Transient hemiplegia due to axis osteomyelitis with epidural abscess

How to cite this article:
Yanagawa Y, Nagasawa H. Transient hemiplegia due to axis osteomyelitis with epidural abscess. J Emerg Trauma Shock 2022;15:113-4

Sir,

As cervical lesions can be stroke mimics and might be fatal, the head and neck should be evaluated together by computed tomography (CT) and magnetic resonance image (MRI) when patients show signs of a stroke.

A 67-year-old man with hypertension, hypothyroidism, depression, osteoporosis, and pharyngeal cancer had repeatedly visited the hospital due to neck pain. One day, when he tried to drink water by flexing his neck, he felt pain lance through his body and became unable to move his left arm and leg. However, emergency medical technicians checked him, his left hemiplegia had subsided. After arrival at the hospital, results of radiological and biochemical studies resulted in a diagnosis of axis osteomyelitis with epidural abscess compressing the upper spinal cord left dominantly [Figure 1]. Results of a blood culture revealed Streptococcus agalactiae. The present case was complicated with pathological fracture but fortunately obtained a favorable outcome with the only infusion of sensitive antibiotics and Halo-vest fixation.

Figure 1: Head (CT, upper left) and neck (MRI, upper right, axial view on T2WI; lower left, sagittal view on T1WI; lower right, sagittal view on T2WI) on arrival. CT on arrival showed a low-density area just below the dens (triangle). Neck MRI revealed a low intensity on T1WI and high intensity on T2WI at the axis (arrow) and fluid collection (triangle) just below the dens, which compressed the upper spinal cord left dominantly. WI: weighted image, CT: Computed tomography MRI: Magnetic resonance image

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Pohl et al. reported stroke mimic using a comprehensive review method. The stroke mimic rate was 24.9% overall.[1] Among stroke mimics, spinal lesions accounted for approximately 1%, similar to the Hand et al.[2] However, neither report described the details concerning spinal lesions and the mechanism involved in the development of stroke mimics. Kim et al. reported cases of stroke mimics that were incorrectly treated with tissue plasminogen activator over 4 years at a single institute.[3] There were nine cases of stroke mimic, all of which demonstrated hemiparesis, and five of the nine cases were spinal lesions. The details of those five cases were cervical disc herniation in two, epidural hematomas in two, and cervical SEA in one. Accordingly, the present case was the second case of stroke mimic induced by a cervical SEA. As cervical lesions can be stroke mimics and might be fatal, the head and neck should be evaluated together by CT and MRI when patients show signs of a stroke.[4]

Finally, the patient had red-flag signs associated with neck pain, including older age, history of cancer, and neck pain that could not be controlled with a standard pain killer.[5] Such patients should be carefully evaluated by CT, MRI, and biochemical studies.

Declaration of patient consent

We certify that we have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Research quality and ethics statement

We followed applicable EQUATOR Network (http://www. equator-network. org/) guidelines, notably the CARE guideline, during the conduct of this report.

Financial support and sponsorship

This work was supported in part by a Grant-in-Aid for Special Research in Subsidies for ordinary expenses of private schools from The Promotion and Mutual Aid Corporation for Private Schools of Japan.

Conflicts of interest

There are no conflicts of interest.

References

1.Pohl M, Hesszenberger D, Kapus K, Meszaros J, Feher A, Varadi I, et al. Ischemic stroke mimics: A comprehensive review. J Clin Neurosci 2021;93:174-82.

2.Hand PJ, Kwan J, Lindley RI, Dennis MS, Wardlaw JM. Distinguishing between stroke and mimic at the bedside: The brain attack study. Stroke 2006;37:769-75.

3.Kim MC, Kim SW. Improper use of thrombolytic agents in acute hemiparesis following misdiagnosis of acute ischemic stroke. Korean J Neurotrauma 2018;14:20-3.

4.Boody BS, Jenkins TJ, Maslak J, Hsu WK, Patel AA. Vertebral osteomyelitis and spinal epidural abscess: An evidence-based review. J Spinal Disord Tech 2015;28:E316-27.