Spontaneous Cervical Epidural Hematoma Treated with rt-PA: A Pitfall in Stroke Practice

Although hemorrhagic complications may arise with thrombolytic therapy using recombinant tissue plasminogen activator (rt-PA), deterioration following administration of rt-PA for hemorrhagic disease is an iatrogenic complication. Caution has recently been raised regarding aortic dissection. A case of cervical epidural hematoma treated with rt-PA is reported herein. The patient was an 87-year-old woman with a history of hemodialysis, brainstem infarction, and stenosis of bilateral internal carotid arteries treated with ticlopidine. She was transferred to our hospital with severe occipital and neck pain. Diffusion-weighted imaging revealed patchy signal hyperintensity in the left cerebellar hemisphere. Right hemiparesis appeared 2 h later, but repeat magnetic resonance imaging (MRI) revealed no new lesions. Administration of rt-PA was performed under a diagnosis of hyper-acute cerebral infarction. Irregular hemodialysis was initiated for pulmonary edema. Complete tetraplegia appeared after hemodialysis, 10 h after rt-PA administration. Repeat MRI revealed cervical epidural hematoma, and hematoma removal was performed. After 10 days, hemiparesis recovered to manual muscle testing (MMT) 2 in the left extremities but remained at MMT0 in the right extremities. Cervical epidural hematoma is a rare complication in stroke practice. Although rt-PA should be administered as soon as possible, since "time is brain," spending a few minutes on spinal MRI is preferable to prevent iatrogenic deterioration. For atypical cases of cerebral infarction, the possibility of cervical epidural hematoma should be considered.