warfarin and Spinal-Diseases

Warfarin-associated intracranial hemorrhage is associated with a high mortality rate. Ongoing coagulopathy increases the likelihood of hematoma expansion and can result in catastrophic hemorrhage if surgery is performed without reversal. The current standard of care for emergency reversal of warfarin is with fresh frozen plasma (FFP). In April 2013, the USA Food and Drug Administration approved a new reversal agent, 4-factor prothrombin complex concentrate (PCC), which has the potential to more rapidly correct coagulopathy. We sought to determine the feasibility and outcomes of using PCC for neurosurgical patients. A prospective, observational study of all patients undergoing coagulopathy reversal for intracranial hemorrhage from April 2013 to December 2013 at a single, tertiary care center was undertaken. Thirty three patients underwent emergent reversal of coagulopathy using either FFP or PCC at the discretion of the treating physician. Intracranial hemorrhage included subdural hematoma, intraparenchymal hematoma, and subarachnoid hemorrhage. FFP was used in 28 patients and PCC was used in five patients. International normalized ratio at presentation was similar between groups (FFP 2.9, PCC 3.1, p=0.89). The time to reversal was significantly shorter in the PCC group (FFP 256 minutes, PCC 65 minutes, p<0.05). When operations were performed, the time delay to perform operations was also significantly shorter in the PCC group (FFP 307 minutes, PCC 159 minutes, p<0.05). In this preliminary experience, PCC appears to provide a rapid reversal of coagulopathy. Normalization of coagulation parameters may prevent further intracranial hematoma expansion and facilitate rapid surgical evacuation, thereby improving neurological outcomes.

Topics: Anticoagulants; Antidotes; Blood Coagulation Factors; Brain Injuries; Hemorrhage; Humans; International Normalized Ratio; Intracranial Hemorrhages; Plasma; Practice Guidelines as Topic; Prospective Studies; Randomized Controlled Trials as Topic; Spinal Diseases; Subarachnoid Hemorrhage; Tertiary Care Centers; Warfarin

Nervous system infections by Cryptococcus neoformans may occur not only in congenital or acquired immunodeficiency syndromes, but also in immunocompetent hosts. Neurological manifestations of C. neoformans infection include meningitis and, less commonly, parenchymal CNS granulomatous disease. This paper provides detailed clinical descriptions of highly unusual neurological manifestations of cryptococcal nervous system infections. Medical records and diagnostic data including magnetic resonance imaging, histopathology, serology, and CSF analysis were reviewed. A conus medullaris abscess was found in a patient infected with the human immunodeficiency virus (HIV). A patient with Hodgkin's disease was diagnosed with cryptococcal meningitis and dermatitis mimicking ophthalmic zoster. An immunocompetent patient presented with recurrent cerebral infarctions in the setting of cryptococcal meningitis. Cryptococcal infections of the nervous system can cause severe neurological disability when diagnosis is delayed. Sensitive and specific tests are readily available and should be considered when an unusual clinical presentation is encountered.

Topics: Abscess; Adult; Aged; Amphotericin B; Anticoagulants; Antifungal Agents; Brain; Central Nervous System Fungal Infections; Cryptococcosis; Cryptococcus neoformans; HIV Infections; Hodgkin Disease; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Spinal Diseases; Tomography, X-Ray Computed; Warfarin

This case report illustrates an unusual complication of chronic warfarin administration.. The presurgical determination that the destructive process at L1-L2 was not infection or neoplasm involved the recognition that there was instability at this level resulting from chronic stress fractures.. Periosteal or osseous hemorrhagic masses (pseudotumors) have been well described in patients with hemophilia. To the authors' knowledge, this is the first reported case of this well-known phenomenon occurring in the axial skeleton as a consequence of warfarin administration.. Serial radiographic studies of the lumbar spine were available showing a progressive destructive lesion at L1-L2 and coinciding with the initiation of warfarin anticoagulation after aortic valve replacement.. The destructive mass was demonstrated surgically to represent a large partially solidified chronic hematoma.. Patients with stress fractures of the posterior arch and subsequent instability may be subject to development of such a spondyloarthropathy. Recognition of this unusual potential complication of warfarin therapy would prevent an incorrect diagnosis of tumor or infection. Early recognition of its occurrence could lead to early spinal stabilization.

Topics: Aged; Fractures, Stress; Hematoma; Humans; Lumbar Vertebrae; Male; Radiography; Spinal Diseases; Spondylitis, Ankylosing; Warfarin

A 59-year-old male with a mechanical aortic valve taking warfarin presented to hospital with Brown-Séquard syndrome caused by a spontaneous spinal epidural hematoma (SSEH) precipitated by a coughing fit. Guided by a literature review of the risks of administering or withholding anticoagulation in this patient, doctors advised a regimen of warfarin to achieve an international normalized ratio of 1.5 to 2 and dipyridamole (75 mg qid) to protect against thromboembolic complications while minimizing the risk of recurrent SSEH.

Topics: Anticoagulants; Aortic Valve; Dose-Response Relationship, Drug; Embolism; Epidural Space; Exercise; Heart Valve Prosthesis; Hematoma, Epidural, Cranial; Humans; Male; Middle Aged; Risk Factors; Spinal Diseases; Thrombosis; Warfarin

Although spinal subdural hematoma is a rare condition, it has a higher incidence in persons with a bleeding diathesis and in those with a bleeding diathesis who have had a lumbar puncture. We report a case of a 65-year-old woman on oral anticoagulants presenting with atypical symptoms who developed a spinal subdural hematoma over a six-hour period. This resulted in complete paraplegia of her lower extremities with no improvement after surgical spinal cord decompression.

Topics: Female; Hematoma, Subdural; Hemorrhagic Disorders; Humans; Laminectomy; Middle Aged; Paraplegia; Spinal Cord Compression; Spinal Diseases; Warfarin

Topics: Anticoagulants; Blood Coagulation Tests; Cerebrospinal Fluid; Chiropractic; Female; Hematoma; Humans; Laminectomy; Meninges; Middle Aged; Neurologic Manifestations; Prothrombin Time; Spinal Diseases; Subarachnoid Hemorrhage; Warfarin