[EPIDURAL HEMATOMA WITH SPINAL CHORD COMPRESSION ASSOCIATED WITH WARFARIN INTAKE]

The most serious life-threatening warfarin-associated complications is hemorrhage in CNS structures. Reports of spontaneous spinal epidural hematomas in patients using warfarin, methods of diagnostics and treatment are but few. We describe the first case of warfarin-associated spontaneous spinal epidural hematoma in this country and a literature review of this issue.

Effects of timing of dexamethasone treatment on the outcome of collagenase-induced intracerebral hematoma in rats

The effect of timing in providing dexamethasone treatment after intracerebral hematoma was evaluated in rats with hematoma induced by a subcortical collagenase injection. Male Sprague-Dawley rats (n = 30; body weight, 185 to 230 g) received dexamethasone (1 mg/kg) intraperitoneally at 2 h, 4 h, or 6 h (1 group per time point) after intracerebral collagenase injection, with another dose (1 mg/kg) administered at 24 h after collagenase injection. Neurologic examinations and rotarod treadmill tests were used to evaluate motor behavior before and at 24 and 48 h after intracerebral injection. Rats were euthanized after the last behavioral test. Brains were evaluated for hematoma size, number of penumbral necrotic neurons, neutrophils within the hematoma, and astrocytic response. Compared with the control and other treatment groups, rats treated with dexamethasone at 2 and 24 h after intracerebral collagenase injection scored significantly better on neurologic exams and rotarod tests. Hematoma volume was significantly smaller in all treated groups than in the control group but did not differ between treatment groups. Fewer neutrophils were seen in the perihematoma region of all treated rats compared with controls, but the number of necrotic neurons was decreased significantly only in the group treated with dexamethasone at 2 and 24 h. These results indicate that a 1-mg/kg dose of dexamethasone is beneficial for treatment of intracerebral hemorrhage, particularly if administered early after the hemorrhagic insult.

Spinal epidural hematoma associated with oral anticoagulation therapy

Spontaneous spinal epidural hematoma is an uncommon cause of spinal cord compression. It may be associated with various causative factors, but in many patients, anticoagulation can be implicated. It is noteworthy that many of the reported cases were anticoagulated in the therapeutic range. Spontaneous spinal epidural hematoma should be suspected in any patient receiving anticoagulant agents who complains of local or referred spinal pain associated with limb weakness, sensory deficits, or urinary retention. Early diagnosis and treatment are very important for the functional recovery of the patient. Spinal magnetic resonance imaging is the most suitable neuroradiological method for early diagnosis. Although primary management is the surgical evacuation of the spinal epidural hematoma via laminectomy, rare cases in which the patient is improving rapidly and progressively could be treated conservatively. A 22-yr-old man with a spontaneous spinal epidural hematoma who was receiving warfarin treatment for a mechanical aortic valve is presented in this article.

Early antithrombotic prophylaxis with low molecular weight heparin in neurosurgery

BACKGROUND

Despite the high risk of venous thromboembolic events (VTE) in neuro-surgical patients, heparin prophylaxis has not been routinely established due to concern about bleeding complications. After initiating early low molecular weight heparin (LMWH) prophylaxis, we reviewed our patients in order to examine the viability of this practice.

METHOD

Over a 3 year period, the records of patients admitted for elective neuro-surgery (ES), head injury (HI) or spontaneous intracranial haemorrhage (ICH) were analysed. Prophylaxis was performed with certoparin (3000 U anti-factor Xa s.c.) on the evening before ES and within 24 hours after surgery or admission whenever a CT did not show a progressive haematoma. Contraindications for LMWH were prothrombin time <70%, partial thrombo-plastin time >40 s, platelet count <100.000/ml, and platelet aggregation test sum <60%. The incidence of bleeding complications, VTE, and resulting morbidity/mortality was assessed.

FINDINGS

294 patients were admitted for ES, 344 for HI, and 302 for ICH. 155 of these were excluded because of contraindications. Intracranial bleeding was recorded in 1.5% (ES 1.1%, HI 3.5%, ICH 0%) and operative revision was performed in 1.1% (ES 0.7%, HI 2.8%) of patients. One case of moderate disability and no mortality occurred. The incidence of VTE and pulmonary embolism was documented in 0.2% and 0.1% of patients, with no associated mortality. No heparin induced thrombocytopenia was observed.

INTERPRETATION

In neurosurgical patients, antithrombotic prophylaxis with certoparin was determined to be safe and efficacious when contraindications are carefully considered and a 12-hour time interval before and after surgery was guaranteed. This retrospective analysis should encourage a prospective trial of early LMWH prophylaxis.

Epidural Hematoma Associated with Dextran Infusion

The authors describe a case of epidural hematoma in association with dextran infusion in a patient who had undergone a peripheral vascular operation with epidural analgesia. Possible mechanisms for the anticoagulant effect of dextran and guidelines for the use of anticoagulant therapy in patients undergoing epidural anesthesia are discussed.

[ A rare complication of thrombolytic therapy: spinal epidural hematoma. A case report ]

Spinal epidural hematoma is a rare complication of thrombolytic therapy (only 9 cases described in the literature). We report the case of a 59-year-old female with hypertension, admitted to the coronary care unit for acute inferior myocardial infarction and treated with tissue-type plasminogen activator 100 mg in 90 min, intravenous heparin 25,000 U, aspirin 100 mg, and metoprolol 50 mg orally once daily. On the third day she suffered from sudden and violent dorsal pain, followed 22 hours later by paraplegia. Magnetic resonance imaging showed a large posterior spinal epidural hematoma, with compression and anterior dislocation of the spinal cord. The patient underwent neurosurgery. After 1 year, she still cannot walk. In patients treated with thrombolytic therapy and presenting with sudden and violent spinal pain, the physician should take into consideration the diagnosis of epidural hemorrhage. Early neurosurgery can save the patient and facilitate neurological recovery.

A case report of a spinal epidural haematoma associated with warfarin therapy

Spinal epidural haematoma is an uncommon, but recognised, clinical entity that needs emergency management. The association of spinal epidural haematomata with warfarin therapy has been described and, in 1956, Alderman stated that this diagnosis should be entertained in any patient receiving anticoagulants presenting with low back pain or sciatic pain. The purpose of this case report is to increase the awareness of this entity among medical personnel and to stress the urgency of management.

[Acute cervical spinal epidural hematoma during antithrombotic therapy: dual warnings against antithrombotic therapy]

Two aged women suddenly suffered from severe cervical and back pain followed by ipsilateral hemiparesis sparing the face. One woman had taken anticoagulant for prosthetic mitral valve and another had taken antiplatelet for prevention of recurrent brain infarction. On admission, MRI did not document any definite lesions in the brain, and revealed epidural hematoma compressing the cervical spinal cord for both patients. We promptly stopped their anticoagulants and antiplatelets use, because the agents seemed to be the leading cause of hematoma. In addition, we performed emergent laminectomy and evacuation of hematoma for the former patient. These cases suggest dual warnings against recently prevalent antithrombotic therapy for patients with histories of thromboembolic accidents. First, we should be careful about spinal epidural hematoma as a hemorrhagic complication of antithrombotic therapy. Second, we should not misdiagnose spinal epidural hematoma as ischemic stroke nor select hyperacute thrombolytic therapy. Cervical pain and hemiparesis sparing face are important signs for distinction of spinal epidural hematoma from stroke.

Spinal epidural hematoma complicating thrombolytic therapy with tissue plasminogen activator--a case report

Patients who receive thrombolytic therapy are at risk of central nervous system (CNS) hemorrhage, and this diagnosis must be sought in any patient who develops neurologic complaints after thrombolysis and anticoagulation. Early imaging and neurosurgical consultation are essential to improve outcome after hemorrhage occurs. We describe a patient who developed spinal epidural hematoma (SEH) after thrombolysis and anticoagulation for acute myocardial infarction. Delay in diagnosis and management may have contributed to a poor outcome. The literature on SEH is reviewed, and approaches to improve the prognosis of patients suffering CNS hemorrhage after thrombolysis are discussed.

Anticoagulant effect at the time of epidural catheter removal in patients receiving twice-daily or once-daily low-molecular-weight heparin and continuous epidural analgesia after orthopedic surgery

In patients who receive co-administered low-molecular-weight heparin (LMWH) and continuous epidural analgesia (CEA) after orthopedic surgery, there is concern about an increased risk of a spinal epidural hematoma. The practice of twice-daily LMWH dosing in North America might, in part, account for the greater number of epidural hematomas reports compared to Europe where once-daily LMWH is used. We performed a prospective cohort study in patients who had orthopedic surgery and received co-administered LMWH and CEA. We investigated the trough anticoagulant effect, as measured by an anti-Xa heparin level, at the time of epidural catheter removal in patients who received twice-daily or once-daily LMWH. Twenty-five patients who received enoxaparin, 30 mg twice-daily, and 25 patients who received dalteparin, 5,000 IU once-daily, had anti-Xa heparin levels measured on the second or third post-operative day at the time of epidural catheter removal. In patients who received twice-daily enoxaparin, or once-daily dalteparin, the anti-Xa heparin level was measured, on average, 10.4 h and 21.8 h, respectively, after the preceding LWMH dose. All 25 patients who received once-daily LMWH had an anti-Xa heparin level < 0.10 U/ml at the time of catheter removal. Of 25 patients who received twice-daily LMWH, the anti-Xa heparin level at the time of catheter removal was > or = 0.20 U/ml in 5 patients (P = 0.050), and > or = 0.10 U/ml in 7 patients (P = 0.009). We conclude that in patients who are receiving co-administered LMWH and CEA after orthopedic surgery, twice-daily but not once-daily LMWH administration is more likely to be associated with a clinically important anticoagulant effect at the time of epidural catheter removal.

Spinal epidural hematoma following tissue plasminogen activator and heparinization for acute myocardial infarction

The case of a 43-year-old Taiwanese man who presented with spinal epidural hematoma following intravenous administration of recombinant tissue plasminogen activator (rTPA) and heparin therapy for acute myocardial infarction (AMI) is reported. Upper back pain and progressive neurological dysfunction ensued, secondary to spinal epidural hematoma with spinal cord compression. The patient did not recover neurologic function postsurgically, possibly because the operation was delayed. In conclusion, cardiologists should be alert to this rare, severe complication of rTPA and should perform early laminectomy (in < or = 36 hours for those with complete deficit and in < or = 48 hours for those with incomplete deficit) if possible.

Spinal epidural haematoma as a result of warfarin/fluconazole drug interaction

This is the first reported case in the emergency medicine literature of a drug interaction between warfarin and fluconazole. We present a case of spinal epidural haematoma and summarize four other case reports reported elsewhere from 1988 to 1996. We admonish emergency physicians to be aware of this dangerous drug combination. Warfarin and fluconazole are frequently encountered drugs in the emergency department and thus any interaction between these drugs is of considerable importance.

[Spontaneous intraspinal epidural hematoma secondary to use of platelet aggregation inhibitors]

HISTORY AND ADMISSION FINDINGS

A 64-year-old woman previously in good health experienced an acute onset of severe neck pain and weakness of the left arm that had developed within minutes. Neurological examination revealed paresis of the left arm. There was a previous history of cardiovascular disease and she had been treated with 100 mg of aspirin per day.

INVESTIGATIONS

MRI revealed a left posterolateral intraspinal mass extending from C3 to C7. The hemostatic evaluation showed no abnormalities (platelet count, prothrombin time, partial thromboplastin time).

TREATMENT AND COURSE

A laminectomy with evacuation of the epidural hematoma was performed. The postoperative course was uneventful, with complete disappearance of the neurological deficit.

CONCLUSION

We report a rare condition of spontaneous spinal epidural hematoma that was associated with aspirin intake. A short time interval from onset of symptoms to diagnosis (MRI) and surgery is crucial for the outcome.

Spontaneous cervical epidural hematoma associated with oral anticoagulant therapy

A 54-year-old woman who was on anticoagulant treatment with acenocoumarol for a mitral prothesis developed a cervical spinal epidural hematoma, probably triggered by coughing fits together with supratherapeutic anticoagulation. Because of the subacute evolution of the hematoma, it was not diagnosed until the patient was admitted to the hospital with profuse hemorrhages. Given the subacute nature of the hematoma, along with the favorable evolution, conservative treatment with dexamethasone was decided upon, and it was resolved with almost no sequelae. This unusual clinical entity definitely should be suspected in patients on anticoagulants who complain of severe localized neck pain, most often with radicular irradiation.

Paraplegia subsequent to administration of tissue plasminogen activator and intravenous heparin following myocardial infarction--a case report

A case involving spinal epidural hematoma following tissue plasminogen activator and intravenous heparin therapy administered after acute myocardial infarction is reported here. The symptoms of spinal epidural hematoma following thrombolytic therapy are outlined and a recommended course of action for arriving at a definitive diagnosis of suspected epidural hematoma is provided.

[Caution for prophylaxis of thrombosis in connection with spinal anesthesia. Risk of hemorrhage when low-molecular-weight heparin is administered in epidural/spinal anesthesia]

There is an increasing awareness of the risk of haematoma in patients anticoagulated with low molecular weight heparins and scheduled to undergo epidural or spinal anaesthesia. The mechanisms causing this are not always clear, the incidence is very low. Risk factors are discussed as well as possible precautions to avoid this iatrogenic complication.

Regional anesthesia and issues of coagulation status

Regional anesthesia has generally been accepted as safe and is associated with a relatively low incidence of neurological injury. In 1993, the Food and Drug Administration approved the use of low molecular weight heparin for perioperative thromboprophylaxis. In the past 5 years, there has been an alarming increase in the number of intraspinal hematomas and neurological injury associated with its use in patients undergoing neuraxial anesthesia. This article reviews the coagulation cascade, the various laboratory studies used to assess the coagulation system, and issues related to neuraxial block in the patient with perioperative anticoagulation therapy. The various anticoagulant drugs and their potential to cause intraspinal hemorrhage are addressed with special attention paid to low molecular weight heparin. Finally, recommendations for managing the patient who receives these drugs is presented.

Delayed postoperative epidural hematoma formation after heparinization in lumbar spinal surgery

Treatment of thromboembolic disease in the postoperative lumbar spine patient is controversial. This case report describes an epidural hematoma with neurologic sequelae in an elderly patient who received intravenous heparin therapy over 2 weeks after lumbar decompression. Implications for treatment of thromboembolic disease in the postoperative lumbar spine is reviewed.

Intraspinal hemorrhage complicating oral anticoagulant therapy: an unusual case of cervical hematomyelia and a review of the literature

Intraspinal hemorrhage is a rare but dangerous complication of anticoagulant therapy. It must be suspected in any patient taking anticoagulant agents who complains of local or referred spinal pain associated with limb weakness, sensory deficits, or urinary retention. We describe a patient with hematomyelia, review the literature on hematomyelia and other intraspinal hemorrhage syndromes, and summarize intraspinal hemorrhage associated with oral anticoagulant therapy. The patient (a 62-year-old man) resembled previously described patients with hematomyelia in age and sex. However, he was unusual in having cervical rather than thoracic localization. As with intracranial bleeding, the incidence of intraspinal hemorrhage associated with anticoagulant therapy might be minimized by close monitoring and tight control of the intensity of anticoagulation. However, it is noteworthy that many of the reported cases were anticoagulated in the therapeutic range. If intraspinal hemorrhage is suspected, anticoagulation must be reversed immediately. Emergency laminectomy and decompression of the spinal cord appear mandatory if permanent neurologic sequelae are to be minimized. A high index of suspicion, prompt recognition, and immediate intervention are essential to prevent major morbidity and mortality from intraspinal hemorrhage.

Epidural haematoma after removal of an epidural catheter in a patient receiving high-dose enoxaparin

A patient developed an epidural haematoma 6 days after removal of an epidural catheter resulting in paraplegia and death. Insertion and removal of the epidural catheter during anticoagulation with prophylactic unfractionated heparin and subsequent administration of high-dose enoxaparin (Clexane), which commenced 3 days after catheter removal, were implicated.

Neuroaxial blocks and LMWH thromboprophylaxis

In the last 12 months, the Food and Drug Administration issued two documents warning the medical profession about the concurrent use of low molecular weight heparins (LMWHs) and neuroaxial blocks. This article summarizes the American and European experiences with LMWH thromboprophylaxis that could help with risk assessment.

Complications of subcutaneous low-dose heparin therapy in neurosurgical patients

BACKGROUND

Venous thromboembolism is a major cause of postoperative morbidity and mortality in neurosurgery. The use of low-dose unfractionated heparin therapy perioperatively for prophylaxis against deep vein thromboses and pulmonary embolism has been well demonstrated in many other surgical specialties but is less commonly used in neurosurgery because of fears of devastating postoperative hematomas.

METHODS

The safety of such therapy has been analyzed in 950 patients undergoing an inpatient neurosurgical procedure. 872 patients (152 cranial procedures) completed treatment with 5000 U sodium heparin subcutaneously twice a day, commencing before surgery and continuing till patients were ambulatory.

RESULTS

There were three minor hemorrhagic complications-two superficial wound hematomas (one requiring treatment) and one gastrointestinal hemorrhage-identified. Three clinically significant major complications developed, two epidural hematomas after spinal surgery requiring evacuation and one intraventricular hemorrhage after brain biopsy.

CONCLUSION

This report, along with an analysis of previously published reports of low-dose perioperative heparin therapy in neurosurgical patients, suggests that such therapy is unlikely to be associated with increased morbidity. Given the known efficacy of low-dose heparin in reducing venous thromboembolism in other surgical patients, such therapy may reduce mortality and morbidity from thromboembolic complications in neurosurgical patients with minimal risk.

Spontaneous spinal epidural hematoma associated with thrombolysis and anticoagulation therapy: report of three cases

Three patients with a spontaneous spinal epidural hematoma are presented, one of which is exceptional because it could be attributed to thrombolysis with alteplase. The other two were correlated with oral anticoagulant therapy. Our second case suggests that Morbus Kahler may be an underlying pathology in spinal extradural hematoma. In the third patient neither an obvious 'locus minoris resistentiae' nor a pathological coagulation test could be held responsible for the spontaneous bleeding. All three patients underwent laminectomy and evacuation of the hematoma. Although two of our cases are examples of complete recuperation after late operative intervention, early surgery is preferable. Permanent clinical attention together with a low threshold to perform magnetic resonance imaging (MRI) leads to a quicker diagnosis of spinal epidural hematoma. We show that administration of gadolinium may facilitate correct preoperative localization of the hematoma because there may be contrast enhancement of the hematoma. Finally, the postoperative policy concerning thromboembolic prophylaxis is discussed.

Delayed severe airway obstruction due to hematoma following stellate ganglion block

BACKGROUND AND OBJECTIVES

Delayed onset of airway obstruction following stellate ganglion block (SGB) may be life threatening. We treated a patient who developed a severe airway obstruction caused by a large hematoma several hours after an SGB.

METHODS

A 62-year-old woman suffering from sudden deafness developed dyspnea 2 hours after undergoing her fourth SGB, and evidenced swelling and tenderness in her anterior neck and chest. Her pharyngolaryngeal tissues were edematous, and the glottis was markedly narrowed. Computed tomograms and magnetic resonance images revealed a large soft tissue mass extending from the first cervical vertebra to the diaphragm.

RESULTS

Surgical tracheotomy was performed to maintain her airway. Swelling of the vocal cord disappeared on the eleventh day after the operation.

CONCLUSIONS

We believe that the SGB needle injured the vertebral artery and caused massive hemorrhage anterior to the cervical vertebra, subsequently inducing pharyngolaryngeal edema by obstructing the venous and lymphatic drainage of the cervical region.

[Spontaneous spinal epidural hematoma: good outcome after delayed treatment]

Spinal epidural haematomas are rare and are often encountered after previous operations on spinal disease and in combination with anticoagulation therapy. Usually early diagnosis and surgical treatment are the most important factors for a good result and neurological recovery. In 4 cases of spinal epidural haematoma treated in our institution, we found that also after some delay of diagnosis and treatment, surgery is always worthwhile even after some days to achieve a better neurological function.

Fatal spontaneous spinal epidural hematoma following thrombolysis for myocardial infarction

BACKGROUND

This is the first communication of a fatal spontaneous spinal epidural hematoma following thrombolysis.

CLINICAL PRESENTATION

Spine pain may precede neurologic deterioration by many hours. The diagnosis can be accurately made with axial computed tomography (CT) of the involved spinal segment.

TREATMENT

Emergency surgery is the treatment for this condition, but conditions such as the acute stage of a myocardial infarction or intraoperative bleeding difficulties due to iatrogenic coagulopathy, the degree of preoperative neurologic deficit, and the timing of surgery must be cautiously considered.

CONCLUSIONS

Neurosurgeons will be faced with another devastating complication of thrombolytic therapy, as long as the available drugs are being used. Early clinical suspicion and availability of CT or magnetic resonance imaging for prompt diagnosis are essential to initiate appropriate medical therapy and timely surgery. New strategies must include the development of completely fibrin-specific thrombolytics and drugs that may rapidly reverse the systemic and local clotting disorder.

[Cervical extradural hematoma under coagulants. Review of etiologies and prognosis]

We report a case of cervical epidural hematoma associated with anticoagulant therapy in a 68 year-old man, who presented with tetraplegia. He was operated 12 hours after the onset. Three months later, he had recovered almost completely. The etiologies and prognosis of such lesions are reviewed.

Management of spinal epidural hematoma after tissue plasminogen activator. A case report

STUDY DESIGN

This case report illustrates a patient with a spontaneous epidural hematoma after tissue plasminogen activator therapy who presented 10 days after the incident with a resolving Brown-Sèquard syndrome.

OBJECTIVES

The treatment of this patient involves the principles of conservative follow-up directed by an improving examination and an understanding of the pathophysiology of coagulopathy-induced spontaneous epidural bleeds.

SUMMARY OF BACKGROUND DATA

The use of tissue plasminogen activator therapy for thrombolysis in patients with early acute myocardial infarction is becoming increasingly routine. Use is limited most significantly by bleeding complications. Recently, several groups have drawn attention to the neurologic complications associated with intracranial hemorrhage after tissue plasminogen activator therapy. Spontaneous spinal epidural hemorrhage has, by comparison, received little attention. The authors report the second case in the literature and the first without a history of antecedent trauma.

METHODS

The onset of the painful myelopathy in this patient was missed in the acute setting because of low suspicion. When the diagnosis was made, coadministered heparin had already been discontinued without reversal, and the patient's examination had already improved. Careful follow-up by neurologic examination and magnetic resonance imaging was obtained without spinal angiography being performed.

RESULTS

The patient regained his prehemorrhage neurologic status, experienced no further bleeding, and his coronary ischemia remained subclinical.

CONCLUSIONS

Spinal epidural hemorrhage secondary to thrombolytic therapy is becoming increasingly common. Urgent surgical decompression is generally warranted to preserve neurologic function. In cases where the deficit is minimal or resolving, a conservative approach may be warranted with magnetic resonance imaging but not angiographic follow-up.

Spontaneous resolution of a large spinal epidural hematoma: case report

Spontaneous spinal epidural hematoma is a rare condition that usually requires surgical evacuation of the hematoma. We report a case of spontaneous spinal epidural hematoma that was probably associated with aspirin intake. The initial clinical signs and symptoms included sharp, left-sided neck pain and weakness of the left arm. The initial magnetic resonance image showed a spinal epidural hematoma extending from C2 to C6, with compression of the myelon. This case is remarkable for dramatic clinical improvement within 12 hours and the magnetic resonance imaging documentation of complete resolution within 3 days. For each patient with a stable or improving neurological status, conservative management monitored by magnetic resonance imaging might be the treatment of choice.

Is there a link between acute spinal epidural hematoma and aspirin?

STUDY DESIGN

This is a report of a patient with acute spinal epidural hematoma taking aspirin, 250 mg/day.

OBJECTIVE

To describe the association of spinal epidural hematoma and aspirin.

SUMMARY OF BACKGROUND DATA

In about 50% of patients, the cause of acute spinal epidural hematoma is obscure. Analysis of possible mechanisms is necessary.

METHODS

Diagnostic lumbar puncture, suboccipital myelography, and surgical removal of the hematoma was performed.

RESULTS

Increased bleeding was noticed during these procedures. Bleeding time was normal 6 days after discontinuance of aspirin.

CONCLUSION

Because aspirin is widely used, its role in causing spinal epidural hematoma will remain conjectural. For the present patient, however, it was postulated that aspirin had a major impact on the extent of the epidural bleeding. There should be awareness of a possible link between aspirin and spinal epidural hematoma.