Paradoxical contralateral hemiparesis in spontaneous spinal epidural hematoma: a case report

BACKGROUND: Hemiparesis associated with spontaneous spinal epidural hematoma (SSEH) usually occurs ipsilateral to the hematoma. We here report the case of a patient with paradoxical hemiparesis contralateral to a spinal lesion due to SSEH. CASE PRESENTATION: A 70-year-old woman was identified in routine clinical practice; she presented with acute-onset neck pain and left hemiparesis. Neurological examination showed left-sided sensory-motor hemiparesis without facial involvement. Cervical MRI showed a dorsolateral epidural hematoma compressing the spinal cord at the C2 to C3 level. Axial imaging demonstrated a crescent hematoma on the right side, which is contralateral to the hemiparesis, and lateral displacement of the spinal cord. Spinal angiography revealed no abnormal vessels. Based on clinical presentation and MRI findings, a diagnosis of SSEH was made. The patient was managed conservatively. The symptoms completely resolved without any neurological deficits, and the hematoma disappeared on the follow-up MRI. CONCLUSIONS: Paradoxical contralateral hemiparesis is one of the possible presenting symptoms in patients with SSEH. This case demonstrates the existence of the paradoxical contralateral hemiparesis associated with spinal compressive lesions. A plausible mechanism of the phenomenon is discussed.