Abstract
A 40-year-old Maori man presented to a rural hospital with syncope and a fall with head strike to the occiput. A non-contrast computed tomography (CT) of head and cervical spine excluded injuries. He was thrombolysed with Tenecteplase 50 mg for suspected ST elevation myocardial infarction (STEMI). He was transferred to the nearest tertiary hospital for coronary angiogram (CAG). He received intravenous bolus heparin 5000 units followed by continuous heparin infusion (25000 units) and 180 mg ticagrelor prior to transfer, and further intravenous heparin (2500 units) during CAG. The CAG suggested mild coronary artery disease only. Transthoracic echocardiogram was normal.
He developed mild asymmetric lower limb weakness following the CAG and a code stroke was activated. CT Brain, CT angiogram and CT cerebral perfusion were normal. Clinical examination the following day showed ataxic gait, absent lower limb reflexes and urinary retention with focal lower cervical tenderness. On revisiting the history patient reported blunt-force trauma to the neck during the fall. Urgent spinal magnetic resonance imaging (MRI) showed facet joint injury to mid-lower cervical spine with cord compression secondary to epidural hematoma at the C5 level. Urgent surgical spinal decompression was undertaken. There was near complete resolution of neurological deficits at discharge following a short inpatient admission.
Spinal epidural hematoma is a rare significant complication following systemic thrombolysis1. Anticoagulation and antiplatelets can have an additive effect. A careful history of trauma and close neurological observation can lead to early recognition and prompt treatment of this rare complication.
