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Lin T, Li M, Bian K, Qiu C, Cheng L. Delayed postoperative spontaneous spinal epidural hematoma: Case based review. Int J Surg Case Rep 2024; 120:109871. [PMID: 38852561 PMCID: PMC11220556 DOI: 10.1016/j.ijscr.2024.109871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 05/27/2024] [Accepted: 05/31/2024] [Indexed: 06/11/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Postoperative spontaneous spinal epidural hematoma (SSEDH) is a rare complication in clinical practice. Despite its rarity, SSEDH is a critical emergency situation associated with neurological deficits, and improper or delayed management may lead to severe consequences. Therefore, surgical operators should familiarize themselves with SSEDH and give it more attention. CASE PRESENTATION This study describes the case of an elderly woman diagnosed with a left unilateral femoral neck fracture, severe osteoporosis, and multi-segmental vertebral compression fracture. Following artificial femoral head replacement surgery, the patient developed postoperative SSEDH. Subsequently, the patient underwent surgical removal of the posterior epidural hematoma and spinal cord decompression. The postoperative recovery was favorable, with normal muscle strength and tension in both lower limbs. A 4-year follow-up showed no complications. CLINICAL DISCUSSION The occurrence of SSEDH during the perioperative period of non-spinal surgeries is relatively uncommon. However, SSEDH is a neurosurgical emergency associated with neurological deficits, and prompt surgical intervention is crucial for successful treatment. CONCLUSION Clinicians should enhance their knowledge of SSEDH and remain vigilant towards this condition. Literature review highlights the significance of factors such as aging in the development of SSEDH following non-spinal surgeries in the perioperative period.
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Affiliation(s)
- Tiehan Lin
- Department of Burn and Plastic Surgery, Qilu Hospital of Shandong University, No. 107, Wenhua West Road, Jinan 250012, PR China; Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, PR China
| | - Manyu Li
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, PR China; Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, PR China
| | - Kai Bian
- Department of Burn and Plastic Surgery, Qilu Hospital of Shandong University, No. 107, Wenhua West Road, Jinan 250012, PR China
| | - Cheng Qiu
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, PR China.
| | - Lin Cheng
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, PR China; Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, Shandong 250012, PR China.
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Vastani A, Baig Mirza A, Khoja AK, Bartram J, Shaheen S, Rajkumar S, China M, Lavrador JP, Bleil C, Bell D, Thomas N, Malik I, Grahovac G. Prognostic factors and surgical outcomes of spontaneous spinal epidural haematoma: a systematic review and meta-analysis. Neurosurg Rev 2022; 46:21. [PMID: 36538111 DOI: 10.1007/s10143-022-01914-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
Spontaneous spinal epidural haematoma (SSEH) is a rare disease defined as blood accumulation within the vertebral epidural space without a cause identified, which can lead to severe neurological deficits. We aim to provide a comprehensive understanding of the prognostic factors affecting surgical outcomes in true SSEH and propose a critical time frame for operative management. A systematic literature search was performed and registered, using OVID Medline and EMBASE, in line with the PRISMA guidelines. Relevant demographic, clinical, surgical, and outcome data were extracted. The ASIA scale was uniformly used throughout our systematic review. Statistical analysis was performed via logistic regression. Of the 1179 articles examined, we included 181 studies involving 295 adult patients surgically treated for SSEH. SSEH were most commonly found in the cervicothoracic spine, with 2-4 spinal segments most commonly involved. Multivariable logistic regression model showed that the following factors were statistically significant in the post-operative outcome: operation type (P = 0.024), pre-operative neurologic status (P < 0.001), use of warfarin (P = 0.039), and operative interval (P = 0.006). Our retrospective analysis confirms the reversibility of severe neurological deficits after surgical intervention, with a prognosis of post-operative outcomes determined by the use of warfarin, pre-operative ASIA grade, and above all surgical evacuation within 12 h.
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Affiliation(s)
- Amisha Vastani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK.
| | - Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Abbas Khizar Khoja
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - James Bartram
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Safwan Shaheen
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Shivani Rajkumar
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Musa China
- Division of Medicine, University College London (UCL), London, UK
| | - Jose Pedro Lavrador
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Cristina Bleil
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - David Bell
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Nick Thomas
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Irfan Malik
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Gordan Grahovac
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
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Siahaan AMP, Tandean S, Nainggolan BWM. Spontaneous epidural hematoma induced by rivaroxaban: A case report and review of the literature. Surg Neurol Int 2022; 13:420. [PMID: 36324933 PMCID: PMC9610455 DOI: 10.25259/sni_608_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/03/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Trauma is the most frequent reason for epidural bleeding. However, numerous investigation had discovered that anticoagulants such as rivaroxaban could cause epidural hematoma. Here, we present a case of epidural hematoma in young man who got rivaroxaban as treatment of deep vein thrombosis. Case Description: A 27-year-old male with a history of deep vein thrombosis and one month of rivaroxaban medication presented with seizure and loss of consciousness following a severe headache. A CT scan of the head revealed epidural bleeding, and emergency blood clot removal was performed. As a reversal, prothrombin complex was utilized. Conclusion: Rivaroxaban has the potential to cause an epidural hemorrhage. Reversal anticoagulant should be administered before doing emergency surgery.
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Affiliation(s)
| | - Steven Tandean
- Department of Neurosurgery, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
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Esmaeili T, Rezaee M, Abdar Esfahani M, Davoudian A, Omidfar D, Rezaee S. Rivaroxaban population pharmacokinetic and pharmacodynamic modeling in Iranian patients. J Clin Pharm Ther 2022; 47:1284-1292. [PMID: 35504629 DOI: 10.1111/jcpt.13673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 03/30/2022] [Accepted: 04/05/2022] [Indexed: 12/22/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Although predictable pharmacokinetic and pharmacodynamic of rivaroxaban allow fixed dosing regimens without routine coagulation monitoring, there is still the necessity to monitor and predict the effects of rivaroxaban in specific conditions and different populations. The current study was designed and conducted to analyze the rivaroxaban population pharmacokinetics in Iranian patients and establish a pharmacokinetic/pharmacodynamic model to predict the relationship between rivaroxaban concentration and its anticoagulant activity. METHODS A sequential nonlinear mixed effect pharmacokinetic/pharmacodynamic modeling method was used to establish the relation between rivaroxaban concentration and anti-factor Xa activity, prothrombin time, and activated partial thromboplastin time (aPTT) as pharmacodynamic biomarkers in a population of sixty-nine Iranian patients under treatment with oral rivaroxaban. Rivaroxaban plasma concentration was quantified by a validated high-performance liquid chromatography-tandem mass spectrometry. RESULTS AND DISCUSSION The typical population values (inter-individual variability%) of the oral volume of distribution and clearance for a one-compartment model were 61.2 L (21%) and 3.68 L·h-1 (61%), respectively. Creatinine clearance and Child-Turcotte-Pugh score were found to affect the clearance. A direct link linear structural model best fitted the data for both prothrombin time and aPTT. The baseline estimates of aPTT and prothrombin time in the population were 35.0 (15%) and 12.6 (2%) seconds, respectively. The slope of the relationship between apTT, prothrombin time, and rivaroxaban concentration was 0.033 (28%) and 0.018 (54%) s·ml·ng-1 , respectively. The selected model for anti-factor Xa activity consisted of a direct link inhibitory Emax model with Hill coefficient. The maximum level of inhibition (Emax ) was 4 IU·ml-1 . The concentration of rivaroxaban producing 50% of the maximum inhibitory effect (EC50 ) was 180 (24%) ng·ml-1 , and Hill coefficient (γ) was 1.44 (108%). No covariates showed a statistically significant effect on PT and activated partial thromboplastin time prolonging properties and anti-factor Xa activity. WHAT IS NEW AND CONCLUSION Our results confirmed that pharmacokinetic/pharmacodynamic models similar to those of the other studies describe the relationship between the rivaroxaban concentration and its anticoagulant effect in Iranian patients. However, considerable differences were observed in the parameters of the pharmacodynamics-pharmacokinetic models with the results of other reports that can explain the unpredictable effects of rivaroxaban in some patients.
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Affiliation(s)
- Tayebeh Esmaeili
- Department of Pharmaceutics, School of Pharmacy, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Mahmood Rezaee
- Department of Cardiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Morteza Abdar Esfahani
- Department of Cardiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azadeh Davoudian
- Department of Cardiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Saeed Rezaee
- Department of Pharmaceutics, School of Pharmacy, Zanjan University of Medical Sciences, Zanjan, Iran
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Krupa P, Kanta M, Hosszu T, Soukup J, Ryska P, Dulicek P, Cesak T. A rare case of non-traumatic spinal epidural hematoma in lumbar region associated with apixaban therapy. J Thromb Thrombolysis 2021; 52:1215-1219. [PMID: 33956281 DOI: 10.1007/s11239-021-02462-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
Spontaneous spinal epidural hematoma (SSEH) is a very rare clinical entity with potential diagnostic difficulties and which can result in severe neurological deficit. The etiology of this rare condition is largely not known, but with potential predisposition in patients on anticoagulation medication. This includes the novel anticoagulants with direct inhibition of the factor Xa mechanism (DOACs). These medications are supposed to have more predictable pharmacokinetics with fewer severe haemorrhagic adverse events in comparison with standard warfarin therapy. However, in the last few years, an increasing number of case reports have been published of haemorrhage into the central nervous system. We present a case of non-traumatic spinal epidural hematoma in the lumbar region in a patient on chronic apixaban therapy. To the best of our knowledge, it is the first described SSEH in the lumbar region associated with apixaban therapy.
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Affiliation(s)
- Petr Krupa
- Department of Neurosurgery, Charles University Medical Faculty and Faculty Hospital, Hradec Králové, Czech Republic. .,Department of Neuroregeneration, Institute of Experimental Medicine, Czech Academy of Sciences, Prague, Czech Republic.
| | - Martin Kanta
- Department of Neurosurgery, Charles University Medical Faculty and Faculty Hospital, Hradec Králové, Czech Republic
| | - Tomas Hosszu
- Department of Neurosurgery, Charles University Medical Faculty and Faculty Hospital, Hradec Králové, Czech Republic
| | - Jiri Soukup
- The Fingerland Department of Pathology, Charles University Medical Faculty and Faculty Hospital Hradec Kralove, Hradec Králové, Czech Republic
| | - Pavel Ryska
- Department of Radiology, Charles University Medical Faculty and Faculty Hospital Hradec Kralove, Hradec Králové, Czech Republic
| | - Petr Dulicek
- Fourth Department of Internal Medicine and Hematology, Charles University Medical Faculty and Faculty Hospital Hradec Kralove, Hradec Králové, Czech Republic
| | - Tomas Cesak
- Department of Neurosurgery, Charles University Medical Faculty and Faculty Hospital, Hradec Králové, Czech Republic
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Mezzacappa FM, Surdell D, Thorell W. Spontaneous Spinal Epidural Hematoma Associated With Apixaban Therapy: A Report of two Cases. Cureus 2020; 12:e11446. [PMID: 33324528 PMCID: PMC7732784 DOI: 10.7759/cureus.11446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Spontaneous spinal epidural hematoma (SSEH) is a rare clinical entity that can result in severe neurological deficit and warrants emergent neurosurgical evaluation and management. The exact etiology of this entity remains unknown, but certain risk factors exist, including the use of anticoagulant medications. There are few published reports of the association of SSEH with direct factor Xa inhibitors. We aimed to present 2 cases of SSEH in patients on chronic apixaban therapy. To the best of our knowledge, there is only 1 other report of SSEH in the setting of apixaban therapy. A comparison between the cases suggests the importance of rapid recognition and management of SSEH in order to achieve favorable neurological outcomes.
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Affiliation(s)
| | - Daniel Surdell
- Neurological Surgery, University of Nebraska Medical Center, Omaha, USA
| | - William Thorell
- Neurological Surgery, University of Nebraska Medical Center, Omaha, USA
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Yang X, Hao D, Wang X, Gao W, Hui H. [Efficacy and safety of tranexamic acid sequential rivaroxaban on blood loss in elderly patients during lumbar interbody fusion]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1158-1162. [PMID: 32929910 DOI: 10.7507/1002-1892.202002041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the effect and safety of tranexamic acid sequential rivaroxaban on perioperative blood loss and preventing thrombosis for elderly patients during lumbar interbody fusion (LIF) with a prospective randomized controlled study. Methods Between April and October 2019, the elderly patients with lumbar degenerative diseases requiring LIF were included in the study, among which were 80 patients met the selection criteria. According to the antifibrinolysis and anticoagulation protocols, they were randomly divided into a tranexamic acid sequential rivaroxaban group (trial group) and a simple rivaroxaban group (control group) on average. Finally, 69 patients (35 in the trial group and 34 in the control group) were included for comparison. There was no significant difference in general data ( P>0.05) such as gender, age, body mass index, disease duration, diseased segment, type of disease, and preoperative hemoglobin between the two groups. The operation time, intraoperative blood loss, drainage within 3 days after operation, perioperative total blood loss, and proportion of blood transfusion patients were compared between the two groups, as well as postoperative venous thrombosis of lower extremities, pulmonary embolism, and bleeding-related complications. Results The operations of the two groups completed successfully, and there was no significant difference in the operation time ( P>0.05); the intraoperative blood loss, drainage within 3 days after operation, and perioperative total blood loss in the trial group were significantly lower than those in the control group ( P<0.05). The proportion of blood transfusion patients in the trial group was 25.71% (9/35), which was significantly lower than that in the control group [52.94% (18/34)] ( χ 2=5.368, P=0.021). Postoperative incision bleeding occurred in 4 cases of the trial group and 3 cases of the control group, and there was no significant difference in bleeding-related complications between the two groups ( P=1.000). There was 1 case of venous thrombosis of the lower extremities in each group after operation, and there was no significant difference in the incidence between the two groups ( P=1.000). Besides, no pulmonary embolism occurred in the two groups. Conclusion Perioperative use of tranexamic acid sequential rivaroxaban in elderly LIF patients can effectively reduce the amount of blood loss and the proportion of blood transfusion patients without increasing the risk of postoperative thrombosis.
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Affiliation(s)
- Xiaowei Yang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an Shaanxi, 710054, P.R.China
| | - Dingjun Hao
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an Shaanxi, 710054, P.R.China
| | - Xiaodong Wang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an Shaanxi, 710054, P.R.China
| | - Wenjie Gao
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an Shaanxi, 710054, P.R.China
| | - Hao Hui
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an Shaanxi, 710054, P.R.China
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Rahimizadeh A, Hassani V, Soufiani H, Rahimizadeh A, Karimi M, Asgari N. Symptomatic pulmonary cement embolism after pedicle screw polymethylmethacrylate cement augmentation: A case report and review. Surg Neurol Int 2020; 11:18. [PMID: 32123606 PMCID: PMC7049880 DOI: 10.25259/sni_592_2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 01/08/2020] [Indexed: 12/18/2022] Open
Abstract
Background: In osteoporotic patients, a useful technique for significantly enhancing the strength of a pedicle screw is augmentation with polymethylmethacrylate cement. However, a rare complication of this procedure is a symptomatic pulmonary cement embolism. Case Description: A pedicle screw cement augmentation was performed in a middle-aged female for the failed back syndrome. When she developed symptomatic pulmonary cement emboli, she was successfully managed with conservative measures, including anticoagulation. Conclusion: Despite the increased use of cement augmentation for pedicle screw placement and the relatively high incidence of cement leakage into the prevertebral venous system, symptomatic cement pulmonary embolism remains rare. The management of such symptomatic CPE should be evaluated and treated based on both the size and location of the embolism. Here, we presented this case while reviewing three symptomatic and four asymptomatic cases from the literature.
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Affiliation(s)
- Abolfazl Rahimizadeh
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Valiollah Hassani
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Housain Soufiani
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Ava Rahimizadeh
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mona Karimi
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Naser Asgari
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
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