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International Journal of Arrhythmia 2014;15(4): 45-48.
ECG & EP CASES
Warfarin-associated Extensive
Spontaneous Spinal Epidural
Hematoma Mimicking Stroke




Introduction

   Oral anticoagulation (OAC) therapy is strongly recommended to prevent thromboembolic stroke in patients with atrial fibrillation (AF).1 However, strict control is needed to achieve optimal therapeutic level when using warfarin as the anticoagulant. Clinicians usually suspect acute stroke when patients with AF present with neurologic symptoms.2 I report an AF patient on warfarin therapy complaining of acute-onset right hemiplegia, which was diagnosed as extensive spinal epidural hematoma rather than stroke.

Case

   A 70-year-old female patient presented to the emergency department complaining of chest discomfort and motor weakness in the right arm and leg. She had been on warfarin for 6 years after a diagnosis of paroxysmal AF. The patient reported a history of hypertension and dyslipidemia. There had been no recent changes in warfarin dosage, and her international normalized ratio (INR) had been 2.0 at last measurement, within the therapeutic range. Prompt magnetic resonance imaging (MRI) of the brain was performed to evaluate acute stroke events. However, it revealed no evidence of cerebral infarction or hemorrhage. Detailed neurological examination showed decreased motor strength in right upper and lower extremities, reduced pain and temperature sensations below T2, and hyperreflexia in the lower extremities. No cognitive dysfunction or dysarthria was noted. Cranial nerve examination was normal. Taken together, these findings suggested cervical spinal cord compression. Thereafter, cervical MRI was performed and revealed a multiloculated cystic mass (11 × 1.5 ×1 cm) in the posterior and right posterolateral regions of the spinal canal from C1 to T2, with mass effect on the spinal cord and compressive myelopathy on the right side at C6-7. In addition, there was moderate left central disc herniation at C6-7. After intravenous administration of 5 mg of vitamin K, the patient underwent emergency right cervical decompressive laminectomy 24 hours after symptom onset. A massive cervical epidural hematoma extending from C1 to T1 was found and removed. The patient was hospitalized for rehabilitation for 2 weeks after the operation. Follow-up cervical MRI showed complete removal of hematoma from the spinal canal. Anticoagulation was started 2 days after operation with intravenous unfractionated heparin, which was changed to oral warfarin 5 days after operation. At hospital discharge, the motor power of the arm had been completely recovered, and lower limb strength was mostly restored with a power grade of 4/5.



Discussion

   OAC should be considered in AF patients with high risk of thromboembolism.1 However, if warfarin is used for this purpose, the dose must be strictly controlled to avoid severe complications (embolic stroke if INR falls below therapeutic range and hemorrhagic stroke if it rises above). Neurologic deficit in patients on warfarin medication usually indicates acute stroke. However, this patient developed extensive spinal epidural hematoma rather than stroke. Spontaneous spinal epidural hematoma is a rare condition, that usually requires emergent surgical intervention;3 its occurrence in patients on warfarin with an INR within the therapeutic range has previously been reported by other authors.4,5 In the current case, laboratory tests found INR to be within the therapeutic range, and the patient did not have any trauma or underlying coagulopathic disease. The combination of hypertension and cervical disc herniation may have led to the epidural bleeding. Therefore, spinal epidural hematoma should be considered in addition to acute stroke when focal neurologic deficit is found in patients taking warfarin, and detailed neurologic examination is mandatory to differentiate spinal epidural hematoma from stroke.
   Early diagnosis and emergency surgical intervention are essential in spinal epidural hematoma to enable recovery from neurologic sequelae.6 Surgical treatment more than 48 hours after manifestation is likely to result in permanent neurologic impairment with incomplete dysfunction of the spinal cord.7 Spinal epidural hematoma usually manifests as sudden, unexplained cervical or back pain.8 However, the patient only complained of mild chest discomfort in the current case. This shows that spinal epidural hematoma can vary in its clinical presentation, and careful examination is important in patients with neurologic symptoms, especially AF patients on warfarin medication.
   Spinal epidural hematoma should be the first differential diagnosis considered in patients on warfarin medication when neurologic symptoms suggest acute stroke, even without cervical or back pain. Any delay in diagnosis and surgical intervention may result in permanent neurologic impairment.


References

  1. Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P; ESC Committee for Practice Guidelines (CPG). 2012 focused update of the ESC Guidelines for the anagement of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012;33:2719-2747.
  2. McManus DD, Rienstra M, Benjamin EJ. An update on the prognosis of patients with atrial fibrillation. Circulation. 2012;126:e143-146.
  3. Pullarkat VA, Kalapura T, Pincus M, Baskharoun R. Intraspinal hemorrhage complicating oral anticoagulant therapy: an unusual case of cervical hematomyelia and a review of the literature. Arch Internal Med. 2000;160:237-240.
  4. Kirazli Y, Akkoc Y, Kanyilmaz S. Spinal epidural hematoma associated with oral anticoagulation therapy. Am J Phys Med Rehabil. 2004;83:220-223.
  5. Lederle FA, Cundy KV, Farinha P, McCormick DP. Spinal epidural hematoma associated with warfarin therapy. Am J Med. 1996;100:237-238.
  6. Groen RJ, van Alphen HA. Operative treatment of spontaneous spinal epidural hematomas: a study of the factors determining postoperative outcome. Neurosurgery. 1996;39:494-508; discussion 508-509.
  7. Groen RJ. Non-operative treatment of spontaneous spinal epidural hematomas: a review of the literature and a comparison with operative cases. Acta Neurochir. 2004;146:103-110.
  8. Horcajadas A, Katati M, Arraez MA, Ros B, Abdullah O, Castaneda M, de la Linde C. Spontaneous epidural spinal hematoma: report of 2 cases and review of the literature. Neurologia. 1998;13:401-404.
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