warfarin and Hematoma--Epidural--Spinal

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.

Topics: Adult; Hematoma, Epidural, Spinal; Humans; Magnetic Resonance Imaging; Prognosis; Retrospective Studies; Treatment Outcome; Warfarin

Topics: Anesthesia, Obstetrical; Anesthesia, Spinal; Anticoagulants; Aspirin; Clopidogrel; Female; Fibrinolytic Agents; Fondaparinux; Guidelines as Topic; Hematoma, Epidural, Spinal; Heparin; Hirudins; Humans; Polysaccharides; Pregnancy; Ticlopidine; Warfarin

Spinal epidural hematomas are rare, with trauma being the most common cause. Spinal epidural hematomas caused by coagulation dysfunction are even rarer; however, long-term warfarin therapy increases the risk. The clinical manifestations of spinal epidural hematoma are neurological deficits below the corresponding spinal cord segment level. Magnetic resonance imaging (MRI) is the preferred method for diagnosis, and the main treatment for epidural hematoma with typical symptoms is urgent decompression of the lumbar spine. We describe an almost 80-year-old female patient who received long-term oral warfarin therapy for atrial fibrillation. She developed sudden onset waist pain, and 2 days later, she developed pain and weakness in both lower limbs. Computed tomography (CT) of the thoracolumbar spine showed no obvious hematoma. Eight days after admission, contrast-enhanced CT of the thoracolumbar spine showed intraspinal hematomas at T5-T8 and T12-L2 levels. We performed T3-T7 laminectomy, T5-T8 hematoma removal, and spinal dural repair. The clinical symptoms did not improve significantly, postoperatively. The low incidence of spinal epidural hematoma after anticoagulation treatment means this condition is not recognized timely, and it is misdiagnosed easily. Clinicians should consider this condition when patients treated with anticoagulants have neurological deficits below a spinal segmental plane.

Topics: Aged, 80 and over; Anticoagulants; Female; Hematoma, Epidural, Spinal; Humans; Laminectomy; Magnetic Resonance Imaging; Warfarin

Spontaneous spinal epidural hematoma (SSEH) is considered to be a relatively rare disease that can result in serious neurological sequelae. The pathogenesis and risk factors of SSEH are still unknown, and its differential diagnosis varies widely. Misdiagnosis with more common conditions such as stroke or aortic syndromes can occur. We report the case of a 27-year-old man who developed sudden upper back pain with no specific precipitant. Five days later, he visited our emergency department complaining of weakness in both lower limbs and dysuria. He had a history of intracardiac repair and a Blalock-Park procedure for an interrupted aortic arch and ventricular septal defect in infancy. Additionally, he had undergone an aortic root dilatation and aortic valve replacement at the age of 10 because of progression of aortic and supra-aortic stenosis and had received chronic anticoagulation and antiplatelet therapy with warfarin and aspirin, respectively. An emergency spine magnetic resonance imaging scan indicated a mass at the Th3-Th5 level with severe compression of the dural sac and the spinal cord. Emergency excision showed a spinal epidural hematoma. Mild postoperative gait disturbance and dysuria persisted, requiring rehabilitation and intermittent self-urethral catheterization. As patients with adult congenital heart disease have an increased risk of bleeding, they may be at risk of developing SSEH. However, this is the first report to describe such an association.

Topics: Adult; Anticoagulants; Aortic Valve Stenosis; Aspirin; Heart Defects, Congenital; Heart Septal Defects, Ventricular; Heart Valve Prosthesis Implantation; Hematoma, Epidural, Spinal; Humans; Magnetic Resonance Imaging; Male; Platelet Aggregation Inhibitors; Postoperative Complications; Warfarin

Spinal epidural hematoma is a rare condition usually secondary to trauma and coagulopathy. To the best of our knowledge, we present the first case of a patient with an iatrogenic hypercoaguable state performing self-neck manipulation, which resulted in a spinal epidural hematoma and subsequent quadriparesis.. A 63-year-old man presented to the emergency department with worsening interscapular pain radiating to his neck 1 day after performing self-manipulation of his cervical spine. He was found to be coagulopathic upon admission, secondary to chronic warfarin therapy for the management of atrial fibrillation. Approximately 48 h after the manipulation, the patient became acutely quadriparetic and hypotensive. Urgent magnetic resonance imaging revealed a multilevel spinal epidural hematoma from the lower cervical to thoracic spine.. Partial C7, complete T1 and T2, and partial T3 bilateral laminectomy was performed for evacuation of the spinal epidural hematoma. Following a 2-week course of acute inpatient rehabilitation, the patient returned to his baseline functional status. This case highlights the risks of self-manipulation of the neck and potentially other activities that significantly stretch or apply torque to the cervical spine. It also presents a clinical scenario in which practitioners of spinal manipulation therapy should be aware of patients undergoing anticoagulation therapy.

Topics: Anticoagulants; Atrial Fibrillation; Hematoma, Epidural, Spinal; Humans; Laminectomy; Male; Manipulation, Spinal; Middle Aged; Warfarin

Topics: Hematoma, Epidural, Spinal; Humans; Lower Extremity; Paraplegia; Warfarin

Epidural hematoma is a possible complication after neuraxial procedures. Recently, caudal epidural pulsed radiofrequency (PRF) stimulation was reported as an effective method for controlling several types of chronic pain. Herein, we report on a patient who developed a lumbar epidural hematoma after receiving caudal epidural PRF stimulation.. A 75-year-old woman, who was taking oral warfarin (2 mg/d), received caudal epidural PRF stimulation for symmetrical neuropathic pain in both legs due to chronic idiopathic axonal polyneuropathy. She did not discontinue warfarin use before undergoing the procedure. Three days and 12 hours after the procedure, motor weakness suddenly manifested in the right leg (manual muscle testing [MMT] = 2-3).. Lumbar magnetic resonance imaging (MRI) performed 7 days after the PRF procedure showed a spinal epidural hematoma at the L1 to L5 levels, compressing the thecal sac. The international normalized ratio was 6.1 at the time of the MRI.. Decompressive laminectomy from L1 to L5 with evacuation of the hematoma was performed.. Three months postoperatively, the motor weakness in the patient's right leg improved to MMT = 4 to 5.. This case suggests that clinicians should carefully check if patients are taking an anticoagulant medication and ensure that it is discontinued for an appropriate length of time before a caudal epidural PRF procedure is performed.

Topics: Aged; Anesthesia, Caudal; Anticoagulants; Female; Hematoma, Epidural, Spinal; Humans; Polyneuropathies; Pulsed Radiofrequency Treatment; Warfarin

Spontaneous spinal epidural hematoma (SSEH) manifests from blood accumulating in the epidural space, compressing the spinal cord, and leading to acute neurological deficits. The disease's cloudy etiology and rarity contribute to dangerously suboptimal therapeutic principles. These neural deficits can be permanent, even fatal, if the SSEH is not treated in a timely and appropriate manner. Standard therapy is decompressive laminectomy, though nonsurgical management is a viable course of action for patients who meet a criterion that is continuously being refined.. A 76-year-old woman on warfarin for a past pulmonary embolism presented to the emergency room with jaundice, myalgia, hematuria, neck pain, and an International Normalized Ratio (INR) of 14. Upon admission, she rapidly developed quadriplegia and respiratory distress that necessitated intubation.. T2-weighted magnetic resonance imaging (MRI) revealed an epidural space-occupying hyperintensity from C2 to S5 consistent with a spinal epidural hematoma. An incidental finding of dilated intrahepatic and common bile ducts prompted an endoscopic retrograde cholangiopancreatography, which demonstrated choledocholithiasis.. The patient's INR was normalized with Vitamin K and Beriplex. Upon transfer to the surgical spine team for assessment of a possible intervention, the patient began to demonstrate recovery of neural functions. The ensuing sustained motor improvement motivated the team's preference for close neurologic monitoring and continued medical therapy over surgery. Thirteen hours after the onset of her symptoms, the patient was extubated. A sphincterotomy was later performed, removing 81 common bile duct stones.. MRI demonstrated complete resorption of the SSEH and the patient maintained full neurological function at final follow-up.. Nonsurgical management of SSEH should be considered in the context of early and sustained recovery. Severe initial neural deficit does not necessitate surgical decompression. Choledocholithiasis and subsequent Vitamin K deficiency, particularly when coupled with anticoagulant use, can increase INR and is a novel proposed risk factor for SSEH. Furthermore, coagulopathies should be medically corrected before surgical intervention within a given timeframe, as spontaneous recovery may manifest. This should be favored over surgery in patients demonstrating early and sustained recovery, as nonsurgical management is 25% more effective in achieving full recovery.

Topics: Aged; Cholangiopancreatography, Endoscopic Retrograde; Choledocholithiasis; Conservative Treatment; Emergency Service, Hospital; Female; Follow-Up Studies; Hematoma, Epidural, Spinal; Humans; International Normalized Ratio; Intubation, Intratracheal; Pulmonary Embolism; Quadriplegia; Recovery of Function; Respiratory Insufficiency; Risk Assessment; Severity of Illness Index; Warfarin

Intracerebral hemorrhage is a well-known complication resulting from warfarin use; however, warfarin-associated intraspinal hematoma is very rare. Warfarin-associated intraspinal hematoma may exhibit delayed progression, and patients may present with atypical symptoms, occasionally resulting in delayed diagnosis. We report the case of a 65-year-old man who visited our emergency department (ED) with acute urinary retention. He had been previously diagnosed with non-valvular atrial fibrillation, arterial hypertension, and benign prostatic hyperplasia, and he used warfarin for the prevention of systemic embolism. The patient was initially diagnosed with worsening of the prostatic hyperplasia. After 2 days, he revisited the ED with painless paraparesis. Magnetic resonance imaging of the thoracic spine revealed an intraspinal hematoma at Th7-8, and blood coagulation tests indicated a prothrombin time-international normalized ratio of 3.33. Despite attempts to reverse the effects of warfarin with vitamin K administration, the paraparesis progressed to paraplegia, necessitating urgent surgical removal of the hematoma. Partial recovery of motor function was evident after surgery. From the present case, we learned that intraspinal hematoma should be included in the differential diagnosis of patients using warfarin who present with acute urinary retention. Although there are no evidence-based treatment guidelines for warfarin-associated intraspinal hematoma, surgical treatment may be warranted for those who exhibit neurological deterioration.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Delayed Diagnosis; Diagnosis, Differential; Disease Progression; Hematoma, Epidural, Spinal; Humans; Hypertension; International Normalized Ratio; Male; Paraparesis; Prostatic Hyperplasia; Prothrombin Time; Recovery of Function; Urinary Retention; Warfarin

Topics: Aged, 80 and over; Anesthesia, Epidural; Anticoagulants; Epidural Space; Female; Hematoma, Epidural, Spinal; Humans; Magnetic Resonance Imaging; Male; Paresthesia; Warfarin

Spontaneous spinal epidural hematoma (SSEH) is an uncommon but clinically important disease, and delayed diagnosis of this condition can have severe consequences. General physicians should consider the possibility of SSEH when they encounter a patient with a sudden onset of unexplained cervical or back pain or subsequent radicular symptoms during anticoagulant therapy. Immediate magnetic resonance imaging is essential for early diagnosis. In this article, we present a rare case of an 80-year-old man who developed cervical SSEH during warfarin therapy.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Hematoma, Epidural, Spinal; Humans; Magnetic Resonance Imaging; Male; Warfarin

Recombinant Factor VIIa decreases hematoma growth after spontaneous intracerebral hemorrhage (ICH) and rapidly decreases international normalized ratios in patients on warfarin but is also associated with an increased risk for thromboembolic complications. In this study, we assessed the risk of thromboembolic events in patients receiving recombinant Factor VIIa after ICH associated with warfarin treatment.. We reviewed the medical charts, laboratory data, and radiological findings of consecutive patients with anticoagulation-related hemorrhages of the central nervous system who received recombinant Factor VIIa at Mayo Clinic Rochester and Mayo Clinic Florida between 2002 and 2009. The primary end point was the frequency of new thromboembolic events, including myocardial infarction, deep vein thrombosis, ischemic stroke, and pulmonary embolism.. We identified 101 patients; 54% had ICH and 30% subdural hematomas. The most common indications for anticoagulation were atrial fibrillation, deep vein thrombosis, and prosthetic valve. Thirteen patients (12.8%) had new thromboembolic events (10 deep vein thromboses and 3 ischemic strokes) within 90 days after recombinant Factor VIIa administration. Eight of these adverse events occurred within 2 weeks of treatment. In patients with ICH, the rate of thromboembolic complications was 5% and all events were venous.. The risk of thromboembolic events in patients who received recombinant Factor VIIa for anticoagulation-associated ICH was not higher than that seen in patients treated for spontaneous ICH in the Factor Seven for Acute Hemorrhagic Stroke (FAST) trial. Spontaneous deep vein thrombosis was the most common complication in our series.

Topics: Adult; Aged; Aged, 80 and over; Central Nervous System Diseases; Cerebral Hemorrhage; Factor VIIa; Female; Hematoma, Epidural, Spinal; Humans; Male; Middle Aged; Recombinant Proteins; Warfarin

A case of a large spinal epidural haematoma, in a 58 years old male, leading to paraplegia, in a patient on long-term warfarin treatment is presented. Magnetic Resonance imaging (MRI) of the whole spine showed extensive epidural spinal haematoma distal to C4 level surrounding and displacing the spinal cord and the nerve roots up to T2 level. Near complete neurological recovery followed surgical evacuation and multidisciplinary rehabilitation.

Topics: Anticoagulants; Decompression, Surgical; Diagnosis, Differential; Hematoma, Epidural, Spinal; Humans; Laminectomy; Lumbar Vertebrae; Magnetic Resonance Imaging; Male; Middle Aged; Paraplegia; Radiography; Treatment Outcome; Warfarin

Epidural hypotensive anesthesia can, in addition to imparting numerous intraoperative benefits, provide excellent postoperative pain control for patients having joint arthroplasties. However, because of the risk of epidural hematoma, epidural anesthesia is not coadministered with anticoagulation in some centers. We retrospectively ascertained, by chart review, the incidence of epidural hematoma in 11,235 patients having 12,991 knee arthroplasties at our institution who received oral anticoagulation and epidural anesthesia for their surgery. Warfarin was administered on the day of surgery. With the exception of 212 patients, the epidural catheter was removed within 48 hours of surgery. Based on clinical examinations, we detected no epidural hematomas. For 1030 patients (1038 knees) whose charts were reviewed in detail, the mean international normalized ratio at the time of removal of the epidural catheter was 1.54 (range, 0.93-4.25). We identified no other complications related to the coadministration of epidural anesthesia and warfarin. Although administration of epidural anesthesia in patients with coagulopathy can be detrimental, we recognized no cases of epidural hematoma causing neurologic symptoms in patients receiving controlled oral anticoagulation after total knee arthroplasty.

Topics: Anesthesia, Epidural; Anticoagulants; Arthroplasty, Replacement, Knee; Hematoma, Epidural, Spinal; Humans; Retrospective Studies; Warfarin

Case report.. To describe a case of spinal epidural hematoma arising from the synovial joint due to anticoagulation therapy.. Spontaneous spinal epidural hematoma is a rarity in the literature with a variety of etiologies. In 1 study, it was reported to originate from a synovial joint due to osteoarthritis of the joint.. A case of hematoma of the lumber synovial joint is presented.. A 67-year-old man who was on anticoagulation therapy presented with progressive neurologic symptoms in the right lower limb. Magnetic resonance imaging scan revealed what was thought to be a L4-L5 synovial joint cyst. During surgery, it was proven to be an epidural hematoma originating from the synovial joint. Microscopic examination confirmed the diagnosis and excluded the possibility of spinal synovial cyst. After spinal decompression, neurologic symptoms improved completely in 2 weeks.. This is the first report of a synovial cyst hematoma due to anticoagulation therapy. Its magnetic resonance imaging features can be similar to synovial cyst, especially when it is hemorrhagic. Spinal decompression was the definitive treatment.

Topics: Aged; Anticoagulants; Cardiovascular Diseases; Diagnosis, Differential; Hematoma; Hematoma, Epidural, Spinal; Humans; Lumbar Vertebrae; Magnetic Resonance Imaging; Male; Synovial Cyst; Warfarin

Spontaneous spinal epidural hematoma (SSEH) is rare in the pediatric population. This case report reviews the indications and strategies for nonoperative management in selected patients.. An eight-year-old boy presented with back pain. There was no antecedent trauma, but the patient was anticoagulated for a mechanical heart valve. MRI revealed an epidural mass from T12 to L2 consistent with SSEH. The absence of focal neurologic deficits, combined with the high stroke risk with anticoagulation reversal, prompted a nonoperative approach. Clinical symptoms resolved over several weeks while maintaining therapeutic anticoagulation. Follow-up MRI demonstrated resolution of the hematoma.. SSEH can present in the setting of poorly controlled therapeutic anticoagulation in the pediatric population. This case supports the premise that patients who present with SSEH without focal neurologic deficit can be successfully managed while maintaining therapeutic levels of anticoagulation. Close follow-up with frequent neurologic examinations, imaging and monitoring of the prothrombin time is mandatory.

Topics: Administration, Oral; Anticoagulants; Child; Heart Valve Prosthesis; Hematoma, Epidural, Spinal; Humans; Magnetic Resonance Angiography; Male; Warfarin