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A previously well 53 year old man presented with a three hour history of severe chest pain. An ECG showed 4 mm ST segment elevation in the anterior leads. He received reteplase and clopidogrel (aspirin intolerance). Twelve hours later he developed severe neck pain with progressive tetraparesis with a sensory level at C6. Post-thrombolysis heparin and antiplatelet agents were stopped.
Magnetic resonance imaging of the spine (left) showed an extensive posterior extradural haemorrhage within the spinal canal from C2 and T10 with associated spinal cord compression at C5/6 and C6/7.
The patient was transferred as an emergency to the local neurosurgical centre where he underwent emergency evacuation of the haematoma. Seven days later, he had ongoing chest pain with dynamic ECG changes and underwent successful angioplasty to his left anterior descending coronary artery. He has since recovered full function in his upper limbs.
In thrombolysed patients, sudden neck pain should prompt suspicion of the rare, but recognised, complication of a cervical extradural haemorrhage. Urgent neurosurgery can significantly improve neurological prognosis.