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Abu-Abaa M, Jumaah O, Mousa A, Al-Qaysi G. A Spontaneous Spinal Epidural Hematoma Secondary to Long-Term Low-Dose Aspirin and Clopidogrel Use: A Case Report. Cureus 2023; 15:e34537. [PMID: 36879714 PMCID: PMC9985069 DOI: 10.7759/cureus.34537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
The association between antiplatelet agents such as aspirin, clopidogrel, and ticlopidine and spontaneous spinal epidural hematoma is based on multiple case reports in the literature. Here, we present the case of a 76-year-old male patient who presented with acute low back pain associated with sudden-onset paralysis of the lower extremities. His past medical history was remarkable for coronary artery disease with a stent placement history on dual antiplatelet therapy including low-dose aspirin and clopidogrel. An extensive posterior thoracolumbar epidural hematoma was seen on the imaging test, and rapid clinical improvement was evident early during his presentation. This prompted a conservative approach that led to complete neurological recovery. This case is in line with limited English-language literature evidence that suggests a possible association between spontaneous spinal epidural hematoma and antiplatelet agents. We aim to enhance clinicians' awareness of this clinical entity, association, presentation, and management.
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Affiliation(s)
- Mohammad Abu-Abaa
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Omar Jumaah
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Aliaa Mousa
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Ghassan Al-Qaysi
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
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2
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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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Alahmadi MJ, Almolky KS, Rezai DM. Spontaneous Spinal Epidural Hematoma Associated With Short-Term Dual Antiplatelet Therapy: A Case Report. Cureus 2022; 14:e29415. [PMID: 36304344 PMCID: PMC9586495 DOI: 10.7759/cureus.29415] [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] [Accepted: 09/21/2022] [Indexed: 11/13/2022] Open
Abstract
Spinal epidural hematoma (SEDH), either spontaneous or traumatic, is a rare neurosurgical emergency. Typically, the natural history is a sudden onset of severe neck or back pain, associated with neurological deficit, either immediately or after a short period of the pain onset. MRI is the gold standard investigation. The mainstay of treatment is spinal decompression, in the form of laminectomy or hemilaminectomy, with the evacuation of the hematoma. The occurrence of SEDH has been strongly associated with coagulopathy, especially that induced by anticoagulant use. The association between SEDH and antiplatelet therapy has been scarcely reported in the literature. We report a case of spontaneous SEDH in a patient who was on dual antiplatelet therapy. Our case is unique because the patient had been using antiplatelet agents for only six weeks prior to this diagnosis. As antiplatelet agents are widely prescribed, physicians should be able to anticipate SEDH as a possible complication of dual antiplatelet therapy to facilitate early treatment and better outcomes.
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Hayden AM, Arora L, Hobbs RA, Sharafuddin MJ. The Use of Cangrelor Infusions After Endovascular Aortic Repair With Prophylactic Lumbar Drain Placement. J Cardiothorac Vasc Anesth 2020; 35:3723-3726. [DOI: 10.1053/j.jvca.2020.11.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 11/11/2022]
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Çankaya BY, Alper F, Karaman A, Akgün M. Hemorrhagic lesions associated with anticoagulant therapy: a pictorial review. J Thromb Thrombolysis 2020; 51:1067-1077. [PMID: 33034813 DOI: 10.1007/s11239-020-02305-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 12/27/2022]
Abstract
Anticoagulant therapy is a treatment that can cause bleeding complications in many anatomical structures. Intracranial, intramuscular and intraabdominal bleeding are internal bleeding that can be secondary to anticoagulated therapy. The prognosis of these hemorrhages can be very good, depending on the anatomical region involved, or they can be fatal. Early recognition of especially intracranial and renal hemorrhages is important for prognosis. For diagnosis, CT and / or MRI should be evaluated according to the region. Internal bleeding should be kept in mind in cases such as sudden hemoglobin decrease or change in consciousness during anticoagulant therapy.
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Affiliation(s)
- Bahar Yılmaz Çankaya
- Department of Radiology, School of Medicine, Atatürk University, 25240, Erzurum, Turkey.
| | - Fatih Alper
- Department of Radiology, School of Medicine, Atatürk University, 25240, Erzurum, Turkey
| | - Adem Karaman
- Department of Radiology, School of Medicine, Atatürk University, 25240, Erzurum, Turkey
| | - Metin Akgün
- Department of Pulmonary Diseases, School of Medicine, Atatürk University, 25240, Erzurum, Turkey
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Dildar N, Ayaz SB, Aamir MO, Ahmad N. Spontaneous spinal epidural hemorrhage following disseminated intravascular coagulation resulting in paraplegia: a case report. J Spinal Cord Med 2019; 42:265-269. [PMID: 29047318 PMCID: PMC6419632 DOI: 10.1080/10790268.2017.1387717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
CONTEXT Spontaneous spinal epidural hemorrhage (SSEH) mostly presents as low back pain with or without a radiculopathy, and rarely with paraplegia or tetraplegia depending on the site and severity of spinal cord compression. We present here a case who had anemia and developed paraplegia following disseminated intravascular coagulation (DIC) due to a transfusion reaction. FINDINGS A 65-year-old lady presented with sudden onset chest pain radiating to nape of the neck followed by loss of sensations and power in legs few hours after a blood transfusion. Her past history was negative for diabetes mellitus, hypertension, coronary artery disease, or a bleeding disorder. Her blood pressure was 90/57 mmHg and she had a normal pulse, respiratory rate, and temperature. On neurological examination, she had no motor power and unevokable muscle stretch reflexes in the lower limbs. The sensations were intact till T3 dermatome. The laboratory evaluation was suggestive of DIC. The magnetic resonance imaging showed a non-enhancing abnormal signal intensity area in the posterior epidural space, extending from CV4 to LV4 causing cervico-dorsal cord compression associated with cord edema. Following diagnosis, urgent decompressive surgery was carried out due to deteriorating neurological status. The patient was transfused with five bags of red cell concentrate, two bags of platelets, and four bags of fresh frozen plasma during the operation. The patient regained consciousness following operation, however, the neurological status did not improve. She, unfortunately, died on the third post-op day due to cardiac arrest. CONCLUSION SSEH is a rare cause of paraplegia. Early radiological diagnosis is crucial for timely neurosurgical management and saving patient from permanent neurological deficit or a fatal outcome.
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Affiliation(s)
- Nazia Dildar
- Consultant radiologist, department of radiology and diagnostic imaging, Combined Military Hospital, Quetta, and Quetta Institute of Medical Sciences, Quetta87300Baluchistan, Pakistan
| | - Saeed Bin Ayaz
- Consultant Rehabilitation Medicine, Department of Rehabilitation Medicine, Combined Military Hospital, Quetta, and Quetta Institute of Medical Sciences, Quetta87300Baluchistan, Pakistan,Correspondence to: Saeed Bin Ayaz, MBBS, FCPS, MSc; Consultant Physiatrist, Department of Rehabilitation Medicine, Combined Military Hospital, Quetta87300, Baluchistan, Pakistan.
| | - Muhammad Omer Aamir
- Consultant radiologist, department of radiology and diagnostic imaging, Combined Military Hospital, Quetta, and Quetta Institute of Medical Sciences, Quetta87300Baluchistan, Pakistan
| | - Nadeem Ahmad
- Consultant Rehabilitation Medicine, Department of Rehabilitation Medicine, Combined Military Hospital, Quetta, and Quetta Institute of Medical Sciences, Quetta87300Baluchistan, Pakistan
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Spontaneous Spinal Epidural Hematoma Associated With the Use of Low-dose Aspirin in Elderly Patient. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2018; 2:e059. [PMID: 30656250 PMCID: PMC6324892 DOI: 10.5435/jaaosglobal-d-18-00059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Spontaneous spinal epidural hematoma is a rare condition defined by bleeding in the epidural space of the spine with no identifiable causes such as trauma, vascular malformation, or bleeding disorders. This is a case of a 79-year-old woman with a medical history of diabetes mellitus, dyslipidemia, and hypertension presented with the sudden onset of severe thoracolumbar back pain associated with weakness and numbness in her bilateral lower limb. Examination of the lower limb showed bilateral lower limb motor and sensory deficits. Laboratory investigations showed normal results. MRI showed posterior extradural intraspinal hematoma from T11 to L3 vertebrae. Patient underwent right hemilaminectomy and posterior decompression of T12 and L1 vertebrae to evacuate the hematoma. Postoperatively, her neurologic complications improved gradually. Decision was made not to restart aspirin. On follow-up at 1 year, the patient had complete recovery of neurologic complications of both lower limb and had no recurrence of bleeding. In short, this is a case of spontaneous spinal epidural hematoma associated with long-term use of low-dose aspirin in an elderly patient requiring surgical evacuation of hematoma with good functional outcome after the surgery. Therefore, aspirin should be prescribed cautiously especially to elderly patients.
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8
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Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy. Reg Anesth Pain Med 2018; 43:263-309. [DOI: 10.1097/aap.0000000000000763] [Citation(s) in RCA: 442] [Impact Index Per Article: 73.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Okazaki T, Nakagawa H, Hayase H, Irie S, Inagaki T, Saito O, Yamashina M, Nagahiro S, Saito K. Idiopathic and Chronic Epidural Hematoma in the Lumbar Spine: A Case Report and Review of Literatures. Neurol Med Chir (Tokyo) 2018; 58:138-144. [PMID: 29415912 PMCID: PMC5929923 DOI: 10.2176/nmc.cr.2017-0052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Spontaneous and chronic epidural hematoma (SSEH) in the lumbar spine is rare, and idiopathic and chronic SSEH in the lumbar spine is extremely rare disease. Most of lumbar SSEH were acute and secondary with trauma, hematologic disorders, drug, and surgical procedure. Only 20 cases of chronic SSEH in the lumbar spine have been reported and 14 cases among them were considered to be idiopathic. Definitive guidelines for management of this condition are not clear and surgical total evacuation was performed in most of the cases. Some authors reported the epidural bleeding originates in the rupture of Batson’s plexus due to a rise in intra-abdominal pressure, but the mechanism is not clearly clarified. We report a surgical case of idiopathic and chronic SSEH. A 61-year-old woman suffered a sudden onset of severe lumbar pain during sleep. She had no history of trauma, spinal surgery, or hypertension. Magnetic resonance imaging revealed a lumbar chronic epidural hematoma which compressed the dural sac behind and extended from L2 to L5. This patient underwent the partial evacuation of the hematoma with partial hemilaminectomy on left at L2/3, resulting in immediate pain relief and resolution of symptoms and almost absorption of the hematoma within 1 week of the procedure. We presented this rare case and reviewed idiopathic and chronic epidural hematoma in the lumbar spine.
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Affiliation(s)
- Toshiyuki Okazaki
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital.,Department of Neurosurgery, Tokushima University
| | | | - Hitoshi Hayase
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
| | - Shinsuke Irie
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
| | - Toru Inagaki
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
| | - Osamu Saito
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
| | | | | | - Koji Saito
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
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10
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Hibi A, Kasugai T, Kamiya K, Kamiya K, Kominato S, Ito C, Miura T, Koyama K. Successful Recovery from Spontaneous Spinal Epidural Hematoma in a Patient Undergoing Hemodialysis. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:1357-1364. [PMID: 29259148 PMCID: PMC5745891 DOI: 10.12659/ajcr.905953] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Patient: Male, 70 Final Diagnosis: Spontaneous spinal epidural hematoma Symptoms: Abdominal pain • chest pain • complete paraplegia Medication: — Clinical Procedure: Conservative management Specialty: Nephrology
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Affiliation(s)
- Arata Hibi
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Takahisa Kasugai
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Keisuke Kamiya
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Keisuke Kamiya
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Satoru Kominato
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, Kariya, Aichii, Japan
| | - Chiharu Ito
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Toshiyuki Miura
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Katsushi Koyama
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, Kariya, Aichi, Japan
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11
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Elgafy H, Peters N, Lea JE, Wetzel RM. Hemorrhagic lumbar synovial facet cyst secondary to transforaminal epidural injection: A case report and review of the literature. World J Orthop 2016; 7:452-457. [PMID: 27458557 PMCID: PMC4945513 DOI: 10.5312/wjo.v7.i7.452] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 03/12/2016] [Accepted: 05/11/2016] [Indexed: 02/06/2023] Open
Abstract
A 64-year-old-female presented with progressive left foot weakness, low back and radicular pain after a left sided S1 transforaminal epidural steroid injection (ESI). Magnetic resonance imaging revealed left side L5-S1 large extradural heterogeneous mass with layering areas suggesting different stages of hematoma formation. Past medical history was significant for peripheral vascular disease and transient ischemic attacks, for which she took aspirin and clopidogrel (antiplatelet agent). These medications were discontinued one week prior to ESI. Although synovial cysts associated with facet arthropathy are common, hemorrhagic cyst is not. To the best of the authors’ knowledge, this is the first reported case of symptomatic hemorrhagic lumbar facet synovial cyst following ESI on a patient taking anti-platelet medications.
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12
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McCunniff PT, Young ES, Ahmadinia K, Kusin DJ, Ahn UM, Ahn NU. Chronic Antiplatelet Use Associated With Increased Blood Loss in Lumbar Spinal Surgery Despite Adherence to Protocols. Orthopedics 2016; 39:e695-700. [PMID: 27111080 DOI: 10.3928/01477447-20160419-04] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 02/10/2016] [Indexed: 02/03/2023]
Abstract
There are conflicting reports regarding postoperative bleeding risks associated with discontinuation of antiplatelet therapy at least 7 days preoperatively. Most of the studies in the spine literature are based on surveys or anecdotal evidence. The majority of surgeons discontinue therapy 7 days preoperatively, but this varies widely from 5 to 21 days. The purpose of this retrospective study was to assess whether chronic antiplatelet use is associated with increased intraoperative blood loss, need for transfusion, and perioperative complications. Of 454 patients who underwent elective lumbar spinal surgery, 85 were on antiplatelet therapy and 369 were not. All patients stopped antiplatelet therapy at least 7 days preoperatively with approval from their cardiologist or primary care provider. Multiple regression analysis was performed and corrected for age, sex, antiplatelet therapy, number of levels decompressed/fused/instrumented, preoperative hematocrit, and postoperative hematocrit. Results showed that preoperative antiplatelet therapy, despite at least 7 days of discontinuation, is a statistically significant predictor (P=.04) of increased intraoperative blood loss. Blood transfusion was not associated with antiplatelet use but was associated with the number of levels fused, age, and low preoperative hematocrit (all P<.01). There were no recorded complications in either group. The authors conclude that antiplatelet therapy is associated with an increased risk of intraoperative blood loss in spine patients despite discontinuation at least 7 days preoperatively, but the clinical significance of this is unclear given the lack of association with blood transfusions and perioperative complications. [Orthopedics. 2016; 39(4):e695-e700.].
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13
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Hah JM, Noon K, Gowda A, Brun C. Management of a Patient with a Thoracic Epidural After Accidental Clopidogrel Administration. ACTA ACUST UNITED AC 2016; 5:18-20. [PMID: 26171737 DOI: 10.1213/xaa.0000000000000165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a case of accidental clopidogrel administration in a patient receiving ongoing epidural analgesia postoperatively. The epidural catheter was removed 7 hours after the clopidogrel dose without incident. The onset of inhibition of adenosine diphosphate-induced platelet aggregation in healthy individuals has been reported at 12 to 24 hours after administration of a single 75-mg dose of clopidogrel. This case demonstrates the importance of understanding clopidogrel's pharmacology to avoid ordering unnecessary tests, which may delay catheter removal. Consideration of appropriate testing and limitations in the context of unintentional antiplatelet administration with indwelling neuraxial catheters is discussed.
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Affiliation(s)
- Jennifer M Hah
- From the *Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, California; and †Department of Anesthesiology, Veterans Affairs Palo Alto, Palo Alto, California
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14
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Lubnin AY, Karnaukhov VV, Moshkin AV, Rylova AV, Shimansky VN. [Neurosurgery in a patient on dual antiplatelet therapy. Case report and the review of the literature]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2016. [PMID: 28635845 DOI: 10.17116/neiro201680391-98] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION A neurosurgical intervention in a patient on dual antiplatelet therapy is a serious challenge for both the neurosurgeon and anesthesiologist.. MATERIAL AND METHODS The article describes a clinical case of a successful urgent neurosurgical intervention (ventriculoperitoneostomy for obstructive hydrocephalus caused by a large meningioma of the posterior surface of the petrous pyramid) in a patient on dual antiplatelet therapy (DAT) due to a recently placed coronary stent.. CONCLUSION Given a high risk of coronary stent thrombosis, the surgery was performed in the presence of ongoing DAT. There were no intracranial hemorrhagic complications, but subcutaneous hemorrhagic complications developed. The article discusses the features of managing similar patients whose number is growing.
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Affiliation(s)
- A Yu Lubnin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - A V Moshkin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A V Rylova
- Burdenko Neurosurgical Institute, Moscow, Russia
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15
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Bhat KJ, Kapoor S, Watali YZ, Sharma JR. Spontaneous epidural hematoma of spine associated with clopidogrel: A case study and review of the literature. Asian J Neurosurg 2015; 10:54. [PMID: 25767588 PMCID: PMC4352641 DOI: 10.4103/1793-5482.151521] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Spontaneous spinal epidural hematoma (SSEH) is an uncommon neurological emergency which can present with the features ranging from simple back pain with radiculopathy to complete paraplegia or quadriplegia depending on the site and severity of the compression. Spinal hemorrhage associated with anti-platelet drugs is rarely seen. We report a case of SSEH in a 68-year-old hypertensive male who was on a low dose clopidogrel for secondary stroke prophylaxis and presented with bilateral lower limb paralysis, preceeded by severe back bain. A spinal magnetic resonance imaging scan was performed which revealed a posterior epidural hematoma of the thoraco-lumbar spine. To the best of our knowledge, not more than four cases of clopidogrel related spinal epidural hematoma have been reported. Emergent decompressive laminectomy was done within 4 hours of the presentation with excellent clinical outcome. Clinicians should, therefore, consider the remote risk of SSEH in hypertensive patients who are on anti-platelet drugs as early decompressive laminectomy and evacuation of the hematoma minimizes the permanent neurological damage.
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Affiliation(s)
- Khalid Javid Bhat
- Department of Internal Medicine, ASCOMS and Hospitals, Sidhra, Jammu, India
| | - Sidhart Kapoor
- Department of Internal Medicine, ASCOMS and Hospitals, Sidhra, Jammu, India
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16
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Anderson K, Jupiter DC, Abernathy SW, Frazee RC. Should clopidogrel be discontinued before laparoscopic cholecystectomy? Am J Surg 2014; 208:926-31; discussion 930-1. [PMID: 25435299 DOI: 10.1016/j.amjsurg.2014.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 08/21/2014] [Accepted: 08/25/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND The perioperative management of clopidogrel remains an area of controversy. METHODS An institutional review board-approved retrospective review of patients undergoing a laparoscopic cholecystectomy while on clopidogrel from 2008 to 2012 was performed. These patients were then matched with a nonclopidogrel cohort based on American Society of Anesthesiologists score and emergent or elective surgery. Intraoperative estimated blood loss, operative time, length of stay, and 30-day morbidity were compared. RESULTS Thirty-six clopidogrel and 36 control patient records were analyzed. There were no significant differences in age, body mass index, sex, or incidence of coronary artery disease, diabetes, hyperlipidemia, and congestive heart failure. Estimated blood loss averaged 50 mL in the clopidogrel group and 47 mL in the control group (P = nonsignificant). There were no significant differences in operative time, 30-day morbidity, or length of stay between the 2 groups. CONCLUSIONS Laparoscopic cholecystectomy performed on patients maintained on clopidogrel during the perioperative period did not produce an increase in blood loss, operative time, 30-day morbidity, or length of stay.
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Affiliation(s)
- Katherine Anderson
- Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508, USA
| | - Daniel C Jupiter
- Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508, USA
| | | | - Richard C Frazee
- Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508, USA.
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17
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Cakar MA, Kocayigit I, Aydin E, Demirci H, Gunduz H. Clopidogrel-induced spontaneous pectoral hematoma. Indian J Pharmacol 2013; 44:526-7. [PMID: 23087521 PMCID: PMC3469963 DOI: 10.4103/0253-7613.99342] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Revised: 01/27/2012] [Accepted: 04/30/2012] [Indexed: 12/05/2022] Open
Abstract
Clopidogrel is an oral antiplatelet agent used in the treatment of coronary artery disease, peripheral vascular disease and cerebrovascular disease. Gastrointestinal symptomsincluding nausea, diarrhea and constipation are the common side effects ofthis drug. Serious side effects like intracranial hemorrhage and severe neutropenia were also reported but spontaneous pectoral hematoma due to the clopidogrel has not been reported previously. We present a case of large spontaneous pectoral hematoma during clopidogrel therapy in an elderly woman.
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Affiliation(s)
- Mehmet Akif Cakar
- Department of Cardiology, Sakarya Education and Research Hospital, Korucuk, Sakarya, Turkey
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Lee MJ, Chung YS. Spinal subarachnoid hematoma as a complication of an intramuscular stimulation : case report and a review of literatures. J Korean Neurosurg Soc 2013; 54:58-60. [PMID: 24044084 PMCID: PMC3772290 DOI: 10.3340/jkns.2013.54.1.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 05/06/2013] [Accepted: 07/08/2013] [Indexed: 12/28/2022] Open
Abstract
Intramuscular stimulation (IMS) is widely used to treat myofascial pain syndrome. IMS is a safe procedure but several complications have been described. To our knowledge, spinal subarachnoid hematoma has never been reported as a complication of an IMS. The authors have experienced a case of spinal subarachnoid hematoma occurring after an IMS, which was tentatively diagnosed as intracranial subarachnoid hemorrhage because of severe headache. Patient was successfully treated with surgery. Here, we report our case with a review of literature.
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Affiliation(s)
- Myeong Jong Lee
- Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Chungju, Korea
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Khursheed N, Makhdoomi R, Tanki H, Wani A. Spinal epidural hematomas in fast bowlers: report of two unusual cases. Pediatr Neurosurg 2013; 49:303-6. [PMID: 25358817 DOI: 10.1159/000367996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 08/28/2014] [Indexed: 11/19/2022]
Abstract
We report 2 cases of spinal epidural hematomas (SEDH) after a spell of fast bowling in 2 young boys. Both patients presented with spinal pain followed by weakness in both lower limbs. MRI of the spine revealed cervical SEDH in 1 patient and thoracic SEDH in the other. The authors want to highlight this peculiar mode of sports-related spinal injury. This type of injury has not been reported before.
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Affiliation(s)
- Nayil Khursheed
- Department of Neurosurgery, Sher-i-Kashmir Institute of Medical Sciences, Kashmir, India
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20
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Kim T, Lee CH, Hyun SJ, Yoon SH, Kim KJ, Kim HJ. Clinical Outcomes of Spontaneous Spinal Epidural Hematoma : A Comparative Study between Conservative and Surgical Treatment. J Korean Neurosurg Soc 2012; 52:523-7. [PMID: 23346323 PMCID: PMC3550419 DOI: 10.3340/jkns.2012.52.6.523] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 09/07/2012] [Accepted: 12/18/2012] [Indexed: 12/17/2022] Open
Abstract
Objective The incidence of spontaneous spinal epidural hematoma (SSEH) is rare. Patients with SSEH, however, present disabling neurologic deficits. Clinical outcomes are variable among patients. To evaluate the adequate treatment method according to initial patients' neurological status and clinical outcome with comparison of variables affecting the clinical outcome. Methods We included 15 patients suffered from SSEH. Patients were divided into two groups by treatment method. Initial neurological status and clinical outcomes were assessed by the American Spinal Injury Association (ASIA) impairment scale. Also sagittal hematoma location and length of involved segment was analyzed with magnetic resonance images. Other factors such as age, sex, premorbid medication and duration of hospital stay were reviewed with medical records. Nonparametric statistical analysis and subgroup analysis were performed to overcome small sample size. Results Among fifteen patients, ten patients underwent decompressive surgery, and remaining five were treated with conservative therapy. Patients showed no different initial neurologic status between treatment groups. Initial neurologic status was strongly associated with neurological recovery (p=0.030). Factors that did not seem to affect clinical outcomes included : age, sex, length of the involved spinal segment, sagittal location of hematoma, premorbid medication of antiplatelets or anticoagulants, and treatment methods. Conclusion For the management of SSEH, early decompressive surgery is usually recommended. However, conservative management can also be feasible in selective patients who present neurologic status as ASIA scale E or in whom early recovery of function has initiated with ASIA scale C or D.
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Affiliation(s)
- Tackeun Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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21
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Wang L, Liu G, Subramaniam S, Wong TAKW, Kumar N. Spontaneous spinal epidural haematoma after antiplatelet treatment: a report of two cases. J Orthop Surg (Hong Kong) 2012; 20:386-90. [PMID: 23255653 DOI: 10.1177/230949901202000326] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We report 2 cases of spontaneous spinal epidural haematoma after antiplatelet treatment. One patient was on ticlodipine therapy and the other was on aspirin and clopidogrel. Both diagnoses were made using magnetic resonance imaging. One patient underwent multilevel laminectomies and posterior spinal fusion within 24 hours of symptom onset and achieved complete neurological recovery. The other underwent unilateral hemilaminectomies 40 hours after symptom onset and did not show neurological improvement. A high index of suspicion is needed for patients presenting with severe lower back pain and rapid neurological deterioration, especially in those on antiplatelet therapy. Urgent spinal cord decompression and epidural haematoma cord evacuation may provide more favourable outcome.
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Affiliation(s)
- Lushun Wang
- Department of Orthopaedics, National University Hospital, Singapore
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22
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Abstract
BACKGROUND Patients medicated with clopidogrel who require orthopaedic surgery present a particular challenge. Whether in an emergency or elective situation the orthopaedic surgeon must balance the risks of ceasing clopidogrel versus the risk of increased bleeding that dual antiplatelet therapy generates. METHOD This paper reviews the current published evidence regarding the risks of continuing clopidogrel, the risks of discontinuing clopidogrel and associated considerations such as venous thromboprophylaxis. RESULTS Little good quality evidence exists in regard to perioperative clopidogrel for orthopaedic surgery. Available evidence across non-cardiac and cardiac surgery were assessed and presented in regards to current practices, blood loss for orthopaedic operations, risks when continuing clopidogrel, risks of stopping clopidogrel and also the consideration of venous thromboembolism. CONCLUSIONS The patients at greatest risk, when discontinuing clopidogrel therapy, are those with drug eluting stents who may be at risk of stent thrombosis. Where possible, efforts should be made to continue clopidogrel therapy through the perioperative period, taking precautions to minimize bleeding. If the risk of bleeding is too high, antiplatelet therapy must be reinstated as soon as considered reasonable after surgery. In addition, patients on clopidogrel who sustain a fall or other general trauma need to be carefully assessed because of the possibility of occult bleeding, such as into the retroperitoneal space. Until more definitive evidence becomes available, this review aims to provide a guide for the orthopaedic surgeon in dealing with the difficult dilemma of the patient on clopidogrel therapy, recommending that orthopaedic surgeons take a team approach to assess the individual risks for all patients and consider continuation of clopidogrel therapy perioperatively where possible.
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Affiliation(s)
- Mitchell J Steele
- Wollongong Hospital, 4 Mansion Pt Road, Grays Point, Sydney, NSW 2232, Australia.
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Yang SM, Kang SH, Kim KT, Park SW, Lee WS. Spontaneous spinal epidural hematomas associated with acute myocardial infarction treatment. Korean Circ J 2012; 41:759-62. [PMID: 22259609 PMCID: PMC3257462 DOI: 10.4070/kcj.2011.41.12.759] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 03/22/2011] [Accepted: 03/28/2011] [Indexed: 01/30/2023] Open
Abstract
Many studies have reported spontaneous spinal epidural hematoma (SSEH). Although most cases are idiopathic, several are associated with thrombolytic therapy or anticoagulants. We report a case of SSEH coincident with acute myocardial infarction (AMI), which caused serious neurological deficits. A 56 year old man presented with chest pain accompanied with back and neck pain, which was regarded as an atypical symptom of AMI. He was treated with nitroglycerin, aspirin, low molecular weight heparin, and clopidogrel. A spinal magnetic resonance image taken after paraplegia developed 3 days after the initial symptoms revealed an epidural hematoma at the cervical and thoracolumbar spine. Despite emergent decompressive surgery, paraplegia has not improved 7 months after surgery. A SSEH should be considered when patients complain of abrupt, strong, and non-traumatic back and neck pain, particularly if they have no spinal pain history.
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Affiliation(s)
- Seung-Min Yang
- Department of Neurological Surgery, College of Medicine, Chung-Ang University, Seoul, Korea
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Acute spontaneous cervical epidural hematoma with neurological deficit after low-molecular-weight heparin therapy: role of conservative management. Spine J 2010; 10:e11-5. [PMID: 20547109 DOI: 10.1016/j.spinee.2010.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Revised: 02/22/2010] [Accepted: 04/08/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spontaneous spinal hematoma (SSH) after low-molecular-weight heparin (LMWH) therapy is a rare cause of compressive myelopathy with neurological deficit. Emergent surgical decompression is commonly advocated for optimal neurological recovery. Only three cases of spontaneous spinal subdural hematomas after LMWH therapy have been reported in the literature, and this is the first report of a spontaneous cervical epidural hematoma (EDH). PURPOSE To highlight the importance of conservative management in an unusual case of cervical EDH with neurological deficit after LMWH therapy. STUDY DESIGN Clinical case report. METHODS A 65-year-old man presented with weakness of upper and lower limbs with bowel and bladder dysfunction after LMWH therapy for an acute coronary syndrome. Magnetic resonance imaging (MRI) revealed an anterior cervical EDH extending from C4 to T1 with significant cord compression. Associated comorbidities precluded emergent surgical intervention, and the patient was managed conservatively with cessation of LMWH therapy. RESULTS The patient showed signs of early neurological recovery within 24 hours (ASIA C [American Spinal Injury Association] to ASIA D) of cessation of LMWH, and hence surgery was deferred. Complete motor and sensory recovery was observed at 1-month follow up with resolution of the cervical EDH without any cord compression evident on the MRI. CONCLUSIONS LMWH therapy is an important cause of SSH leading to significant neurological deficits. Conservative management is a viable treatment option in patients who demonstrate early and sustained neurological recovery with the cessation of LMWH therapy.
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Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010; 35:64-101. [PMID: 20052816 DOI: 10.1097/aap.0b013e3181c15c70] [Citation(s) in RCA: 659] [Impact Index Per Article: 47.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with neuraxial blockade is unknown. Although the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics, recent epidemiologic surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient populations.Overall, the risk of clinically significant bleeding increase with age,associated abnormalities of the spinal cord or vertebral column, the presence of an underlying coagulopathy, difficulty during needle placement,and an indwelling neuraxial catheter during sustained anticoagulation( particularly with standard heparin or low-molecular weight heparin). The need for prompt diagnosis and intervention to optimize neurologic outcome is also consistently reported. In response to these patient safety issues, the American Society of Regional Anesthesia and Pain Medicine (ASRA) convened its Third Consensus Conference on Regional Anesthesia and Anticoagulation. Practice guidelines or recommendations summarize evidence-based reviews. However, the rarity of spinal hematoma defies a prospective randomized study, and there is no current laboratory model. As a result,the ASRA consensus statements represent the collective experience of recognized experts in the field of neuraxial anesthesia and anticoagulation. These are based on case reports, clinical series, pharmacology,hematology, and risk factors for surgical bleeding. An understanding of the complexity of this issue is essential to patient management.
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Breivik H, Bang U, Jalonen J, Vigfússon G, Alahuhta S, Lagerkranser M. Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand 2010; 54:16-41. [PMID: 19839941 DOI: 10.1111/j.1399-6576.2009.02089.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Central neuraxial blocks (CNBs) for surgery and analgesia are an important part of anaesthesia practice in the Nordic countries. More active thromboprophylaxis with potent antihaemostatic drugs has increased the risk of bleeding into the spinal canal. National guidelines for minimizing this risk in patients who benefit from such blocks vary in their recommendations for safe practice. METHODS The Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) appointed a task force of experts to establish a Nordic consensus on recommendations for best clinical practice in providing effective and safe CNBs in patients with an increased risk of bleeding. We performed a literature search and expert evaluation of evidence for (1) the possible benefits of CNBs on the outcome of anaesthesia and surgery, for (2) risks of spinal bleeding from hereditary and acquired bleeding disorders and antihaemostatic drugs used in surgical patients for thromboprophylaxis, for (3) risk evaluation in published case reports, and for (4) recommendations in published national guidelines. Proposals from the taskforce were available for feedback on the SSAI web-page during the summer of 2008. RESULTS Neuraxial blocks can improve comfort and reduce morbidity (strong evidence) and mortality (moderate evidence) after surgical procedures. Haemostatic disorders, antihaemostatic drugs, anatomical abnormalities of the spine and spinal blood vessels, elderly patients, and renal and hepatic impairment are risk factors for spinal bleeding (strong evidence). Published national guidelines are mainly based on experts' opinions (weak evidence). The task force reached a consensus on Nordic guidelines, mainly based on our experts' opinions, but we acknowledge different practices in heparinization during vascular surgery and peri-operative administration of non-steroidal anti-inflammatory drugs during neuraxial blocks. CONCLUSIONS Experts from the five Nordic countries offer consensus recommendations for safe clinical practice of neuraxial blocks and how to minimize the risks of serious complications from spinal bleeding. A brief version of the recommendations is available on http://www.ssai.info.
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Affiliation(s)
- H Breivik
- Section for Anaesthesiology and Intensive Care Medicine, University of Oslo, Rikshospitalet, Oslo, Norway.
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Spontaneous spinal epidural hematoma: An urgent complication of adding clopidogrel to aspirin therapy. J Neurol Sci 2009; 285:254-6. [DOI: 10.1016/j.jns.2009.06.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Revised: 06/11/2009] [Accepted: 06/12/2009] [Indexed: 11/20/2022]
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Surani S, Estement B, Manchandan S, Sudhakaran S, Varon J. Spontaneous extraperitoneal lumbar artery hemorrhage. J Emerg Med 2008; 40:e111-4. [PMID: 18922660 DOI: 10.1016/j.jemermed.2008.01.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2007] [Revised: 01/02/2008] [Accepted: 01/17/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Spontaneous extraperitoneal hemorrhage (SEH) is an uncommon complication of anticoagulation therapy. Cases of SEH that are unresponsive to management through correction of coagulopathy, fluid resuscitation, blood transfusion, and other supportive measures are typically treated with surgery. Nevertheless, treatment of SEH with the use of angiography and arterial embolization may provide a safe, efficacious alternative to surgery. OBJECTIVES This case is presented to increase awareness among Emergency Physicians of the management options for patients with SEH. CASE REPORT A 67-year-old man presented to the Emergency Department with hemodynamic collapse due to retroperitoneal bleeding secondary to spontaneous rupture of a lumbar artery. An emergency abdominal angiogram revealed an actively bleeding left lumbar vessel. The localized bleeding was treated with catheter embolization and detachable microcoil embolization. This resulted in stabilization of the patient's condition without surgical intervention. CONCLUSION Overall, the improvement in hemodynamic stability and the decreased percentage of transfusion requirements can be achieved safely without surgical intervention through the prompt use of coil or catheter embolization.
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Affiliation(s)
- Salim Surani
- Texas A&M University, Corpus Christi, Texas, USA
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Aksay E, Kiyan S, Kitis O, Yuruktumen A. A rare diagnosis in emergency department. Am J Emerg Med 2008; 26:835.e3-5. [DOI: 10.1016/j.ajem.2008.01.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Accepted: 01/02/2008] [Indexed: 02/06/2023] Open
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