Case Report: A patient with spontaneous spinal epidural hematoma misdiagnosed as ischemic stroke recovered after delayed surgery.

Spontaneous spinal epidural hematoma (SSEH) manifesting acute hemiparesis is a rare stroke mimic that carries a high risk of mismanagement. We present the case of a 52-year-old man who presented with acute right hemiparesis and neck pain, initially diagnosed as an acute ischemic stroke (AIS) and treated with intravenous thrombolysis using tissue plasminogen activator (rt-PA). Persistent neck pain and subsequent urinary retention prompted re-evaluation of the initial cranial computed tomography angiography (CTA), which revealed an epidural hematoma. After limited improvement under 1 week of conservative management, he underwent surgical evacuation on day 12 post-onset, and achieved complete neurological recovery. This case underscores the importance of recognizing neck pain and bladder dysfunction as indicators of spinal pathology in the context of hyperacute stroke. It also demonstrates that delayed surgical intervention may still be effective in carefully selected SSEH patients with slow clinical progression and stable neurological status.