Stimulated by Wang et al 2025.[1]
ACSEH – acute cervical spinal epidural haematoma
paACSEH – post-acupuncture ACSEH
SEH – spinal epidural haematoma
IF – impact factor
rTPA – recombinant tissue plasminogen activator– key to acronyms
I thought this was going to be another first for the blog – a paACSEH mimicking a stroke. Certainly this unnecessarily long acronym is new, but on checking the archives, there was a rather similar case I highlighted 5 years ago – Spinal epidural haematomas 2020.
Also, one case from a series of 2 from last year, which I don’t think I have highlighted on here before, occurred just 10 minutes following acupuncture needle insertion into the neck and involved symptoms that were mostly on the left.[2] Had the patient not been so young (35 year), and the onset of symptoms so close to acupuncture treatment in the neck (10 minutes after needle insertion), perhaps this case might also have mimicked a stroke.
This case is published in the open access journal Clinical Case Reports (IF 0.6), which has been published since October 2013. The case is of a 73-year-old woman who was being treated with acupuncture at a community hospital for neck and shoulder pain. Half an hour after the session she started to feel weakness and numbness in the right arm and leg and was taken to a larger regional hospital in Changsha, Hunan Province, China. She gave such a good impression of hemiplegic stroke that the team had already initiated thrombolysis with alteplase (rTPA – see Spinal epidural haematomas 2020) whilst she was having an urgent CT scan. The latter failed to identify cerebral infarction but instead demonstrated an SEH in the cervical region extending from C2 to C5. A subsequent MRI scan delineated the haematoma and demonstrated leftward displacement of the spinal cord.
At this point, some 2 hours after admission, the patient had recovered some degree of power in the right arm and leg, which was fortunate considering that the combination of recent thrombolysis and her regular consumption of clopidogrel would have meant a considerable risk associated with surgical decompression.
The patient was treated conservatively with mannitol for dehydration and methylprednisolone pulse therapy to prevent spinal cord oedema. She recovered power and could walk after a week. At this point she requested discharge. A 20-day follow-up MRI showed complete resolution of the haematoma and resolution of the previous abnormal signal in the spinal cord at C3 to C4.
The paper also reviews previous publications of paACSEHs,[2–5] plus one that was subdural rather than epidural,[6] which reminds me of a famous clip from the 1983 film The Man With Two Brains, in which the comedian Steve Martin plays a neurosurgeon called Dr Hfuhruhurr. After hitting a character played by Kathleen Turner with his car, he asks a young girl to call for help. The girl is able to recite the impossibly long message with telephone and bleep numbers before suggesting that ‘it sounds like a subdural haematoma’, to which Steve Martin sends her off running with the message and berates her for guessing it is a subdural haematoma when it is actually epidural (with a US accent of course).
Of the 7 cases reviewed, only 2 were treated conservatively. This case, because of prior thrombolysis and another case in which the patient had improved before the surgeons had a chance to operate.[5] The first author of this latter case, also published a very large review of SEH in the same year (n=1010).[7] I have referenced this paper on the blog previously (see the link in the first paragraph), but not discussed any of the details before.
Acupuncture was not mentioned in the paper, but spinal puncture was implicated in 11% of cases. Coagulopathy was present in over a third of these. Spinal puncture alone was the only possible aetiological factor in less than 5%.
Overall mortality was just 7%, with a lower rate (5%) for those subjected to surgical treatment (n=767) and a higher rate (14%) for those managed non-operatively (n=192).
On reviewing my previous blog on SEH, I noted a case associated with dry needling of cervical multifidus.[8] This case was missed by the current paper’s mini review. It was also a non-surgical case, but the shocking aspect of this one was that the problem being treated was tennis elbow rather than neck pain, so needling onto cervical laminae really seems unnecessarily risky when local treatment may be all that is needed.
Needles do not only cause damage to the spinal cord via pressure from a haematoma. Needle fragments from embedded needles or accidentally broken needles are also a cause of neurological symptoms. A case report from Japan in 2010 also found 25 other reports in the literature, most of which were also from Japan, and just over half of them involved the practice of intentionally embedding needles. The latter practice has mostly died out, I understand; however, there is likely to be a subgroup of the elderly population of Japan, and the populations of other countries in the Far East, that are carrying around lots of needle fragments in their tissues, just waiting for the chance to migrate.
References
1 Wang P, Luo P, Xiang Z, et al. Post-Acupuncture Acute Cervical Spinal Epidural Hematoma With Hemiplegia Misdiagnosed as Cerebral Infarction: A Case Report and Literature Review. Clin Case Rep. 2025;13:e70779. doi: 10.1002/ccr3.70779
2 Lee WT, Fun JRS, Yeo YWM. Cervical epidural hematoma: a case series highlighting uncommon causes. Int J Emerg Med. 2024;17:115. doi: 10.1186/s12245-024-00693-3
3 Lee J-H, Lee H, Jo D-J. An acute cervical epidural hematoma as a complication of dry needling. Spine. 2011;36:E891-893. doi: 10.1097/BRS.0b013e3181fc1e38
4 Ji GY, Oh CH, Choi W-S, et al. Three cases of hemiplegia after cervical paraspinal muscle needling. Spine J. 2015;15:e9-13. doi: 10.1016/j.spinee.2014.11.007
5 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
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 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
The BMAS Blog 
You must be logged in to post a comment.