warfarin and Rupture--Spontaneous

An interesting case of spontaneous bleeding from an ependymoma of the filum terminale is presented.. To document a rare case of rapid neurologic deterioration as a consequence of spinal tumoral hemorrhage and to highlight important issues regarding tumor histologic subtype and the impact of anticoagulation that have emerged from an illuminating review of the literature.. To our knowledge, there have been only 8 reported cases of hemorrhage from an ependymoma of the filum terminale or conus medullaris causing acute cauda equina syndrome. Bleeding is described in the pathology texts as being a consequence of the vascular architecture of the myxopapillary subtype and so postulated to be more common in this group. Anticoagulation is recognized to increase the frequency of tumoral bleeding, but no studies report its effect of severity of clinical presentation.. We report the case of a 57-year-old woman who developed nontraumatic acute cauda equina syndrome, including sphincter compromise. She underwent a lumbosacral laminectomy for evacuation of a hematoma, at which stage a filum terminale ependymoma was excised. Histopathologic analysis demonstrated it to be of a nonmyxopapillary subtype.. The patient demonstrated gradual improvement of the neurologic deficit. At 12-month follow-up, her saddle area sensory deficit has resolved, her right lower limb is much stronger allowing her to walk long distances, and she is successfully performing intermittent self-catheterization of her bladder.. The possibility of an underlying tumor should always be borne in mind so that adequate preoperative planning can be undertaken. The presence of the myxopapillary subtype should not prevent a clinician from excluding other reasons for hemorrhage, and counseling when reinstituting anticoagulation must include warning against a worse prognosis from any future hemorrhage.

Topics: Anticoagulants; Atrial Fibrillation; Cauda Equina; Ependymoma; Female; Hematoma; Hemorrhage; Humans; Laminectomy; Magnetic Resonance Imaging; Middle Aged; Mitral Valve Stenosis; Polyradiculopathy; Rheumatic Heart Disease; Rupture, Spontaneous; Spinal Neoplasms; Thrombophilia; Warfarin

A case of intramural esophageal dissection is reported and the literature reviewed. Patients with intramural esophageal dissection are usually women in their seventh or eighth decade. The most common presenting symptoms are chest pain, dysphagia, and hematemesis. The diagnosis is made by contrast esophagography, esophagoscopy, or both. Nonoperative therapy has proved to be uniformly successful.

Topics: Aged; Esophageal Diseases; Female; Humans; Rupture, Spontaneous; Warfarin

The basic mechanisms of atherosclerotic progression leading to the acute coronary syndromes (ACS) have been elucidated during the last few years. In this brief presentation, we outline 1) Definition of Atherosclerotic Lesions: eight morphologically different lesions are defined (Type I to VI) in various phases of disease. 2) Vulnerable Lipid-Rich Plaques and the ACS: The type IV and Va lesions tend to be relatively small in size, but soft or vulnerable to a "passive" phenomenon of plaque disruption; in addition, an "active" macrophage-dependent enzymatic (genesis of metalloproteinase) phenomenon of plaque disruption is evolving. 3) Thrombosis: we have shown that monocytes/macrophages in lipid-rich plaques may play a detrimental role after plaque disruption, promoting thrombin generation and thrombosis through the tissue factor pathway that can be prevented by tissue factor pathway inhibition; such pathway of thrombosis appears to be critical in the development of the ACS. 4) Effect of Lipid-Modifying Strategies and other Risk Factors on the Vulnerable Lipid-Rich Plaques: when high LDL-cholesterol is reduced therapeutically, efflux from the plaques of the liquid or sterified cholesterol, and also its hydrolysis into cholesterol crystals depositing in the vessel wall, predominate over the influx of LDL-cholesterol; consequently, there is a decrease in the softness of the plaque and so, presumably in the "passive" phenomenon of plaque disruption; modification of other risk factors presumably also favorably affect LDL-cholesterol influx and efflux. 5) Antithrombotic Strategies: the evolving antithrombotic approaches under investigation are briefly outlined.

Topics: Anticoagulants; Arteriosclerosis; Aspirin; Clinical Trials as Topic; Coronary Thrombosis; Disease Progression; Drug Therapy, Combination; Endothelium, Vascular; Fibrinolytic Agents; Humans; Lipids; Models, Biological; Platelet Aggregation Inhibitors; Rupture, Spontaneous; Thromboembolism; Thromboplastin; Warfarin

Warfarin, a vitamin K antagonist, is a widely used medication for the treatment and prophylaxis of thromboembolic events. Patients with various clinical conditions due to warfarin overdose present to emergency departments. Although there may be serious bleeding due to a warfarin overdose, no bleeding may also be seen in some clinical conditions. Some of these bleedings may be life-threatening and result in death. Warfarin overdose and related cases of spontaneous bladder rupture are not frequently observed in the literature. We present a case of spontaneous bladder rupture due to warfarin overdose that was unexpectedly seen in a patient using warfarin for coronary artery disease and arrhythmia.. A 77-year-old Caucasian male patient was admitted to the emergency department with abdominal pain, haematuria, and a reduced volume of urine lasting for three days. The patient's amount of urine was reduced, and he came to the hospital for the first time with this complaint. The patient had local bruises on his arms and legs. From the ultrasound, retrograde cystography and computed tomography images, it was thought that there was blood accumulation due to bladder rupture to the intraperitoneal region. Spontaneous bladder rupture secondary to warfarin overdose was considered for this patient who also had an international normalized ratio (INR) level of 13.4. After the INR level was normalized with vitamin K and a prothrombin complex concentrate, the patient underwent surgery. During the operation, a catheter was placed in the bladder, and the bladder mucosa and muscle were closed separately with a primary repair performed by a urologist. The patient was discharged on the 8th postoperative day without any complications.. In addition to the known findings of warfarin overdose in these patients presenting to the emergency department, we think that the emergency department staff should suspect bladder rupture, which is a fatal complication in the presence of signs such as oliguria, haematuria, anuria, abdominal pain, and syncope.

Topics: Aged; Anticoagulants; Dose-Response Relationship, Drug; Humans; Male; Rupture, Spontaneous; Urinary Bladder; Warfarin

Background and Purpose- The effects of anticoagulation therapy and elevated international normalized ratio (INR) values on the risk of aneurysmal subarachnoid hemorrhage are unknown. We aimed to investigate the association between anticoagulation therapy, elevated INR values, and rupture of intracranial aneurysms. Methods- We conducted a case-control study of 4696 patients with 6403 intracranial aneurysms, including 1198 prospective patients, diagnosed at the Massachusetts General Hospital and the Brigham and Women's Hospital between 1990 and 2016 who were on no anticoagulant therapy or on warfarin for anticoagulation. Patients were divided into ruptured and nonruptured groups. Univariable and multivariable logistic regression analyses were performed to evaluate the association of anticoagulation therapy, INR values, and presentation with a ruptured intracranial aneurysm, taking into account the interaction between anticoagulant use and INR. Inverse probability weighting using propensity scores was used to minimize differences in baseline demographics characteristics. The marginal effects of anticoagulant use on rupture risk stratified by INR values were calculated. Results- In unweighted and weighted multivariable analyses, elevated INR values were significantly associated with rupture status among patients who were not anticoagulated (unweighted odds ratio, 22.78; 95% CI, 10.85-47.81 and weighted odds ratio, 28.16; 95% CI, 12.44-63.77). In anticoagulated patients, warfarin use interacts significantly with INR when INR ≥1.2 by decreasing the effects of INR on rupture risk. Conclusions- INR elevation is associated with intracranial aneurysm rupture, but the effects may be moderated by warfarin. INR values should, therefore, be taken into consideration when counseling patients with intracranial aneurysms.

Topics: Adult; Aged; Aneurysm, Ruptured; Anticoagulants; Case-Control Studies; Female; Humans; International Normalized Ratio; Intracranial Aneurysm; Logistic Models; Male; Middle Aged; Multivariate Analysis; Odds Ratio; Propensity Score; Risk Factors; Rupture, Spontaneous; Subarachnoid Hemorrhage; Warfarin

Spontaneous hepatic rupture without underlying liver diseases is uncommon entity. We report a rare case of spontaneous rupture of liver hematoma in patient treated with warfarin end enoxaparin sodium because of pulmonary embolism. Two day after admission the patient complained generalized abdominal pain and hemodynamic instability. The abdominal US and TC scan revealed free fluid and lesion at right liver lobe. The patient, despite intravenous fluid support and blood transfusion, was hemodinamically instable and urgent laparotomy was needed. At laparotomy, it was found that a subcapsular haematoma, involving the diaphragmatic face of the right liver, had ruptured into peritoneum. Hepatic bleeding was stopped using a conservative approach by Pringle manoeuvre, parenchymal suture and fibrin sealant. There was no complication related to hepatic surgery but the patient died because of new massive pulmonary embolism 10 days after surgery. The absence of underlying liver pathology was confirmed by autopsy examination. This case report suggests that the possibility of spontaneous liver rupture should be considered in patients being treated with oral anticoagulants. Early diagnosis are critically important given the high morbidity and mortality. Aggressive resuscitation and immediate exploratory laparotomy is needed when hemodynamic instability occurs. In our case a quick, safe and effective control of bleeding was provided by partial vascular occlusion, parenchymal suture and topical haemostatic agent.. Anticoagulant therapy, Araumatic hemoperitoneum, Liver hematoma.. La rottura spontanea di fegato in assenza di malattie epatiche concomitanti è un evento abbastanza raro. Nel nostro lavoro illustriamo un raro caso di rottura spontanea di fegato in un paziente in trattamento con warfarin ed enoxaparina sodica a causa di una embolia polmonare. Due giorni dopo la dimissione il paziente lamentava dolori addominali generalizzati e presentava instabilità emodinamica. L’ecografia addominale e la TC addome mostravano versamento libero in addome ed una lesione a carico del fegato destro. Nonostante la terapia infusionale di supporto e le trasfusioni, il paziente continuava ad essere instabile da un punto di vista emodinamico; si decideva pertanto di eseguire una laparotomia d’urgenza. Alla apertura della cavità addominale vi è stato il riscontro di un ematoma sotto-glissoniano che coinvolgeva la faccia diaframmatica del fegato di destra e che si era aperto in addome. Il sanguinamento è stato controllato con approccio conservativo utilizzando la manovra di Pringle, sutura del parenchima ed uso di emostatici. Non si sono osservate complicanze correlate all’intervento ma il paziente è deceduto a causa di un nuovo episodio di embolia polmonare massiva, in decima giornata postoperatoria. L’esame autoptico ha confermato l’assenza di patologie epatiche concomitanti. La possibilità di una rottura spontanea di fegato andrebbe sempre considerata in pazienti in trattamento con anticoagulanti. La diagnosi precoce è fondamentale date l’alta morbilità e mortalità. Una terapia rianimatoria aggressiva ed una laparotomia esplorativa d’urgenza sono indicate in caso di instabilità emodinamica. Nel nostro caso, un rapido e sicuro controllo dell’emostasi sono stati possibili grazie ad una emostasi compressiva, sutura diretta del parenchima ed uso di emostatici.

Topics: Anticoagulants; Drug Therapy, Combination; Enoxaparin; Fatal Outcome; Hematoma; Hepatectomy; Humans; Liver Diseases; Pulmonary Embolism; Recurrence; Rupture, Spontaneous; Warfarin

Topics: Aged; Antineoplastic Agents; Female; Humans; Lymph Node Excision; Neoadjuvant Therapy; Ovarian Neoplasms; Rupture, Spontaneous; Salpingo-oophorectomy; Shock, Hemorrhagic; Splenic Rupture; Venous Thrombosis; Warfarin

Spontaneous isolated superior mesenteric artery dissection is a rare disease that may cause bowel ischemia or aneurysm rupture and subsequent death. Thus, the establishment of a correct diagnosis in the early stage is quite important.. To describe the presentation of 3 patients diagnosed with spontaneous isolated supramesenteric artery dissection and briefly summarize the diagnostic procedure, treatment, and clinical course.. We experienced three cases of isolated mesenteric artery dissection in the past 5 years. A definitive diagnosis was obtained by abdominal spiral computed tomography in two cases and angiography in one case. All patients were provided anticoagulation therapy.. One patient died of bowel ischemia, 2 were discharged within 21 days without complications, and one was able to discontinue anticoagulation therapy 12 months after discharge. The remaining patient has continued warfarin, making it difficult to determine the end point of anticoagulation.

Topics: Abdominal Pain; Adult; Anticoagulants; Heparin; Humans; Male; Mesenteric Artery, Superior; Mesenteric Ischemia; Middle Aged; Rupture, Spontaneous; Tomography, Spiral Computed; Vascular Diseases; Warfarin

Venous complications in patients with acute pancreatitis typically occur as a form of splenic, portal, or superior mesenteric vein thrombosis and have been detected more frequently in recent reports. Although a well-organized protocol for the treatment of venous thrombosis has not been established, anticoagulation therapy is commonly recommended. A 73-year-old man was diagnosed with acute progressive portal vein thrombosis associated with acute pancreatitis. After one month of anticoagulation therapy, the patient developed severe hematemesis. With endoscopy and an abdominal computed tomography scan, hemorrhages in the pancreatic pseudocyst, which was ruptured into the duodenal bulb, were confirmed. After conservative treatment, the patient was stabilized. While the rupture of a pseudocyst into the surrounding viscera is a well-known phenomenon, spontaneous rupture into the duodenum is rare. Moreover, no reports of upper gastrointestinal bleeding caused by pseudocyst rupture in patients under anticoagulation therapy for venous thrombosis associated with acute pancreatitis have been published. Herein, we report a unique case of massive upper gastrointestinal bleeding due to pancreatic pseudocyst rupture into the duodenum, which developed during anticoagulation therapy for portal vein thrombosis associated with acute pancreatitis.

Topics: Acute Disease; Aged; Anticoagulants; Duodenal Diseases; Gastrointestinal Hemorrhage; Hematemesis; Humans; Intestinal Fistula; Male; Pancreatic Pseudocyst; Pancreatitis, Alcoholic; Portal Vein; Risk Factors; Rupture, Spontaneous; Tomography, X-Ray Computed; Treatment Outcome; Venous Thrombosis; Warfarin

Spontaneous coronary artery dissection (SCAD) still is a rare cause of acute coronary syndrome. SCAD has been observed in three groups of patients: those with coronary atherosclerosis, peripartal women and idiopathic group. SCAD may be associated with some conditions. We report an unusual association: SCAD and pulmonary thromboembolism.

Topics: Anticoagulants; Aortic Dissection; Coronary Aneurysm; Coronary Angiography; Diagnosis, Differential; Echocardiography; Fibrinolytic Agents; Heparin; Humans; Male; Middle Aged; Pulmonary Embolism; Rupture, Spontaneous; Streptokinase; Warfarin

Topics: Anticoagulants; Hematoma; Humans; International Normalized Ratio; Male; Middle Aged; Pancreatic Pseudocyst; Peritoneal Diseases; Retroperitoneal Space; Rupture, Spontaneous; Tomography, X-Ray Computed; Warfarin

Topics: Adult; Anticoagulants; Corpus Luteum; Female; Hemoperitoneum; Humans; Protein S Deficiency; Rupture, Spontaneous; Warfarin

Although there are many reports describing spontaneous rupture of either the spleen or the liver, the simultaneous rupture of both organs is a rare event, especially during anticoagulant therapy. We report a case of spontaneous rupture of the spleen and liver in a patient on warfarin therapy for deep venous thrombosis.

Topics: Adult; Chemical and Drug Induced Liver Injury; Follow-Up Studies; Hepatectomy; Humans; Liver Diseases; Male; Risk Assessment; Rupture, Spontaneous; Splenectomy; Splenic Rupture; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography, Doppler; Venous Thrombosis; Warfarin

Lateral abdominal wall hematomas are rare. We describe a patient with a delayed rupture of a femoral artery pseudoaneurysm, who presented with such a hematoma. In contrast to other types of abdominal wall hematomas, which are often managed conservatively, a ruptured femoral artery pseudoaneurysm frequently requires emergent surgical intervention. Rupture of a pseudoaneurysm can be catastrophic. Due to the rising incidence of femoral artery pseudoaneurysms and shorter hospital stays, it is useful for the emergency physician to be familiar with the diagnosis and management of femoral artery pseudoaneurysms and their potentially life-threatening complications.

Topics: Abdominal Wall; Aged; Aneurysm, False; Anticoagulants; Atrial Fibrillation; Diagnosis, Differential; Emergency Medicine; Enoxaparin; Female; Femoral Artery; Heart Septal Defects, Atrial; Hematoma; Humans; Hypotension; Radiography; Rupture, Spontaneous; Treatment Outcome; Warfarin

Topics: Anticoagulants; Contraceptives, Oral; Female; Hemoperitoneum; Hemostasis; Humans; Ovarian Cysts; Retrospective Studies; Rupture, Spontaneous; Warfarin

Topics: Administration, Oral; Anticoagulants; Female; Hematoma; Humans; Mesenteric Arteries; Middle Aged; Rupture, Spontaneous; Shock, Hemorrhagic; Warfarin

Topics: Adult; Anticoagulants; Caudate Nucleus; Cerebral Hemorrhage; Female; Humans; Rupture, Spontaneous; Sneddon Syndrome; Warfarin

Non-traumatic (spontaneous) rupture of the spleen is a rare condition. Predisposing factors such as haematological disease, malignant tumour, inflammatory disease, infection, connective tissue disease and miscellaneous disorders have been reported. This report describes two patients with ruptured spleens, one of whom used warfarin, the other had a ruptured haemangioma.

Topics: Aged; Female; Hemangioma; Humans; Male; Rupture, Spontaneous; Splenic Neoplasms; Splenic Rupture; Warfarin

Mitral valve prolapse (MVP), often the result of myxomatous degeneration of the mitral valve, is the most commonly known pathologic entity leading to pure mitral regurgitation (MR). Reconstruction of the mitral valve rather than replacement is particularly applicable to this pathologic defect, but is not often used in the U.S. Experience with reconstruction of the mitral valve for MR secondary to MVP during the period January 1970 to January 1984 was reviewed. A total of 479 patients with mitral valve disease underwent operation during this period, 82 (17%) of whom had MR secondary to MVP. Thirty-one patients (6%) had valve reconstruction by a technique of leaflet plication and posteromedial anuloplasty. Eleven of these patients had associated cardiac disease requiring correction: 2 requiring aortic valve replacement and 9 requiring coronary artery bypass grafting procedures. One hospital death (3%) and 6 late deaths (19%) occurred, of which only 3 were related to cardiac factors. Major complications included recurrent MR in 5 patients and cerebral embolus in 1 patient. The adjusted 5-year survival rate was 89 +/- 6 (mean +/- standard error of the mean), and the overall survival rate of patients free of cardiac-related complications was 73 +/- 9%. Thus, reconstruction of the mitral valve is a highly effective surgical approach to the management of symptomatic patients with MR secondary to MVP, and its use is favored over replacement in the management of these patients.

Topics: Actuarial Analysis; Chordae Tendineae; Female; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Mitral Valve Prolapse; Postoperative Complications; Recurrence; Rupture, Spontaneous; Thromboembolism; Warfarin

Therapeutic doses of oral anticoagulants have been associated with spontaneous hemorrhage and rupture of apparently normal abdominal viscera. To our knowledge, this is the second reported case of such rupture involving the liver. The patient had sudden severe epigastric pain and signs of acute abdomen and shock. Discrete microscopic changes in the liver may precede massive hemorrhage.

Topics: Aged; Autopsy; Female; Hematoma; Hemorrhage; Humans; Liver Diseases; Rupture, Spontaneous; Warfarin

Topics: Adult; Anticoagulants; Female; Hemorrhage; Heparin; Humans; Ovarian Cysts; Pulmonary Embolism; Recurrence; Rupture, Spontaneous; Warfarin

A 43-year old woman had recurrent massive intraperitoneal hemorrhage from rupture of a hemorrhagic corpus luteum in two successive menstrual cycles while receiving anticoagulant therapy. Left oophorectomy was performed on the first occasion and right salpingo-oophorectomy with left salpingectomy on the second. While the precise incidence cannot be determined, rupture from a hemorrhagic corpus luteum appears to be a rare but potentially catastrophic complication of anticoagulant therapy. Hence possible ovarian hemorrhage should be considered in women of reproductive age receiving heparin or sodium warfarin therapy.

Topics: Adult; Anticoagulants; Corpus Luteum; Female; Hemorrhage; Humans; Ovarian Diseases; Rupture, Spontaneous; Warfarin

The unpredictability of hemorrhagic complications during anticoagulant therapy is well known. An unusual case of massive intraperitoneal hemorrhage from a ruptured corpus luteum during such therapy is presented. That this complication is uncommon may be because relatively few premenopausal women are placed on anticoagulant therapy. In addition, the most likely condition for which premenopausal women are given anticoagulants is thrombophlebitis associated with pregnancy and childbirth when ovulation is inhibited.

Topics: Corpus Luteum; Female; Hematuria; Hemoperitoneum; Heparin; Humans; Middle Aged; Ovarian Diseases; Rupture, Spontaneous; Thrombophlebitis; Warfarin

Three cases of women in the reproductive age group who received warfarin sodium therapy for pulmonary embolism are presented. The therapy was complicated by rupture of ovarian cysts with intraperitoneal hemorrhage necessitating exploratory laparatomy. The possibility of intraperitoneal hemorrhage must be considered in patients who present with abdominal pain and a history of anticoagulant therapy. Lack of awareness of the complication may result in delay in making a correct diagnosis and instituting appropriate therapy.

Topics: Adult; Female; Humans; Ovarian Cysts; Ovarian Diseases; Pulmonary Embolism; Rupture, Spontaneous; Warfarin

Topics: Autopsy; Cerebral Angiography; Cerebral Arterial Diseases; Cerebral Arteries; Female; Humans; Middle Aged; Pons; Rupture, Spontaneous; Subarachnoid Hemorrhage; Warfarin

Topics: Anticoagulants; Female; Heparin; Humans; Kidney Diseases; Male; Middle Aged; Nephrectomy; Prothrombin Time; Rupture, Spontaneous; Warfarin