Unusual localization of bleeding under acenocoumarol: Spinal subdural hematoma

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CASE REPORT – OPEN ACCESS

InternationalJournalofSurgeryCaseReports59(2019)15–18

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International Journal of Surgery Case Reports

j o u r n al ho m e p a g e :w w w . c a s e r e p o r t s . c o m

Unusual localization of bleeding under acenocoumarol:

Spinal subdural hematoma

Ismail Aissa

^a,∗

, Abdelghafour Elkoundi

^a

, Rabi Andalousi

^a

, Aziz Benakrout

^a

,

Abdelatif Chlouchi

^a

, Mohamed Moutaoukil

^a

, Jawad Laaguili

^b

, Mustapha Bensghir

^a

, Hicham Balkhi

^a

, Salim Jaafar Lalaoui

^a

aDepartmentofAnesthesiologyandIntensiveCare,MilitaryHospitalMohammedV,FacultyofMedicineandPharmacyofRabat,MohammedVUniversity, Rabat,Morocco

bDepartmentofNeurosurgery,MilitaryHospitalMohammedV,FacultyofMedicineandPharmacyofRabat,MohammedVUniversity,Rabat,Morocco

a r t i c l e i n f o

Articlehistory:

Received26February2019 Accepted28April2019 Availableonline10May2019

Keywords:

Spinalsubduralhematoma Acenocoumarol Spinalcordcompression

a b s t r a c t

BACKGROUND:Thespinalsubduralhematoma(SSH)isanextremelyrareentitywhichrepresentsonly 4.1%ofallspinalhematomas.Itneedsaccuratediagnosisandrapidinterventionbecauseofthemajor neurologicalriskinducedbyspinalcompression.Severaletiologieshavebeenreported:anticoagulant treatments,haematologicaldisorders,arterio-venousmalformation,repeatedattemptsatlumbarpunc- turesandtumors.Wereportthecaseofan82-year-oldpatientunderacenocoumarolforatrialﬁbrillation whopresentedwithparaplegiasecondarytoSSH.

CASEREPORT:An82-year-oldpatientwithahistoryofischemicheartdiseaseandatrialﬁbrillationunder acenocoumarolwasadmittedtoemergencydepartmentwithsuddenonsetofparaplegiaandintenseback painassociatedwithurinaryincontinenceandanalsphincterdisorder.Onexaminationhislowerlimb powerwasMRCgrade0outof5inallrangesofmovementbilaterallyandacompletebilateralanesthesia reachingtheT12dermatomewasnoted.BiologicaltestresultsshowedanInternationalNormalized Ratioat10.MagneticresonanceimagingrevealedaposteriorlylocatedspinalhematomaatT12level, measuring36mmwithspinalcordcompression.Aftercorrectionofhemostasisdisordersthepatientwas admittedtotheoperatingroomforaT11-L1laminectomywithevacuationofthesubduralhematoma.

Musclepowershowedagradualimprovementinthelowerlimbsestimatedat3/5withregressionof sphincterdisordersbutunfortunatelyasequellarsensoryimpairmentpersisted.

CONCLUSION:SSHisararesituationofacenocoumarolbleedingincident,itshouldbeevokedinany patienttreatedbythismoleculewithsignsofspinalcordcompression.

1. Introduction

FirstdescribedbyShilleretal.[1],thespinalsubduralhematoma (SSH)isanextremelyrareentitywhichrepresentsonly4.1%ofall spinalhematomas[2].Itneedsaccuratediagnosisandrapidinter- ventionbecauseofthemajorneurologicalriskinducedbyspinal compression.Severaletiologieshavebeenreported:haematologicaldisorders,arterio-venousmalformation,repeatedattemptsat lumbarpuncturesandtumors[3–6].

We report the case of an 82-year-oldpatient under acenocoumarol for atrial ﬁbrillation who presented with paraplegia secondarytoSSH.Thisworkhasbeenreportedinlinewiththe SCAREcriteria[7].

∗Correspondingauthorat:HayRyad,10100,Rabat,Morocco.

E-mailaddresses:[email protected],[email protected](I.Aissa).

2. Casereport

An 82-year-old patient with a history of diabetes mellitus, hypertension,ischemicheart diseaseand atrial ﬁbrillation,was admittedtoemergencydepartmentwithsuddenonsetofparaple- giaandintensebackpainassociatedwithurinaryincontinenceand analsphincterdisorder.

His regular medications were acenocoumarol 2mg / day, ramipril,bisoprolol,furosemide,metforminand simvastatin.No traumaoccurredinthedaysprecedinghisneurologicsymptoms.

Onexamination,hewasconsciousandwelloriented,lethargic, andafebrile.Hisbloodpressurewas150/80mmHg,andheartrate 120beats/min.HislowerlimbpowerwasMRCgrade0outof5in allrangesofmovementbilaterally.Osteo-tendinousreﬂexeswere abolished,and acomplete bilateralanesthesia reachingtheT12 dermatomewasnoted.Theanalsphinctertonewasalsoreduced.

BiologicaltestresultsshowedanInternationalNormalizedRatio (INR)at10,anormallevelofplatelets,andarenalinsufﬁciency

https://doi.org/10.1016/j.ijscr.2019.04.053

org/licenses/by/4.0/).

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16 I.Aissaetal./InternationalJournalofSurgeryCaseReports59(2019)15–18

(urea1.71g/l,creatinine27mg/l).Magneticresonanceimaging (MRI)revealedaposteriorlylocatedspinalhematomaatT12level, measuring36mmwithspinalcordcompression(Fig.1).Therewas notumororunderlyingvascularmalformation.

A pericardial effusion was individualized on Trans-thoracic echocardiographyeffusion(approximately 300ml)along witha septalhypokinesisandleftventricularhypertrophy.

Thepatientreceived10mgofvitaminKintravenouslyand10 unitsof freshfrozenplasma.Afterobtainingan INRof 1.4,the patientwasadmittedtotheoperatingroomforaT11-L1laminec- tomy with evacuation of the subdural hematoma (Fig. 2). The operativeﬁndingsdidnotrevealanyarteriovenousorneoplastic malformation.Attheendofthesurgery,thepatientwastransferred totheintensivecareunitandthentoneurosurgeryward.

Afterconsultationwiththesurgeonand thecardiologist,the anticoagulant treatment was interrupted for 6 days after the surgery and then reintroduced for 72h with heparin sodium in continuous infusion (in order to obtainan activatedpartial thromboplastintimetargetbetween2and3timesthecontrol).

Acenocoumarolwasthenstarted targetinganINRof 2.5 which authorizedstoppingheparininfusion.

Musclepower showeda gradual improvement in the lower limbsestimatedat3/5withregressionofsphincterdisordersbut unfortunately a sequellar sensory impairment persisted. Spinal MRIperformed3weekslatershowedcompleteresolutionofthe hematoma.ThepatientwasthenreferredtothePhysicalRehabili- tationDepartmentforadditionalcare.

3. Discussion

ThehaemorrhagiceventsduetovitaminKantagonists(VKA) representtheleadingcauseofiatrogenichospitalizationinFrance (17,000/year)andthethirdintheUnitedKingdom[8,9].Clinical trials have shown that VKAincreases the risk of majorbleed- ingby0.5%peryearandtheriskofintracranialhemorrhageby approximately0.2%peryear[10].Theeffectivenessofthisthera- peuticclassinthepreventionofthromboemboliceventshasbeen demonstratedinmanystudies,however,theiruserequiresregular biologicalmonitoring.

Severalriskfactorshavebeenassociatedwiththeriskofbleed- ingduringVKAtreatment;overdosagehasbeenclearlyidentiﬁed intheliteratureasamajorriskfactor.Inthecontextofatrialﬁb- rillation,theriskofhaemorrhageincreasesbyafactorof30foran INRgreaterthan4[11].Ageisalsoamajorriskfactor.Therelative riskofintracranialhemorrhagewas2.5(95%CI2.3–9.4)inpatients over85yearsoldcomparedtopatientsagedbetween70–74years [10].InstabilityofINR(pooradherencetotherapy,takingdrugsor foodsinterferingwithAVK)wasalsoreportedasariskfactor[12].

Otherfactorshavebeenimplicated:historyofgastrointestinal haemorrhageor strokeandsomecomorbidities (diabetes,renal failure,severeanemia,recentmyocardialinfarction,presenceof neoplasticpathology)[13]. Somegeneticfactorshavealsobeen reportedrecently[14].Ourpatientassociatedalotofriskfactors includingINRat10,advancedage,diabetesandkidneyfailure.

ThelocalizationofbleedingunderVKAismostoftengastroin- testinal,urinary orcerebral. SSHis anatypicalmanifestation of VKAoverdosage.Domenicucci et al.found thatin 106cases of non-traumaticSSH,35%ofthepatientswereunderanticoagulant therapy [15]. Only a few number of them were onVKA. War- farinismostlyassociatedwithSSH,whileacenocoumarolhasbeen sparselyreported.

SSH is most often located in the thoracic region [16]. The etiopathogenicmechanismsinvolved intheconstitutionof SSH remainsunclear[17–19].Inthesubduralspinalspace,thereare nomajorbloodvesselsincontrastwiththespinalepiduralspace

Fig.1. preoperativeimagesfrom(A).sagittalT2-weightedmagneticresonance imaging (MRI) scan, (B). axial T2-weighted MRI revealed a spinal subdural hematomaatT12(arrows)compressingthemyelumfrombehind.

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I.Aissaetal./InternationalJournalofSurgeryCaseReports59(2019)15–18 17

Fig.2.Intraoperativephotographshowingthespinalsubduralhematoma.

ortheintracranialsubduralspace[18].Atheoryhasbeenraised thathemorrhageoriginatesinthemorevascularizedsubarachnoid space,probablyafterhighintra-abdominalorintrathoracicpres- sure,andthenbreaksthroughtheveryfragilearachnoidmembrane inthesubduralspacewherethehematomaisconstituted.Thisthe- oryseemsunlikelyinourpatientinwhomthesurgicalexploration didnotﬁndanybreak-inofthismembrane.Morandietal.suggest inasimilarsituationthatthesubduralhematomacouldcomefrom smallbrokenvesselsontheinnersurfaceoftheduramater[17].

SSHcanhavea widespectrum ofpresentationrangingfrom spinalpainradiatingsometimestolimbortrunktoacutemotor deﬁcitsdependinguponseverity,rapidityandlevelofcompres- sion[19].Urinaryorfecalincontinencecanbeobserved.However, somecasesweredescribedwithnomotororsensorydeﬁcits[20].

Thesesymptomsmustleadtotherealizationwithoutdelayofa spinalMRIwhichisconsideredtheinvestigationofchoice.Delim- itingtheduramateranddifferentiatingasubduralhematomafrom anepiduralhematomacanbedifﬁcult.Thelatterusuallyappearsas abiconvexlesionwithwidesagittalinsertionbase,whiletheSSH tendstobeagglomeratedandconcave[17].MRIalsodetermines heightextension,and theexistenceofunderlyinglesions.Some authorsrecommendtheuseofspinalangiographywheneveritis availableasitmakesitpossibletosearchforsomepossiblearteri- ovenousﬁstulas,malformationsorvascularaneurisms[19,21].

Treatmentoptionsincludesacorrectionofbleedingdisorders;

VKAshouldbediscontinuedimmediatelyupon suspicion.Rapid antagonismrequirestheadministrationofclottingfactorconcen- tratesorfreshfrozenplasma,andadministrationofvitaminK[22].

ThegoalistobringtheINRtovaluesbelow1.5asquicklyaspossible.

Patientswithmajor deﬁcitsorwithclinicaland radiological aggravation(CT,MRI)shouldbetreatedurgently,evenafterlong compressionofthespinalcord.Insuchcasesearlydecompression bylaminectomywithevacuationofthehematomaisconsideredto bethebesttreatment[23].

Conservativetreatmentmaybediscussedincaseswithmini- malneurologicaldeﬁcits,earlyspontaneousrecovery,orwhenthe generalconditionofthepatientisprecarious[15].Theneurological prognosisofSSHisconditionedbyseveralfactors:thesizeofthe hematoma,theinducedmedullarylesions,theextentoftheinitial deﬁcit,theimportanceoftheoverdosageofVKAandespeciallythe intervalbetweentheonsetofsymptomsanddecompression[2].

Thedecisionofwhetherandwhentoresumeanticoagulation followingableedingeventunderVKAischallengingandrequiresan assessmentofassociatedrisksandbeneﬁts.Apartfromintracere- bralhemorrhage,a48–72-htherapeuticwindowisrecommended [24].

ThepreventionofhaemorrhagicaccidentsunderVKAremains crucial toavoid sucha dramatic situation.It isprimarilybased onthecontinuousinformationandeducationofpatientsallowing betteradherencetotreatment.Ithasbeenclearlydemonstrated thatthemanagementofthesemoleculesbyaspecializedcenterin anticoagulationleadstoabettertherapeuticefficacywithaclear reductioninsideeffects[25].Finally,severalstudieshaveidenti- fiedthatneworalanticoagulantswereanalternativewithalower riskofbleedinginpatientswithatrialfibrillation[26,27].

4. Conclusion

SSHisararesituationwhichshouldbeevokedinanypatient treatedbyVKAwithsignsofspinalcordcompression.MRIisthe imagingexamofchoicetoestablishthediagnosis.Rapidcorrection ofbleeding disordersis required.Sometimes,emergent surgical evacuation of the hematoma is the only therapeutic option to ensureoptimalneurologicalprognosis.Finally,theproceduresfor resuminganticoagulationshouldbesubjecttoamultidisciplinary consultation.

Conﬂictsofinterest

Theauthorsdeclarenoconﬂictsofinterestassociatedwiththis manuscript.

Sourcesoffunding None.

Ethicalapproval

Ethicalapprovalhasbeenexemptedbyourinstitution.

Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Authorcontribution

All authors contributed the perioperative management and writingthispaper.Studydesignandmanuscriptwasperformed byI.Aissa,andotherauthorsreadthismanuscriptandapproved submission.M.Bensghir,H.Balkhi,SJ.Lalaouiweredecidedﬁnal decisionforsubmission,otherauthorsdiscussedthismanuscript together.

Registrationofresearchstudies Thisinnothumanstudy.

Guarantor

DrI.AissaistheGuarantorofthisreportandhasfullresponsi- bilitytoit.

Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed

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