Painless Spontaneous Spinal Epidural Hematoma Mimicking Acute Ischemic Stroke: A Case Report

AIM: Spontaneous spinal epidural hematoma is a rare neurological emergency. Its painless variant is particularly uncommon and can easily be misdiagnosed as acute ischemic stroke, especially in patients receiving anticoagulant therapy. This study aims to enrich the clinical recognition of painless spontaneous spinal epidural hematoma and emphasize its differential diagnosis from acute stroke in high-risk medicated patients. CASE PRESENTATION: We report a rare case of painless spontaneous spinal epidural hematoma mimicking acute ischemic stroke in a woman in her early 60s receiving anticoagulation and antiplatelet therapies. She initially presented with neck tightness and bilateral limb numbness without pain, followed by transient right hemiplegia and rapid neurological deterioration. Magnetic resonance imaging (MRI) revealed a C4–T2 cervical epidural hematoma causing severe spinal cord compression. RESULTS: The patient underwent emergent C4–C6 laminectomy with partial C7 laminectomy and hematoma evacuation. Despite partial strength recovery, extensive and prolonged cord compression may have contributed to the poor prognosis. CONCLUSIONS: Painless spontaneous spinal epidural hematoma is an easily overlooked stroke-mimicking emergency. For patients receiving anticoagulant or antiplatelet therapy who present with acute bilateral limb weakness or stroke-mimicking neurological deficits without typical spinal pain, spontaneous spinal epidural hematoma should be included in the early differential diagnosis to avoid delayed treatment and unfavorable prognosis.