RESUMO
We report two cases of patients who developed cervical epidural hematoma while receiving oral anti-platelet agents and achieved satisfactory outcomes following early diagnosis and treatment. Both patients attained decompression within 12 hours of symptom onset and achieved independent gait at an early stage. Decompression was attained in a shorter amount of time(<6 hours)in case 1, and neurological symptoms rapidly and fully improved immediately following surgery. In contrast, sensory abnormality remained in case 2 despite early decompression(<12 hours.)Although there is a tendency to focus on improving motor function with regards to this condition, we found that the persistence of sensory abnormality affects the patient activities of daily living(ADL)more than expected. Based on these findings, we postulate that the reduction in the time until treatment completion is associated with better functional prognosis in patients who are receiving anti-platelet agents or have advanced motor paralysis.
Assuntos
Hematoma Epidural Craniano , Hematoma Epidural Espinal , Atividades Cotidianas , Descompressão Cirúrgica , Diagnóstico Precoce , Hematoma Epidural Craniano/induzido quimicamente , Hematoma Epidural Craniano/cirurgia , Hematoma Epidural Espinal/induzido quimicamente , Hematoma Epidural Espinal/cirurgia , Humanos , Inibidores da Agregação Plaquetária/efeitos adversosRESUMO
According to our research, this is the first case described in the literature of spontaneous intracranial epidural hematoma secondary to the use of Xareltor. Spontaneous intracranial epidural hematomas are rarely described in the literature. They are associated with infectious diseases of the skull, coagulation disorders, vascular malformations of the dura mater and metastasis to the skull. Long-term post-marketing monitoring and independent reports will probably detect the full spectrum of hemorrhagic complications of the use of rivaroxaban.
Assuntos
Inibidores do Fator Xa/efeitos adversos , Hematoma Epidural Craniano/induzido quimicamente , Rivaroxabana/efeitos adversos , Adulto , Hematoma Epidural Craniano/diagnóstico por imagem , Hematoma Epidural Craniano/cirurgia , Humanos , Masculino , Risco , Tomografia Computadorizada por Raios XRESUMO
Summary According to our research, this is the first case described in the literature of spontaneous intracranial epidural hematoma secondary to the use of Xareltor. Spontaneous intracranial epidural hematomas are rarely described in the literature. They are associated with infectious diseases of the skull, coagulation disorders, vascular malformations of the dura mater and metastasis to the skull. Long-term post-marketing monitoring and independent reports will probably detect the full spectrum of hemorrhagic complications of the use of rivaroxaban.
Resumo Segundo nossa pesquisa, descrevemos o primeiro caso na literatura de hematoma epidural intracraniano espontâneo secundário ao uso de Xareltor. Hematomas epidurais intracranianos espontâneos raramente são descritos na literatura, sendo comumente associados a doenças infecciosas cranianas, distúrbios de coagulação, malformações vasculares da dura-máter e metástases cranianas. A elaboração de relatórios de monitoramento em longo prazo de pós-comercialização e relatórios independentes provavelmente irá detectar o espectro completo de complicações hemorrágicas do uso desse medicamento.
Assuntos
Humanos , Masculino , Adulto , Inibidores do Fator Xa/efeitos adversos , Rivaroxabana/efeitos adversos , Hematoma Epidural Craniano/induzido quimicamente , Tomografia Computadorizada por Raios X , Risco , Hematoma Epidural Craniano/cirurgia , Hematoma Epidural Craniano/diagnóstico por imagemRESUMO
The most serious life-threatening warfarin-associated complications is hemorrhage in CNS structures. Reports of spontaneous spinal epidural hematomas in patients using warfarin, methods of diagnostics and treatment are but few. We describe the first case of warfarin-associated spontaneous spinal epidural hematoma in this country and a literature review of this issue.
Assuntos
Anticoagulantes/efeitos adversos , Hematoma Epidural Craniano/induzido quimicamente , Compressão da Medula Espinal/etiologia , Varfarina/efeitos adversos , Hematoma Epidural Craniano/complicações , Hematoma Epidural Craniano/diagnóstico , Hematoma Epidural Craniano/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Compressão da Medula Espinal/diagnóstico , Compressão da Medula Espinal/cirurgiaRESUMO
The effect of timing in providing dexamethasone treatment after intracerebral hematoma was evaluated in rats with hematoma induced by a subcortical collagenase injection. Male Sprague-Dawley rats (n = 30; body weight, 185 to 230 g) received dexamethasone (1 mg/kg) intraperitoneally at 2 h, 4 h, or 6 h (1 group per time point) after intracerebral collagenase injection, with another dose (1 mg/kg) administered at 24 h after collagenase injection. Neurologic examinations and rotarod treadmill tests were used to evaluate motor behavior before and at 24 and 48 h after intracerebral injection. Rats were euthanized after the last behavioral test. Brains were evaluated for hematoma size, number of penumbral necrotic neurons, neutrophils within the hematoma, and astrocytic response. Compared with the control and other treatment groups, rats treated with dexamethasone at 2 and 24 h after intracerebral collagenase injection scored significantly better on neurologic exams and rotarod tests. Hematoma volume was significantly smaller in all treated groups than in the control group but did not differ between treatment groups. Fewer neutrophils were seen in the perihematoma region of all treated rats compared with controls, but the number of necrotic neurons was decreased significantly only in the group treated with dexamethasone at 2 and 24 h. These results indicate that a 1-mg/kg dose of dexamethasone is beneficial for treatment of intracerebral hemorrhage, particularly if administered early after the hemorrhagic insult.
Assuntos
Anti-Inflamatórios/administração & dosagem , Dexametasona/administração & dosagem , Hematoma Epidural Craniano/tratamento farmacológico , Hemorragias Intracranianas/tratamento farmacológico , Animais , Encéfalo/efeitos dos fármacos , Encéfalo/patologia , Colagenases/administração & dosagem , Colagenases/toxicidade , Modelos Animais de Doenças , Hematoma Epidural Craniano/induzido quimicamente , Hematoma Epidural Craniano/patologia , Injeções Intraperitoneais , Injeções Intraventriculares , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/patologia , Masculino , Atividade Motora/efeitos dos fármacos , Atividade Motora/fisiologia , Necrose/induzido quimicamente , Necrose/patologia , Neurônios/efeitos dos fármacos , Neurônios/patologia , Neutrófilos/efeitos dos fármacos , Neutrófilos/patologia , Ratos , Ratos Sprague-Dawley , Teste de Desempenho do Rota-Rod/métodos , Fatores de TempoRESUMO
Trauma and emergency department clinicians encounter a growing number of patients admitted with traumatic head injury on prehospital antithrombotic therapies. These patients appear to be at increased risk of developing life-threatening intracranial hemorrhage. It is imperative that trauma clinicians understand the mechanism and duration of commonly prescribed outpatient antithrombotics in order to appropriately assess and treat patients who develop intracranial hemorrhage. This review summarizes current literature on the morbidity and mortality associated with premorbid non-steroidal anti-inflammatory drugs, aspirin, clopidogrel, warfarin, and heparinoids in the setting of traumatic head injury, and also examines the current strategies for reversal of these therapies.
Assuntos
Anticoagulantes/efeitos adversos , Lesões Encefálicas/complicações , Hemorragia Cerebral Traumática/induzido quimicamente , Serviços Médicos de Emergência , Hemostáticos/uso terapêutico , Inibidores da Agregação Plaquetária/efeitos adversos , Idoso , Anticoagulantes/administração & dosagem , Lesões Encefálicas/tratamento farmacológico , Lesões Encefálicas/mortalidade , Hemorragia Cerebral Traumática/tratamento farmacológico , Hemorragia Cerebral Traumática/mortalidade , Terapia Combinada , Cuidados Críticos , Desamino Arginina Vasopressina/administração & dosagem , Fator VIIa/administração & dosagem , Hematoma Epidural Craniano/induzido quimicamente , Hematoma Epidural Craniano/tratamento farmacológico , Hematoma Epidural Craniano/mortalidade , Hematoma Subdural/induzido quimicamente , Hematoma Subdural/tratamento farmacológico , Hematoma Subdural/mortalidade , Mortalidade Hospitalar , Humanos , Pessoa de Meia-Idade , Plasma , Inibidores da Agregação Plaquetária/administração & dosagem , Transfusão de Plaquetas , Protaminas/administração & dosagem , Proteínas Recombinantes/administração & dosagem , Fatores de Risco , Vitamina K 1/administração & dosagemRESUMO
Spontaneous spinal epidural hematoma is an uncommon cause of spinal cord compression. It may be associated with various causative factors, but in many patients, anticoagulation can be implicated. It is noteworthy that many of the reported cases were anticoagulated in the therapeutic range. Spontaneous spinal epidural hematoma should be suspected in any patient receiving anticoagulant agents who complains of local or referred spinal pain associated with limb weakness, sensory deficits, or urinary retention. Early diagnosis and treatment are very important for the functional recovery of the patient. Spinal magnetic resonance imaging is the most suitable neuroradiological method for early diagnosis. Although primary management is the surgical evacuation of the spinal epidural hematoma via laminectomy, rare cases in which the patient is improving rapidly and progressively could be treated conservatively. A 22-yr-old man with a spontaneous spinal epidural hematoma who was receiving warfarin treatment for a mechanical aortic valve is presented in this article.
Assuntos
Anticoagulantes/efeitos adversos , Hematoma Epidural Craniano/induzido quimicamente , Varfarina/efeitos adversos , Adulto , Descompressão Cirúrgica , Hematoma Epidural Craniano/diagnóstico , Hematoma Epidural Craniano/reabilitação , Hematoma Epidural Craniano/cirurgia , Humanos , Laminectomia , Imageamento por Ressonância Magnética , Masculino , Retenção Urinária/etiologiaRESUMO
BACKGROUND: Despite the high risk of venous thromboembolic events (VTE) in neuro-surgical patients, heparin prophylaxis has not been routinely established due to concern about bleeding complications. After initiating early low molecular weight heparin (LMWH) prophylaxis, we reviewed our patients in order to examine the viability of this practice. METHOD: Over a 3 year period, the records of patients admitted for elective neuro-surgery (ES), head injury (HI) or spontaneous intracranial haemorrhage (ICH) were analysed. Prophylaxis was performed with certoparin (3000 U anti-factor Xa s.c.) on the evening before ES and within 24 hours after surgery or admission whenever a CT did not show a progressive haematoma. Contraindications for LMWH were prothrombin time <70%, partial thrombo-plastin time >40 s, platelet count <100.000/ml, and platelet aggregation test sum <60%. The incidence of bleeding complications, VTE, and resulting morbidity/mortality was assessed. FINDINGS: 294 patients were admitted for ES, 344 for HI, and 302 for ICH. 155 of these were excluded because of contraindications. Intracranial bleeding was recorded in 1.5% (ES 1.1%, HI 3.5%, ICH 0%) and operative revision was performed in 1.1% (ES 0.7%, HI 2.8%) of patients. One case of moderate disability and no mortality occurred. The incidence of VTE and pulmonary embolism was documented in 0.2% and 0.1% of patients, with no associated mortality. No heparin induced thrombocytopenia was observed. INTERPRETATION: In neurosurgical patients, antithrombotic prophylaxis with certoparin was determined to be safe and efficacious when contraindications are carefully considered and a 12-hour time interval before and after surgery was guaranteed. This retrospective analysis should encourage a prospective trial of early LMWH prophylaxis.
Assuntos
Lesões Encefálicas/cirurgia , Neoplasias Encefálicas/cirurgia , Derivações do Líquido Cefalorraquidiano , Fibrinolíticos/administração & dosagem , Heparina de Baixo Peso Molecular/administração & dosagem , Hemorragias Intracranianas/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Pré-Medicação , Neoplasias da Coluna Vertebral/cirurgia , Tromboembolia/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Encefálicas/secundário , Contraindicações , Avaliação da Deficiência , Feminino , Fibrinolíticos/efeitos adversos , Hematoma Epidural Craniano/induzido quimicamente , Hematoma Epidural Craniano/diagnóstico por imagem , Hematoma Epidural Craniano/cirurgia , Hematoma Subdural/induzido quimicamente , Hematoma Subdural/diagnóstico por imagem , Hematoma Subdural/cirurgia , Heparina de Baixo Peso Molecular/efeitos adversos , Humanos , Injeções Subcutâneas , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/induzido quimicamente , Complicações Pós-Operatórias/diagnóstico por imagem , Reoperação , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
Spinal epidural hematoma is a rare complication of thrombolytic therapy (only 9 cases described in the literature). We report the case of a 59-year-old female with hypertension, admitted to the coronary care unit for acute inferior myocardial infarction and treated with tissue-type plasminogen activator 100 mg in 90 min, intravenous heparin 25,000 U, aspirin 100 mg, and metoprolol 50 mg orally once daily. On the third day she suffered from sudden and violent dorsal pain, followed 22 hours later by paraplegia. Magnetic resonance imaging showed a large posterior spinal epidural hematoma, with compression and anterior dislocation of the spinal cord. The patient underwent neurosurgery. After 1 year, she still cannot walk. In patients treated with thrombolytic therapy and presenting with sudden and violent spinal pain, the physician should take into consideration the diagnosis of epidural hemorrhage. Early neurosurgery can save the patient and facilitate neurological recovery.
Assuntos
Aspirina/efeitos adversos , Fibrinolíticos/efeitos adversos , Hematoma Epidural Craniano/induzido quimicamente , Heparina/efeitos adversos , Quimioterapia Combinada , Feminino , Hematoma Epidural Craniano/cirurgia , Humanos , Pessoa de Meia-Idade , Medula Espinal , Resultado do TratamentoRESUMO
The authors describe a case of epidural hematoma in association with dextran infusion in a patient who had undergone a peripheral vascular operation with epidural analgesia. Possible mechanisms for the anticoagulant effect of dextran and guidelines for the use of anticoagulant therapy in patients undergoing epidural anesthesia are discussed.
Assuntos
Anestesia Epidural/efeitos adversos , Anticoagulantes/efeitos adversos , Dextranos/efeitos adversos , Hematoma Epidural Craniano/induzido quimicamente , Idoso , Anestesia Epidural/métodos , Anestesia Geral/métodos , Anticoagulantes/administração & dosagem , Descompressão Cirúrgica , Dextranos/administração & dosagem , Drenagem , Monitoramento de Medicamentos , Emergências , Feminino , Oclusão de Enxerto Vascular/prevenção & controle , Hematoma Epidural Craniano/diagnóstico , Hematoma Epidural Craniano/cirurgia , Humanos , Infusões Intravenosas , Claudicação Intermitente/cirurgia , Laminectomia , Dor Lombar/induzido quimicamente , Imageamento por Ressonância Magnética , Doenças Vasculares Periféricas/cirurgia , Compressão da Medula Espinal/induzido quimicamente , Tomografia Computadorizada por Raios XRESUMO
Two aged women suddenly suffered from severe cervical and back pain followed by ipsilateral hemiparesis sparing the face. One woman had taken anticoagulant for prosthetic mitral valve and another had taken antiplatelet for prevention of recurrent brain infarction. On admission, MRI did not document any definite lesions in the brain, and revealed epidural hematoma compressing the cervical spinal cord for both patients. We promptly stopped their anticoagulants and antiplatelets use, because the agents seemed to be the leading cause of hematoma. In addition, we performed emergent laminectomy and evacuation of hematoma for the former patient. These cases suggest dual warnings against recently prevalent antithrombotic therapy for patients with histories of thromboembolic accidents. First, we should be careful about spinal epidural hematoma as a hemorrhagic complication of antithrombotic therapy. Second, we should not misdiagnose spinal epidural hematoma as ischemic stroke nor select hyperacute thrombolytic therapy. Cervical pain and hemiparesis sparing face are important signs for distinction of spinal epidural hematoma from stroke.
Assuntos
Anticoagulantes/efeitos adversos , Infarto Encefálico/prevenção & controle , Fibrinolíticos/efeitos adversos , Hematoma Epidural Craniano/induzido quimicamente , Terapia Trombolítica/efeitos adversos , Doença Aguda , Idoso , Feminino , Implante de Prótese de Valva Cardíaca , Humanos , Estenose da Valva Mitral/tratamento farmacológico , Estenose da Valva Mitral/cirurgiaAssuntos
Acenocumarol/efeitos adversos , Anticoagulantes/efeitos adversos , Hematoma Epidural Craniano/induzido quimicamente , Traumatismos da Medula Espinal/induzido quimicamente , Acenocumarol/uso terapêutico , Anticoagulantes/uso terapêutico , Valva Aórtica/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Próteses Valvulares Cardíacas , Hematoma Epidural Craniano/diagnóstico , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Traumatismos da Medula Espinal/diagnósticoRESUMO
Spinal epidural haematoma is an uncommon, but recognised, clinical entity that needs emergency management. The association of spinal epidural haematomata with warfarin therapy has been described and, in 1956, Alderman stated that this diagnosis should be entertained in any patient receiving anticoagulants presenting with low back pain or sciatic pain. The purpose of this case report is to increase the awareness of this entity among medical personnel and to stress the urgency of management.
Assuntos
Anticoagulantes/efeitos adversos , Hematoma Epidural Craniano/induzido quimicamente , Varfarina/efeitos adversos , Emergências , Feminino , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-IdadeRESUMO
Patients who receive thrombolytic therapy are at risk of central nervous system (CNS) hemorrhage, and this diagnosis must be sought in any patient who develops neurologic complaints after thrombolysis and anticoagulation. Early imaging and neurosurgical consultation are essential to improve outcome after hemorrhage occurs. We describe a patient who developed spinal epidural hematoma (SEH) after thrombolysis and anticoagulation for acute myocardial infarction. Delay in diagnosis and management may have contributed to a poor outcome. The literature on SEH is reviewed, and approaches to improve the prognosis of patients suffering CNS hemorrhage after thrombolysis are discussed.
Assuntos
Fibrinolíticos/efeitos adversos , Hematoma Epidural Craniano/induzido quimicamente , Medula Espinal/patologia , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Hematoma Epidural Craniano/cirurgia , Humanos , Laminectomia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/tratamento farmacológico , Medula Espinal/cirurgiaRESUMO
The case of a 43-year-old Taiwanese man who presented with spinal epidural hematoma following intravenous administration of recombinant tissue plasminogen activator (rTPA) and heparin therapy for acute myocardial infarction (AMI) is reported. Upper back pain and progressive neurological dysfunction ensued, secondary to spinal epidural hematoma with spinal cord compression. The patient did not recover neurologic function postsurgically, possibly because the operation was delayed. In conclusion, cardiologists should be alert to this rare, severe complication of rTPA and should perform early laminectomy (in < or = 36 hours for those with complete deficit and in < or = 48 hours for those with incomplete deficit) if possible.
Assuntos
Hematoma Epidural Craniano/induzido quimicamente , Heparina/efeitos adversos , Infarto do Miocárdio/tratamento farmacológico , Ativador de Plasminogênio Tecidual/efeitos adversos , Adulto , Heparina/administração & dosagem , Humanos , Masculino , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/efeitos adversos , Doenças da Medula Espinal/induzido quimicamente , Ativador de Plasminogênio Tecidual/administração & dosagemRESUMO
In patients who receive co-administered low-molecular-weight heparin (LMWH) and continuous epidural analgesia (CEA) after orthopedic surgery, there is concern about an increased risk of a spinal epidural hematoma. The practice of twice-daily LMWH dosing in North America might, in part, account for the greater number of epidural hematomas reports compared to Europe where once-daily LMWH is used. We performed a prospective cohort study in patients who had orthopedic surgery and received co-administered LMWH and CEA. We investigated the trough anticoagulant effect, as measured by an anti-Xa heparin level, at the time of epidural catheter removal in patients who received twice-daily or once-daily LMWH. Twenty-five patients who received enoxaparin, 30 mg twice-daily, and 25 patients who received dalteparin, 5,000 IU once-daily, had anti-Xa heparin levels measured on the second or third post-operative day at the time of epidural catheter removal. In patients who received twice-daily enoxaparin, or once-daily dalteparin, the anti-Xa heparin level was measured, on average, 10.4 h and 21.8 h, respectively, after the preceding LWMH dose. All 25 patients who received once-daily LMWH had an anti-Xa heparin level < 0.10 U/ml at the time of catheter removal. Of 25 patients who received twice-daily LMWH, the anti-Xa heparin level at the time of catheter removal was > or = 0.20 U/ml in 5 patients (P = 0.050), and > or = 0.10 U/ml in 7 patients (P = 0.009). We conclude that in patients who are receiving co-administered LMWH and CEA after orthopedic surgery, twice-daily but not once-daily LMWH administration is more likely to be associated with a clinically important anticoagulant effect at the time of epidural catheter removal.
Assuntos
Analgesia Epidural/métodos , Fator X/antagonistas & inibidores , Heparina de Baixo Peso Molecular/administração & dosagem , Procedimentos Ortopédicos , Idoso , Cateteres de Demora , Estudos de Coortes , Dalteparina/administração & dosagem , Dalteparina/sangue , Quimioterapia Combinada , Enoxaparina/administração & dosagem , Enoxaparina/sangue , Feminino , Hematoma Epidural Craniano/induzido quimicamente , Heparina de Baixo Peso Molecular/sangue , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios , Estudos ProspectivosAssuntos
Hematoma Epidural Craniano/induzido quimicamente , Hemorragia/induzido quimicamente , Heparina/efeitos adversos , Pneumopatias/induzido quimicamente , Embolia Pulmonar/tratamento farmacológico , Escoliose/cirurgia , Adolescente , Evolução Fatal , Feminino , Heparina/uso terapêutico , Humanos , Complicações Pós-Operatórias/tratamento farmacológico , Embolia Pulmonar/etiologiaRESUMO
This is the first reported case in the emergency medicine literature of a drug interaction between warfarin and fluconazole. We present a case of spinal epidural haematoma and summarize four other case reports reported elsewhere from 1988 to 1996. We admonish emergency physicians to be aware of this dangerous drug combination. Warfarin and fluconazole are frequently encountered drugs in the emergency department and thus any interaction between these drugs is of considerable importance.