Correct!
5. All the above.
CT scans are poorly sensitive for cortical stroke in the first 24 hours. Lacunar strokes in the internal capsule typically cause hemiparesis but not aphasia (which is a cortical finding). Although we often consider spinal cord injuries as the cause of paraplegia or quadriplegia, a lateralized cord injury could cause a hemiparesis mimicking a stroke.
A CT angiogram of the neck was performed and demonstrated a focal 50% narrowing of the left common carotid artery (see below) compatible with, but not specific for an acute traumatic carotid dissection.
Figure 2. Panel A: axial view of the MRI of the spine. Panel B: saggital view. In both panels a right-sided epidural hematoma is demonstrated (red arrow) compressing the spinal column.
The scan did not show a central cord lesion with cervical spondylosis, but rather a right lateral epidural hematoma from C4-C6 with cord compression and cord edema.
Four units of fresh frozen plasma, 1500 units of prothrombin complex concentrate and 10 mg vitamin K were administered intravenously, and the patient underwent emergent cervical decompressive laminectomy from C4-T1 with evacuation of the hematoma. The right shoulder pain immediately resolved and she has regained some grip strength post operatively, but is still early in her recovery. Vascular surgery opined that the CT angiogram findings described earlier likely were not due to carotid dissection.
Spinal epidural hematoma can be caused by trauma in a patient taking anticoagulation and antiplatelet drugs. It is usually caused by venous bleeding, and can therefore progress slowly. It presents with local and/or radicular pain, and loss of motor sensory and autonomic function below the level of the lesion. Lateral spinal epidural hematomas have been reported to cause Brown-Sequard syndrome (hemi-cord syndrome), and also to mimic stroke because they can cause hemiplegia, as in this case.
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