Background Spinal epidural haematoma is a rare condition usually regarded as a surgical emergency. Approximately half of all cases are spontaneous, and the rest associated with anticoagulation, blood dyscrasias, vascular malformations and trauma. Symptoms and signs are typically bilateral at onset, but may be unilateral initially and subsequently become bilateral as the haematoma enlarges.

Case report A 66 year old woman attended the emergency department following sudden onset of left-sided hemiparesis. Urgent computed tomography of the head showed no evidence of intracerebral ischaemia or haemorrhage. A putative diagnosis of ischaemic stroke was made, and she was prepared for emergency thrombolysis. Just prior to treatment, her hemiparesis worsened and she developed right leg weakness. Treatment was withheld. MRI of the brain and cervical spine identified an acute cervical epidural haematoma extending from C2 to C7, causing significant canal stenosis and cord compression. In retrospect, she recalled mild neck discomfort accompanying onset of her symptoms. The haematoma was surgically evacuated and within three months she was mobilising with a unilateral aid. Investigations failed to show a cause for the haemorrhage.

Conclusion With the increasing prevalence of thrombolysis for the treatment of acute stroke, spinal epidural haematoma is an important differential diagnosis to consider in patients manifesting acute-onset limb weakness due to the potentially catastrophic consequences of thrombolysing these patients erroneously.