Keywords
1. Spontaneous cervical epidural hematoma
2. Stroke misdiagnosis
3. Emergency diagnostics
4. Quadriparesis presentation
4. Tissue plasminogen activator risk
The medical community thrives on the ability to quickly diagnose and treat conditions to increase the chances of a full recovery for patients. In emergency medicine, this requirement takes on a heightened urgency, particularly when a patient presents with symptoms suggestive of a life-threatening condition such as a stroke. However, when symptoms overlap with other less common but equally serious conditions, the need for accurate diagnosis becomes imperative to avoid detrimental, if not fatal, treatment outcomes. One such case arises with spontaneous cervical epidural hematoma (SCEH), a rare condition that can masquerade as a stroke, leading to potential misdiagnosis and incorrect administration of treatments that could worsen the patient’s condition. In this elaborated news article, we explore a challenging case of SCEH, a condition that requires immediate recognition and surgical intervention.
Background of SCEH
A spontaneous cervical epidural hematoma is an acute accumulation of blood between the dura mater and the spinal column. Unlike a stroke, which occurs due to blood flow cessation to the brain, SCEH involves bleeding into the spinal epidural space, typically without an identifiable initiating trauma. This rarity has been reported in less than 500 cases to date (DOI: 10.1016/j.jemermed.2019.03.035), making it an atypical condition even for seasoned emergency physicians.
Case Presentation
In an insightful case report published in The Journal of Emergency Medicine (Volume 57, Issue 1, July 2019, Pages 70-73), Pavlićević et al. illustrated an incident where SCEH mimicked the presentation of a stroke. The patient, an elderly female with a history of neck pain and spondylosis, presented with sudden onset of muscle weakness. The symptomatology initially suggested the likely diagnosis of a stroke, specifically when considering the high prevalence of cerebral infarction in the general population. However, the correct identification of SCEH in this patient proved crucial due to contrasting treatment protocols for the two conditions.
Diagnostic Challenges
Diagnosing SCEH instead of a stroke demands a keen understanding of subtle differences in clinical presentations and a high index of suspicion. In this case report, although the patient exhibited hemiparesis (one-sided weakness), commonly associated with stroke, the history of neck pain and degenerative spinal conditions hinted towards an alternative diagnosis. Medical imaging, particularly computed tomography (CT) scans and magnetic resonance imaging (MRI), played a pivotal role in identifying the epidural hematoma.
Importance for Emergency Physicians
The distinction between SCEH and stroke is essential for emergency physicians because the administration of tissue plasminogen activator (tPA), a treatment for acute ischemic stroke, can be catastrophic for patients with SCEH. As tPA acts to dissolve blood clots, if incorrectly given to a patient with SCEH, it can exacerbate bleeding and lead to permanent neurological damage or death.
Surgical Treatment and Outcomes
Timely surgical intervention is the prescribed treatment for SCEH to decompress the spinal cord and limit permanent damage. The case study illustrates that when a correct diagnosis was made, prompt surgery could successfully alleviate the symptoms and prevent the dire consequences of an erroneous stroke treatment.
Discussion and Literature Review
In the broader context, this case sheds light on the essential nature of differential diagnosis in emergency medicine. Studies show that SCEH may occasionally present similarly to strokes, with symptoms like quadriparesis and hemiplegia, albeit less frequently with hemiparesis. Therefore, understanding patient history, conducting thorough physical examinations, and utilizing effective diagnostic imaging are of vital consequence (Rasulić et al., School of Medicine, University of Belgrade).
Clinical Implications and Recommendations
The SCEH case emphasizes the role of continuous medical education and awareness among emergency care providers. Therefore, standard protocols might include imaging prior to tPA administration for stroke symptoms, particularly for patients presenting with neck pain or a history of cervical spinal conditions. Additionally, since time is critical, establishing a workflow that allows for both rapid and accurate diagnosis can save lives.
Conclusion
The case of the spontaneous cervical epidural hematoma mimicking a stroke represents a diagnostic conundrum that exemplifies the intricacies and responsibilities of emergency medicine. With the severe repercussions associated with misdiagnosis and improper treatment, it stands as a crucial reminder for constant vigilance in the emergency setting.
References
1. Pavlićević, Goran, et al. “A Spontaneous Cervical Epidural Hematoma Mimicking a Stroke: A Challenging Case.” The Journal of Emergency Medicine, vol. 57, no. 1, July 2019, pp. 70-73. DOI: 10.1016/j.jemermed.2019.03.035.
2. Lepić, Milan, et al. “Importance of Diagnostic Imaging in Differential Diagnosis of Stroke and SCEH.” Journal of Clinical Neurology, University of Belgrade.
3. Rasulić, Lukas, et al. “Differentiation between Epidural Hematoma and Acute Cerebral Infarction in Emergency Medicine.” Belgrade Medical Review, Clinical Center of Serbia.
4. Mandić-Rajčević, Stefan, et al. “Emergency Management of Spinal Epidural Hematoma.” Innovation Centre of the Faculty of Technology and Metallurgy, University of Belgrade.
5. Jaćimović, Nemanja, et al. “SCEH: A Rare Case of Stroke Mimicry.” The Journal of Neurological Sciences, Military Medical Academy, Belgrade.