A 69-year-old woman fell asleep at around 9:30 p.m. the previous day, and came to our emergency room at 2:19 a.m. due to neck pain and right-sided hemiplegia that occurred at around 00:00 a.m. She was diagnosed with diabetes 20 years ago. There was no history of trauma before or after the symptoms began to manifest. Upon admission, her blood pressure was recorded as 192/100 mmHg. Neurological examination revealed right-sided hemiplegia (Medical Research Council grade 2/3), and there was no other neurological deficit. She had a National Institute of Health Stroke Scale (NIHSS) score of 5. According to the stroke system, multimodal CT was performed, wherein it was found that there was no intracranial hemorrhage, and degenerative change and stenosis of C3-C5 were detected in the aortic arch to vertex view (Fig. 1A). However, a high-density lesion on the axial view of the CT scan was identified in the right posterior epidural space at the C3-C5 level (Fig. 1B). High signal intensity was detected at the same level on spine magnetic resonance imaging (MRI) (Fig. 1C, D). The patient was finally diagnosed with spontaneous cervical epidural hematoma. Emergency decompression surgery was performed. On the 4th day after surgery, the patient was able to walk again.

An 85-year-old male fell asleep at around 7:00 p.m. the previous day, and was admitted to our emergency room at 12:50 a.m. due to right-sided hemiplegia when he woke up. He had a history of stroke 9 years prior, for which he took an antiplatelet agent. There was no trauma history. Recorded vital signs were within the normal range. He had neck pain that was exacerbated by movement and was relieved by rest. Neurological examination revealed right hemiplegia (Medical Research Grade 1/1), and there was no other neurologic deficit. The patient had a NIHSS score of 6. According to the stroke system, multimodal CT was performed; based on this, there was no intracranial hemorrhage, and degenerative change and stenosis of C5-C6 were detected in the aortic arch to vertex view (Fig. 2A). However, a high-density lesion on the axial view of CT was identified in the right posterior epidural space at the C3-C6 level (Fig. 2B). High signal intensity was detected at the same level on spine MRI (Fig. 2C, D). The patient was finally diagnosed with spontaneous cervical epidural hematoma. Emergency decompression surgery was performed. After surgery, the patient was able to walk again.

Our cases showed that spontaneous cervical epidural hematoma must be differentiated from stroke before intravenous tPA. Our patients presented with neck pain followed by hemiplegia without cranial nerve manifestations. Multimodal brain CT, including the aortic arch to vertex view, showed the reason why neck pain was provoked.

Spontaneous cervical epidural hematoma is a rare disease that has been reported to be around 1 in every 1 million people.² Generally, the patient experiences paraplegia and tetraplegia accompanied by neck pain without cranial nerve abnormality.³ However, there are numerous descriptions of hemiparesis as an initial manifestation of spontaneous cervical epidural hematoma. In such cases, the patient is often misdiagnosed with ischemic stroke. Among the cases of spontaneous cervical epidural hematoma that have been reported so far in the PubMed database (https://pubmed.ncbi. nlm.nih.gov/), eight were suspected with having stroke and were treated with intravenous tPA. Four of these cases had deterioration of neurological symptoms after tPA use (Table 1). All of the reported cases initially had symptoms of hemiplegia, which could be due to cerebral infarction. However, the deterioration of neurological symptoms after administration of intravenous tPA included quadriplegia, Brown-Sequard syndrome, dysuria, and Horner’s syndrome, which are suspected to be manifestations of spinal cord disease rather than cerebral infarction. Emergency decompression surgery was performed as treatment, and most of the postoperative neurological symptoms showed improvement. However, some symptoms reportedly persisted.

In reperfusion therapy, the time from onset to needle time is correlated with the prognosis of patients with stroke symptoms. For this reason, non-contrast brain CT is widely used for initial imaging examinations to exclude hemorrhage before initiating tPA treatment. However, the appropriate administration of tPA is also correlated with patient prognosis. Because inappropriate tPA can worsen hematoma, physicians should be aware of the potential for spontaneous cervical epidural hematoma within the time window for tPA treatment. In this regard, multimodal brain CT that includes non-contrast brain CT, CT angiography, and CT perfusion has the advantage of being a rapid and effective screening tool for acute ischemic stroke.⁴ Furthermore, the aortic arch to vertex view and angiographic-enhancing imaging performed in this case are useful for diagnosing cervical diseases, such as spontaneous cervical epidural hematoma, while evaluating acute stroke.

Spontaneous cervical epidural hematoma with hemiparesis can be mistaken for an acute ischemic stroke, and treatment with intravenous tPA has a severe risk of aggravating the neurological symptoms, delaying surgery, and worsening the surgical outcome. If the patient presented with hemiparesis and neck pain and no cranial nerve abnormalities were observed, spontaneous cervical epidural hematoma must be considered before administering intravenous tPA.