|
|
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
- 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.
- McManus DD, Rienstra M, Benjamin EJ. An update on the prognosis of patients with atrial fibrillation.
Circulation. 2012;126:e143-146.
- 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.
- Kirazli Y, Akkoc Y, Kanyilmaz S. Spinal epidural hematoma associated with oral anticoagulation therapy.
Am J Phys Med Rehabil. 2004;83:220-223.
- Lederle FA, Cundy KV, Farinha P, McCormick DP. Spinal epidural hematoma associated with warfarin therapy.
Am J Med. 1996;100:237-238.
- 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.
- 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.
- 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.
|
|
|
|
PDF Links
Full text via DOI 
Download Citation 
