An 80-year-old man with hypertension and type 2 diabetes mellitus had a sudden fall at home. At sight, he complained of right hemiparesis and was transported to hospital. In the emergency room, his National Institutes of Health Stroke Scale (NIHSS) score was 5, he had a normal level of consciousness, his arterial blood pressure was 157/85 mm Hg, and electrocardiography showed normal sinus rhythm. Neurological examination revealed right hemiparesis with a focus in his right leg, facial palsy of the central type, and mild cervical pain. On the right side, he reacted to pain by flexing both the upper and lower right limbs. After noncontrast brain computed tomography which revealed no abnormalities, the patient received intravenously 66.6 mg of alteplase according to our institutional protocol 2.5 h from symptom onset. During the infusion, he first complained of numbness in his right arm, then neck pain, followed by left leg numbness. Babinski's sign became positive on the left side. Subsequent brain CT showed no hemorrhage, and CT angiography of the cervical arteries ruled out basilar artery occlusion. Alteplase infusion was completed, resulting in lessened bilateral symptoms in the lower extremities and improvement of facial palsy.
Two hours after the thrombolysis, the patient's NIHSS score was 4. He complained of severe lower cervical pain and slowly progressing paraparesis with decreasing sensation of touch and pinprick below the mamilla. MRI of the spine demonstrated an acute spinal dorsal epidural hematoma extending from the C6 to the T6 level, compressing the spinal cord (). The patient's prothrombin time (23 s), activated partial thromboplastin time (30 s), fibrinogen (2.0 g/l), and platelet count (154 g/l) all fell within the normal range. Promptly, he received fresh frozen plasma, cyclokaprone, and thrombocytes, and hematoma evacuation and laminectomy took place the next morning, 12 h after the symptom progression.
Fig. 1 Magnetic resonance images of the spinal cord sagittal (a) and axial (b). In the fat-saturated T2-weighted sagittal image an acute spinal dorsal epidural hematoma is visible, compressing the spinal cord and extending from foramen magnum to Th5 level. The (more ...)
Three months after the operation, he was still paraplegic with no movement in his legs, but retaining moderate sensation of touch. At that point, MRI of the spine showed a postoperative lesion with myelopathy, but as expected, no longer any visible hematoma.