Spinal subarachnoid hemorrhage complicating oral anticoagulant therapy

Delayed diagnosis of spinal subarachnoid hemorrhage in association with warfarin administration: a case report and literature review

Spinal subarachnoid hemorrhage is a life-threatening condition often associated with markedly high morbidity and mortality rates. However, diagnosis is difficult because of its atypical symptoms. We herein describe a 52-year-old Chinese man who had been receiving warfarin therapy since having undergone mechanical mitral valve replacement surgery 3 years previously. Two days before admission to our hospital, he suddenly developed low back pain, urinary incontinence, and paraplegia. He was diagnosed with acute myelitis at a local hospital, but he subsequently developed a slight headache and was transferred to our hospital 2 days later. The patient was suspected to have subarachnoid hemorrhage based on his computed tomography (CT) findings. On the third day after admission, a CT scan showed both subarachnoid and cerebral hemorrhage. Blood tests revealed an international normalized ratio ranging from 1.44 to 1.86 and a prothrombin time of 16.5 to 21.3 s. We performed a lumbar puncture and obtained bloody cerebrospinal fluid. The patient also underwent spinal CT and angiography, which confirmed the diagnosis of spontaneous spinal subarachnoid hemorrhage. Because his general condition was poor, he underwent conservative treatment, and his neurologic function slightly improved after discharge.

Intracranial extension of spinal subarachnoid hematoma causing severe cerebral vasospasm

Spinal subarachnoid hemorrhages (SAH) can extend into the intracranial subarachnoid space, but, severe cerebral vasospasm is rare complication of the extension of intracranial SAH from a spinal subarachnoid hematoma. A 67-year-old woman started anticoagulant therapy for unstable angina. The next day, she developed severe back pain and paraplegia. MRI showed intradural and extramedullar low signal intensity at the T2-3, consistent with intradural hematoma. High signal intensity was also noted in the spinal cord from C5 to T4. We removed subarachnoid hematoma compressing the spinal cord. The following day, the patient complained of severe headache. Brain CT revealed SAH around both parietal lobes. Three days later, her consciousness decreased and left hemiplegia also developed. Brain MRI demonstrated multiple cerebral infarctions, mainly in the right posterior cerebral artery territory, left parietal lobe and right watershed area. Conventional cerebral angiography confirmed diffuse severe vasospasm of the cerebral arteries. After intensive care for a month, the patient was transferred to the rehabilitation department. After 6 months, neurologic deterioration improved partially. We speculate that surgeons should anticipate possible delayed neurological complications due to cerebral vasospasm if intracranial SAH is detected after spinal subarachnoid hematoma.

Drug interaction as cause of spontaneously resolving epidural spinal hematoma on warfarin therapy

We present a case of a 42-year-old male, an old case of deep vein thrombosis on warfarin and other drugs like quetiapine, aspirin, diclofenac sodium, fenofibrate, atorvastatin, propanolol and citalopram for concurrent illnesses, who presented with widespread mucocutaneous bleeding and epidural spinal hematoma. The epidural bleed presented clinically as a nontraumatic, rapidly improving myeloradiculopathy. Magnetic resonance imaging (MRI) of the spine revealed an epidural hematoma at D12-L1 level. The case was managed conservatively due lack of neurosurgical facilities. The patient gained full neurological recovery on conservative management alone. This case highlights the problem of drug interaction on warfarin therapy and also an unusual spontaneous recovery of spinal hematoma. Our case was anticoagulated in the recommended therapeutic INR range of 2.2 to 2.4. Most of the similar cases reported in literature were also anticoagulated in the therapeutic range. Thus intraspinal hemorrhage is a rare but dangerous complication of anticoagulant therapy. It must be suspected in any patient on anticoagulant agents who complains of local or referred spinal pain associated with neurological deficits. Drug interactions with warfarin are common. High suspicion and immediate intervention are essential to prevent complications from intraspinal hemorrhage.

Sciatica and incomplete paraplegia after spontaneous haematoma of the spinal cord due to a cumarine - induced coagulopathy: case report

Spontaneous spinal haematoma is a rare cause of sciatica. We present a case of a 73 year old patient, who was admitted to our department and suffered from spontaneous sciatica over 24 hours. During the examination, the patient presented undulating symptoms of paraplegia, varying from incomplete loss of power in the left lower limb to complete plegia. The patient presented multiple diseases like biological aortic valve replacement, diabetes, hypertonia in her medical history, etc. Due to an additional absolute arrhythmia she ingested a cumarine medication. The tomographic imaging revealed a spontaneous lumbar and cranial subarachnoidal haematoma.

Rare cause of subarachnoid hemorrhage: spinal meningeal carcinomatosis. Case report

Subarachnoid hemorrhage (SAH) of spinal origin is a rare entity accounting for approximately 1% of all cases of SAH. Its most frequent causes are trauma and vascular malformations. Although primary spinal tumors, especially ependymomas, are also relatively common causes, SAH secondary to a metastatic spinal tumor arising from outside the central nervous system is an extremely rare condition; only one case has been reported in the literature. The authors present a case of spinal meningeal carcinomatosis secondary to cutaneous malignant melanoma in which the patient presented with only symptoms of SAH. Although very rare, this case underscores several factors. 1) Spinal SAH due to spinal metastases should be considered in the differential diagnosis of patients with previously known malignancy. 2) Spinal SAH may manifest without paraparesis or sensory deficit. 3) Magnetic resonance imaging of the spinal cord may be important to determine the source of SAH in patients in whom four-vessel cerebral angiography demonstrates no abnormal findings.

Thrombocytopenia in patients receiving oral anticoagulant therapy

The aim of this report was to determine the frequency of thrombocytopenia in a cohort of 1,126 patients receiving oral anticoagulant therapy (OAT), and to compare the grade of thrombocytopenia and the severity of bleeding complications. Severe thrombocytopenia was observed in five patients, and moderate and light thrombocytopenia were observed in 208 patients. Thrombocytopenic patients receiving OAT presented five major and six minor hemorrhages. The presence of hepatitis markers and autoantibodies was assessed. All parameters at the time of the bleeding complication were in the therapeutic range.