Spontaneous cervical epidural haematoma: role of antiplatelets

This eighty-year-old gentleman presented to accident and emergency with right arm weakness. The patient reported a sudden onset of right neck pain at rest radiating to his right shoulder and back, leading to immediate numbness and tingling down his right arm and associated heaviness. There was no report of any preceding trauma or headache. He had a past history of hypertension, tablet controlled diabetes mellitus, previous transient ischaemic attacks, bilateral carotid endarterectomies and peripheral vascular disease. His medications included aspirin 75mg once a day and dipyridamol sustained release 200mg twice a day. Neurological examination revealed 3/5 power in his right upper limb with reduced sensation throughout. He had pain on right lateral neck movement but no stiffness. Cranial nerves and lower limbs were normal. He was haemodynamically stable with a systolic blood pressure of 140mmHg. Electrocardiogram showed sinus rhythm with no acute features. Blood results were unremarkable. The main differential diagnoses were cerebral stroke, aortic dissection and cervical myelopathy. An urgent Computed Tomography (CT) aortic angiogram was normal. Cervical spine x-ray showed no fracture. CT head scan did not reveal any infarct or haemorrhage and his dual antiplatelets were continued. A non-urgent Magnet Resonance Imaging (MRI) of his cervical spine was arranged. The patient underwent rehabilitation therapy. Symptom resolution occurred within 24 hrs of presentation. On day 6 of admission he was fit to be discharged home with follow-up in one month. The MRI neck report was still outstanding but as the patient was well, we did not wish to delay discharge. On review of the MRI the next day, it showed ‘a right sided shallow fluid collection projecting into the spinal canal from the posterolateral aspect of the canal between C4 and C7. Cause uncertain but includes haematoma or abscess’ (Figure 1). There was also spondylosis with potential nerve impingement at C6/C7 bilaterally. The patient was contacted and advised to stop the dipyridamole. The images were linked to our nearest neurosurgical centre and discussed with the doctor on duty. It was agreed that due to his symptom resolution, conservative management was appropriate. A repeat MRI after a further 3 weeks showed the epidural haematoma to have resolved.