Ventral Cervical Epidural Abscess Presenting as a Stroke Mimic With Paradoxical Thoracic Sensory Level: Diagnostic Challenges and Multimodal Management

Rare disease Background:Cervical spinal epidural abscesses are uncommon; ventral lesions are rare, often arising from contiguous spondylodiscitis.Atypical presentations without cranial nerve involvement or altered consciousness are easily misattributed to intracranial diseases, delaying care. Case Report:We report the case of a 51-year-old man with poorly controlled hypertension and recent heroin use who developed progressive back and neck pain along with 3 days of fever, followed by rapidly progressive asymmetric weakness.Neurological examination revealed a paradoxical T4/T5 sensory level with preserved mentation and cranial nerve function, an important bedside clue suggesting a spinal process despite an initial stroke workup.Cervical gadolinium-enhanced magnetic resonance imaging (MRI) later revealed a long-segment ventraldorsal C2-C7 epidural abscess with compressive myelopathy and C4-C6 spondylodiscitis; blood cultures grew methicillin-resistant Staphylococcus aureus.The patient underwent urgent C3-C7 decompressive laminectomy with abscess drainage, followed by 6 weeks of pathogen-directed intravenous antibiotics.Adjunctive hyperbaric oxygen therapy and intravascular laser irradiation of the blood were initiated; repetitive transcranial magnetic stimulation was instituted as a rehabilitative neuromodulation strategy.Bacteremia cleared and inflammatory markers normalized; motor function improved from flaccid quadriplegia to partial antigravity strength in the selected muscle groups, although he still needed to use a wheelchair at discharge. Conclusions:This case emphasizes that a thoracic sensory level with fever and preserved consciousness should prompt early spinal MRI.Standard surgical antimicrobial therapy remains important, and carefully selected adjuncts (eg, adjunctive hyperbaric oxygen therapy, intravascular laser irradiation of the blood, and repetitive transcranial magnetic stimulation) may be considered to support infection control and neurorecovery.