by 54 mg over next hour). Following the intravenous thrombolysis, his NIHSS was still 7/42 and a detailed neurological examination showed a power of 0/5 in left upper and lower limbs, flaccid tone on left side, absent Babinski response with preserved sensation. He also had urinary retention. His deep tendon reflexes (DTR) were absent on the left side. Magnetic resonance imaging (MRI) of the brain did not reveal any diffusion restriction and MR angiography of the circle of Willis ruled out a major vessel obstruction. Cervical spinal cord pathology was suspected because his MRI brain did not show any diffusion restriction, positive history of trauma, absent DTR, bladder symptoms, and he had left-sided weakness with non-improving NIHSS score post thrombolysis. MRI of the cervical spine revealed an extruded disc at the C5-C6 level causing spinal canal stenosis (anteroposterior diameter of 2.5 mm) impinging the spinal cord [Figure 1]. He was planned for an emergency C5-6 anterior cervical discectomy and fusion in view of his acute onset of weakness, urinary retention, and the imaging findings.

Figure 1

(a) Normal MRI with no diffusion restriction (b) acute cervical disc prolapse at C5-6 level (right) with signal changes

Since the patient was thrombolysed with alteplase within a period of 24 h (18 h), a thromboelastogram (TEG) was done which showed a fibrinolytic pattern. Other tests of coagulation like bleeding time, clotting time, prothrombin time, internationalised normalised ratio was normal. His serum fibrinogen levels were 134 mg/dl. He was transfused with one unit of pooled cryoprecipitate following which his fibrinogen levels improved to 212 mg/dl and tranexamic acid 10 mg/kg bolus followed by an infusion of 1 mg/kg/hr until completion of surgery. A rotational thromboelastometry (ROTEM) was done which was normal [Figure 2].

Figure 2

(a) Initial TEG showing a fibrinolytic pattern (b) ROTEM showing a normal coagulation following transfusion of cryoprecipitate

Perioperative period was uneventful. On follow-up after 6 weeks he had a complete neurologic recovery.

Thrombolysis within the “golden hour” remains the standard of managing patients with suspected stroke provided they reach the hospital within the window period of thrombolysis after ruling out an intracranial bleed.[12]

Acute cervical discs masquerading as stroke is an extremely rare entity and has not been frequently reported in the literature.[3] In an emergency, it is extremely difficult to differentiate stroke from other conditions in a patient presenting with hemiplegia within the window period, and the clinician is compelled to thrombolyse the patient in such scenarios. There is a 16–36% decrease in circulating fibrinogen levels following administration of 100 mg of alteplase, and this decrease in levels last up to a period of 24 h.[4] The present recommendations for reversing the effects of alteplase include cryoprecipitate,tranexamic acid or other antifibrinolytics. Role of platelets is unclear.[5]

We present a rare clinical situation wherein the patient required a spinal surgery following thrombolysis. The clinical implications of this situation include, the nature of the surgery being “urgent” to relieve the spinal cord compression and regain power in limbs, the increased risk of epidural haematoma owing to the thrombolysis and risk of intracerebral bleed.

This report reinforces the importance of repeated basic neurological examination in a neuro intensive care unit, especially if the clinical findings do not fit into the clinical picture and examination-guided radiological imaging methodologies in the perioperative care of neurological emergencies.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.