1
|
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
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.
Collapse
Affiliation(s)
| | - Daniel Surdell
- Neurological Surgery, University of Nebraska Medical Center, Omaha, USA
| | - William Thorell
- Neurological Surgery, University of Nebraska Medical Center, Omaha, USA
| |
Collapse
|
4
|
Fonseca NM, Pontes JPJ, Perez MV, Alves RR, Fonseca GG. [SBA 2020: Regional anesthesia guideline for using anticoagulants update]. Rev Bras Anestesiol 2020; 70:364-387. [PMID: 32660771 DOI: 10.1016/j.bjan.2020.02.006] [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: 11/22/2019] [Revised: 02/10/2020] [Accepted: 02/21/2020] [Indexed: 10/24/2022] Open
Abstract
The development of protocols to prevent perioperative Venous Thromboembolism (VTE) and the introduction of increasingly potent antithrombotic drugs have resulted in concerns of increased risk of neuraxial bleeding. Since the Brazilian Society of Anesthesiology (SBA) 2014 guideline, new oral anticoagulant drugs were approved by international regulating agencies, and by ANVISA. Societies and organizations that try to approach concerns through guidelines have presented conflicting perioperative management recommendations. As a response to these issues and to the need for a more rational approach, managements were updated in the present narrative revision, and guideline statements made. They were projected to encourage safe and quality patient care, but cannot assure specific results. Like any clinical guide recommendation, they are subject to review as knowledge grows, on specific complications, for example. The objective was to assess safety aspects of regional analgesia and anesthesia in patients using antithrombotic drugs, such as: possible technique-associated complications; spinal hematoma-associated risk factors, prevention strategies, diagnosis and treatment; safe interval for discontinuing and reinitiating medication after regional blockade.
Collapse
Affiliation(s)
- Neuber Martins Fonseca
- Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Disciplina de Anestesiologia, Uberlândia, MG, Brasil; Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Centro de Ensino e Treinamento (CET), Uberlândia, MG, Brasil; Comissão de Normas Técnicas da Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil.
| | - João Paulo Jordão Pontes
- Hospital Santa Genoveva de Uberlândia, CET/SBA, Uberlândia, MG, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; European Diploma in Anaesthesiology and Intensive Care, European Society of Anaesthesiology, Bruxelas, Bélgica
| | - Marcelo Vaz Perez
- Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil; Conselho Editorial da Revista Brasileira de Anestesiologia, São Paulo, SP, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil
| | - Rodrigo Rodrigues Alves
- Hospital Santa Genoveva de Uberlândia, CET/SBA, Uberlândia, MG, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil
| | - Gabriel Gondim Fonseca
- Irmandade da Santa Casa de Misericórdia de São Paulo, Anesthesiology Specialization, São Paulo, SP, Brasil
| |
Collapse
|
5
|
Fonseca NM, Pontes JPJ, Perez MV, Alves RR, Fonseca GG. SBA 2020: Regional anesthesia guideline for using anticoagulants update. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 32660771 PMCID: PMC9373103 DOI: 10.1016/j.bjane.2020.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Neuber Martins Fonseca
- Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Disciplina de Anestesiologia, Uberlândia, MG, Brasil; Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Centro de Ensino e Treinamento (CET), Uberlândia, MG, Brasil; Comissão de Normas Técnicas da Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil.
| | - João Paulo Jordão Pontes
- Hospital Santa Genoveva de Uberlândia, CET/SBA, Uberlândia, MG, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; European Diploma in Anaesthesiology and Intensive Care, European Society of Anaesthesiology, Bruxelas, Bélgica
| | - Marcelo Vaz Perez
- Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil; Conselho Editorial da Revista Brasileira de Anestesiologia, São Paulo, SP, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil
| | - Rodrigo Rodrigues Alves
- Hospital Santa Genoveva de Uberlândia, CET/SBA, Uberlândia, MG, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil
| | - Gabriel Gondim Fonseca
- Irmandade da Santa Casa de Misericórdia de São Paulo, Anesthesiology Specialization, São Paulo, SP, Brasil
| |
Collapse
|
6
|
Spontaneous Spinal Epidural Hematoma in a Patient on Apixaban for Nonvalvular Atrial Fibrillation. Case Rep Hematol 2020; 2020:7419050. [PMID: 32351744 PMCID: PMC7178514 DOI: 10.1155/2020/7419050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/01/2020] [Accepted: 03/26/2020] [Indexed: 12/24/2022] Open
Abstract
Background With the rise in the use of direct oral anticoagulants (DOACs), more hemorrhagic complications are being encountered. Since the first description of a case of spontaneous spinal epidural hematoma (SSEH) related to the utilization of DOACs in 2012, there have been few reports describing a similar association. However, no cases so far have reported an association between SSEHs and apixaban. Case Description: A 76-year-old lady, with a history of nonvalvular atrial fibrillation, presented with a new onset of progressive left lower and upper extremity weakness. She reported back pain and numbness in the left leg up to the knee along with numbness in the left arm up to the shoulder. A CT scan of the neck was suggestive of an epidural hematoma extending from C2-C3 level to C6-C7. As the patient was on apixaban at the time, surgical treatment was delayed for two days to decrease the risk of intraoperative bleeding. Nine days later, she was discharged. Her physical exam was almost unchanged from that on presentation, except for resolution of pain and minimal improvement in motor power in her left lower extremity from 1/5 to 2/5 distally. Conclusions Spinal hematomas represent surgical emergencies with earlier intervention portending better outcome. Based on the few case reports that point to DOACs as a potential culprit, it appears that a high suspicion index resulting in earlier SSEH diagnosis and intervention is crucial for improved neurological outcome and recovery. Prompt diagnosis remains a challenge, especially that SSEH can mimic cerebrovascular accidents.
Collapse
|
7
|
Rahimizadeh A, Malekmohammadi Z, Williamson WL, Rahimizadeh S, Amirzadeh M, Asgari N. Rivaroxaban-induced acute cervical spine epidural hematoma: Report of a case and review. Surg Neurol Int 2019; 10:210. [PMID: 31768290 PMCID: PMC6826300 DOI: 10.25259/sni_390_2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/03/2019] [Indexed: 01/30/2023] Open
Abstract
Background: Spontaneous spinal epidural hematomas (SEHs) due to the utilization of factor Xa inhibitors are rare. Case Description: A 66-year-old female presented with a Brown-Sequard syndrome attributed to a cervical epidural hematoma secondary to the utilization of rivaroxaban, one of the factor Xa inhibitors. Following a cervical laminectomy for the evacuation of the hematoma, the patient completely recovered. Conclusion: A spinal hemorrhagic event should be suspected in patients receiving factor Xa inhibitor drugs. Here, we had an elderly female on rivaroxaban experienced the acute onset of neck/back pain associated with a Brown-Sequard syndrome. A literature review showed that this is the seventh example of SEH occurring as a result of the use of anticoagulation drugs (OACDs; e.g., including Xa inhibitors).
Collapse
Affiliation(s)
- Abolfazl Rahimizadeh
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Zahed Malekmohammadi
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Walter L Williamson
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Shaghayegh Rahimizadeh
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mahan Amirzadeh
- 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
| |
Collapse
|
8
|
Beynon C, Olivares A, Gumbinger C, Younsi A, Zweckberger K, Unterberg AW. Management of Spinal Emergencies in Patients on Direct Oral Anticoagulants. World Neurosurg 2019; 131:e570-e578. [PMID: 31400524 DOI: 10.1016/j.wneu.2019.07.234] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Spine surgeons increasingly encounter acute spinal pathologies in patients treated with direct oral anticoagulants (DOACs), but only limited data on the management of these patients are currently available. METHODS We retrospectively analyzed patients who presented to our department with acute spinal pathology during treatment with DOAC and who required urgent surgical therapy. Patient characteristics and treatment modalities were studied, with specific focus on the management of hemostasis and surgical therapy. Furthermore, we analyzed 19 cases of spinal emergencies during DOAC treatment reported in the literature. RESULTS A total of 12 patients were identified and included in the present analysis. Patients suffered from acute spinal cord compression caused by spinal tumor manifestation (n = 5), empyema (n = 4), degenerative spinal stenosis (n = 1), hematoma (n = 1), and vertebral body fracture/dislocation (n = 2). All patients underwent emergency surgical treatment. Prohemostatic substances were administered perioperatively in 10 patients (83%) and included administration of prothrombin complex concentrates (83%), tranexamic acid (17%), and transfusion of platelets (8%). A total of 9 patients (75%) showed postoperative improvement of neurologic symptoms, and the in-hospital mortality in this patient cohort was 17%. CONCLUSIONS Emergency spine surgery is feasible and should be considered in patients on treatment with DOAC. The (low) risk of intraoperative bleeding complications has to be weighed against the risk of permanent disability if surgical decompression is delayed. Administration of prothrombin complex concentrates and tranexamic acid may improve the coagulation before surgery, especially in cases of unavailable specific antidotes.
Collapse
Affiliation(s)
- Christopher Beynon
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany.
| | - Arturo Olivares
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Gumbinger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Klaus Zweckberger
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
9
|
Goldfine C, Glazer C, Ratzan RM. Spontaneous Spinal Epidural Hematoma from Rivaroxaban. Clin Pract Cases Emerg Med 2018; 2:151-154. [PMID: 29849242 PMCID: PMC5965116 DOI: 10.5811/cpcem.2018.2.37096] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 02/21/2018] [Accepted: 02/27/2018] [Indexed: 12/20/2022] Open
Abstract
Spontaneous spinal epidural hematoma (SSEH) is a rare diagnosis. One known risk factor is anti-coagulation medication. We present a case of SSEH in a 74-year-old male on rivaroxaban therapy who clinically presented with an intermittently resolving and then worsening neurological exam. Due to the extremely high morbidity and mortality associated with this diagnosis, it is important to be aware of the various presentations and adverse effects related to novel anticoagulation.
Collapse
Affiliation(s)
- Charlotte Goldfine
- University of Connecticut School of Medicine, Hartford Hospital, Department of Emergency Medicine, Hartford, Connecticut
| | - Catherine Glazer
- University of Connecticut School of Medicine, Hartford Hospital, Department of Emergency Medicine, Hartford, Connecticut
| | - Richard M Ratzan
- University of Connecticut School of Medicine, Hartford Hospital, Department of Emergency Medicine, Hartford, Connecticut
| |
Collapse
|
10
|
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]
|
11
|
Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition). Reg Anesth Pain Med 2017; 43:225-262. [DOI: 10.1097/aap.0000000000000700] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
12
|
Anghelescu A, Rasina A. Acute spontaneous thoracic epidural hematoma, triggered by weight-lifting training, in a retired sportsman: case report and literature review. Spinal Cord Ser Cases 2017; 3:17090. [DOI: 10.1038/s41394-017-0029-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 10/08/2017] [Accepted: 10/13/2017] [Indexed: 11/09/2022] Open
|