Stimulated by Chen et al.[1]
This paper was published last month and has been waiting in the wings, so to speak. I was intrigued by the reference to mimicking stroke in the title. I was also under the impression that I had highlighted this adverse event before, but on checking, the previous reports were a migrating needle in the neck, epidural abscesses and other needling related adverse events in and around the spine:
Cranial epidural abscess – probably the most read blog to date!
In this case, a 52-year-old man in Taiwan experienced a gradual onset of soreness and weakness in his right arm whilst driving home after an acupuncture session. His right leg was affected as well, but this was ‘like walking on cotton wool’, rather than obvious weakness. The acupuncture had been performed on both sides of the neck and back, and the session lasted 1.5 hours. There are no more details of the treatment available. His symptoms lasted for 3.5 hours, and on admission to the emergency department (ED) it was thought he may have had a transient ischaemic attack. Examination revealed only mild weakness (4/5) of biceps on the right, and ‘pronator drift’, but otherwise an essentially normal neurological examination.
Pronator drift
a test for an upper motor neuron deficit in the upper limb
Trying to read between the lines of this case report, it sounds as though they did a CT scan in the ED and called the acute stroke team. The CT (without IV contrast) showed nothing, but the stroke team routinely performed CT angiography in this unit apparently, and that revealed a spinal epidural haematoma (SEH) – posterolateral spinal canal from C4 to C6.
The authors have ‘sold’ this report to an emergency medicine journal with ‘mimicking stroke’ in the title because you don’t want to be using thrombolysis (IV injection of a drug that causes blood clots to dissolve) in a patient with symptoms caused by bleeding into a tight space with delicate structures such as the cervical spinal cord.
Of course some strokes are caused by intracranial bleeding (10-15%),[2] so I imagine stroke teams will always check before thrombolysis anyway. Perhaps they don’t always look at the cervical spine, and I guess it is probably more difficult to see a cervical SEH than a big intracerebral bleed squashing the brain.
Detour alert…
All this talk of thrombolysis reminds me of my very first night as a house officer (HO) covering the CCU (coronary care unit) at Jimmy’s in Leeds (a huge teaching hospital). I hadn’t heard of rTPA (recombinant tissue plasminogen activator), the subject of a multicentre trial of thrombolysis in acute myocardial infarction (AMI) at the time. The charge nurse called me to see a 37-year-old – a direct admission with AMI. He mentioned the rTPA trial and said first I had to run through a quick checklist, then inject the chap. He handed me a syringe, the contents of which were hidden to me, and then gave me a huge booklet to complete with pages in triplicate. It took ages, and whilst filling it in, I had my eye on the monitors. I watched his ST segments fall, and ventricular ectopic beats multiply, presumably as ischaemic myocardium was presented with oxygenated haemoglobin. Not long after he went into ventricular fibrillation, and I jumped into action. I had already had some experience on the normal medical wards, but this was CCU, and things were different. By the time I had rattled both ends of the bed and checked his carotid pulse, the nursing team had defibrillated him, set up a lignocaine infusion (this was the 80’s remember), and gone back to their chores. Not wanting to seem out of touch, I just returned to the paperwork and then left to see other patients. The rest of the night was uneventful, and I may even have seen my on-call room for an hour or two before the next morning’s ward round. I got a call for the medical registrar wanting to talk about an admission. Why would he want to talk to me on a busy morning when he had been up all night seeing all the patients before releasing them to the tender care of HOs like me. He asked me if I had seen anyone on CCU the previous night. I said yes, and launched into a vivid description of my experience, including injecting a 37-year-old with some unknown stuff and him arresting afterwards. The registrar nodded understandingly, and then gently let me know that everything was fine with the patient, but that I had been the only doctor in the hospital to have seen him before enrolling him in a clinical trial, giving him an experiment drug, and witnessing his cardiac arrest. I was stunned. So that was what direct admission meant… direct from the ambulance… no brief stop at the main door to casualty to say hi to my registrar… no! He smiled and said: “Next time just give me a call.”
“Next time just give me a call”
Sorry about the rather long detour there. Thrombolysis started with streptokinase (derived from streptococcal bacteria), but the more expensive rTPA took over, and some 20 years later its use in acute stroke was established.[3]
Back on track now…
Clearly, we do not want to promote tissue plasminogen activation in SEH. But do we need to evacuate the haematoma or not. To do so would involve fairly major surgery.
In this case the patient’s symptoms had improved somewhat before admission, so a conservative approach was adopted, some steroids administered, and the patient was discharged with a sore arm but no weakness after 5 days. In their discussion the authors state that to the best of their knowledge this is the first such case to present with unilateral weakness of limbs mimicking a stroke.
They searched the literature and found four other cases of cervical SEH. I found three of them relatively easily.[4–6] Two of these three presented with unilateral limb weakness, and I am struggling to see why these could not have mimicked stroke too.
The fourth case has a first author with a distinctive name – Domenicucci et al (2017). But when I searched, I found quite a lot of case reports by this author, and two papers from 2017. The one referenced Chen C-L et al – a large case review on spinal epidural haematomas,[7] and the one they should have referenced on acupuncture that included 7 cases.[8] What puzzled me for a while about Domencicucci’s papers was the fact that one includes 7 cases of SEH attributed to acupuncture, and the other only cites one in 1000, despite being published in the same year. Then I woke up and remembered how the earth rotates, and that it is not around us acupuncture advocates.
The world keeps spinning…
The world keeps spinning and things sometimes just happen for no apparent reason. So, my last reference has to be a report of 2 cases of spontaneous cervical SEH occurring in elderly Japanese men.[9] Thankfully they did not have prior neck pain treated with Japanese acupuncture, otherwise some superficial needling may have been left begging to be handed the blame, because acupuncture is often blamed when it is simply implausible to do so.
But let me end on a note of caution. Never needle towards the epidural space, spinal cord or brain if there is a safer alternative. From a mechanistic perspective there is nearly always an alternative.
Afterthought
I knew I had missed something! One further reference for which I could not access the full text. I asked Jens, and we had a brief discussion about it over email when he got it. This is a case of a cervical SEH in a fit 62-year-old woman being treated for tennis elbow with physical therapy including dry needling.[10] The description of needling is much more detailed than we are used to in such case reports. We are told that contact was made with the lamina with a 30 or 40mm length needle, and a fast in fast out technique was used to treat the multifidus between C3 and C5 on the affected right side.
never try to contact a cervical lamina
All I can say is that I would never try to contact a cervical lamina. The gaps are too big and the laminae too small. C2 is the exception because the spinous process is in the same plane as the lamina, so its position is predictable. Having said that, I would not angulate my needle towards the central spinal canal.
As for using a piston, fast in fast out, technique in cervical multifidus, when the problem is at the elbow… (quietly shakes his head).
References
1 Chen C-L, Chang M-H, Lee W-J. A Case Report: An Acute Spinal Epidural Hematoma after Acupuncture Mimicking Stroke. J Emerg Med 2020;0. doi:10.1016/j.jemermed.2020.01.009
2 Vilela P, Wiesmann M. Nontraumatic Intracranial Hemorrhage. In: Hodler J, Kubik-Huch R, von Schulthess G, eds. Diseases of the Brain, Head and Neck, Spine 2020–2023: Diagnostic Imaging. 2020. https://www.ncbi.nlm.nih.gov/books/NBK554334/.
3 Wardlaw JM, Murray V, Berge E, et al. Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis. Lancet 2012;379:2364–72. doi:10.1016/S0140-6736(12)60738-7
4 Chen J-C, Chen Y, Lin S-M, et al. Acute Spinal Epidural Hematoma after Acupuncture. J Trauma Inj Infect Crit Care 2006;60:414–6. doi:10.1097/01.ta.0000203541.49062.64
5 Lee J-H, Lee H, Jo D-J. An acute cervical epidural hematoma as a complication of dry needling. Spine (Phila Pa 1976) 2011;36:E891-3. doi:10.1097/BRS.0b013e3181fc1e38
6 Park J, Ahn R, Son D, et al. Acute spinal subdural hematoma with hemiplegia after acupuncture: a case report and review of the literature. Spine J 2013;13:e59–63. doi:10.1016/j.spinee.2013.06.024
7 Domenicucci M, Mancarella C, Santoro G, et al. Spinal epidural hematomas: personal experience and literature review of more than 1000 cases. J Neurosurg Spine 2017;27:198–208. doi:10.3171/2016.12.SPINE15475
8 Domenicucci M, Marruzzo D, Pesce A, et al. Acute Spinal Epidural Hematoma After Acupuncture: Personal Case and Literature Review. World Neurosurg 2017;102:695.e11-695.e14. doi:10.1016/j.wneu.2017.03.125
9 Hongo T, Iseda K, Tsuchiya M, et al. Two cases of spontaneous cervical epidural hematoma without back or neck pain in elderly Japanese men. Acute Med Surg 2018;5:181–4. doi:10.1002/ams2.317
10 Berrigan WA, Whitehair CL, Zorowitz RD. Acute Spinal Epidural Hematoma as a Complication of Dry Needling: A Case Report. PM&R 2019;11:313–6. doi:10.1016/j.pmrj.2018.07.009
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