A decade of experience in over 300 surgically treated spine patients with long-term oral anticoagulation: a propensity score matched cohort study.

PURPOSE: The aim of this study was to investigate the risks and outcomes of patients with long-term oral anticoagulation (OAC) undergoing spine surgery. METHODS: All patients on long-term OAC who underwent spine surgery between 01/2005 and 06/2015 were included. Data were prospectively collected within our in-house Spine Surgery registry and retrospectively supplemented with patient chart and administrative database information. A 1:1 propensity score-matched group of patients without OAC from the same time interval served as control. Primary outcomes were post-operative bleeding, wound complications and thromboembolic events up to 90 days post-surgery. Secondary outcomes included intraoperative blood loss, length of hospital stay, death and 3-month post-operative patient-rated outcomes. RESULTS: In comparison with the control group, patients with OAC (n = 332) had a 3.4-fold (95%CI 1.3-9.0) higher risk for post-operative bleeding, whereas the risks for wound complications and thromboembolic events were comparable between groups. The higher bleeding risk was driven by a higher rate of extraspinal haematomas (3.3% vs. 0.6%; p = 0.001), while there was no difference in epidural haematomas and haematoma evacuations. Risk factors for adverse events among patients with OAC were mechanical heart valves, posterior neck surgery, blood loss > 1000 mL, age, female sex, BMI > 30 kg/m2 and post-operative PTT levels. At 3-month follow-up, most patients reported favourable outcomes with no difference between groups. CONCLUSION: Although OAC patients have a higher risk for complications after spine surgery, the risk for major events is low and patients benefit similarly from surgery.

Painful shoulder in a patient receiving anticoagulation therapy with rivaroxaban. / Hombro doloroso en paciente anticoagulado con rivaroxabán.

We report the case of an 83-year-old man on rivaroxaban treatment, with pain in right shoulder, back of the upper arm, forearm and wrist, and inability to extend the wrist and fingers, as the result of an injury. The radiographs were normal, but thoracic CT showed an axillary artery pseudoaneurysm and a secondary hematoma that compressed the brachial plexus. This should be borne in mind in patients with painful shoulder, treated with anticoagulant therapy and without associated radiographic changes.

Hematoma location and morphology of anticoagulation-associated intracerebral hemorrhage.

OBJECTIVE: To study hematoma location and morphology of intracerebral hemorrhage (ICH) associated with oral anticoagulants (OAC) and delineate causes and mechanism. METHODS: We performed a systematic literature research and meta-analysis of studies comparing neuroimaging findings in patients with OAC-ICH compared to those with ICH not associated with OAC (non-OAC ICH). We calculated pooled risk ratios (RRs) for ICH location using the Mantel-Haenszel random-effects method and corresponding 95% confidence intervals (95% CI). RESULTS: We identified 8 studies including 6,259 patients (OAC-ICH n = 1,107, pooled OAC-ICH population 17.7%). There was some evidence for deep ICH location (defined as ICH in the thalamus, basal ganglia, internal capsule, or brainstem) being less frequent in patients with OAC-ICH (OAC-ICH: 450 of 1,102/40.8% vs non-OAC ICH: 2,656 of 4,819/55.1%; RR 0.94, 95% CI 0.88-1.00, p = 0.05, I 2 = 0%) while cerebellar ICH location was significantly more common in OAC-ICH (OAC-ICH: 111 of 1,069/10.4% vs non-OAC ICH: 326 of 4,787/6.8%; RR 1.45, 95% CI 1.12-1.89, p = 0.005, I 2 = 21%) compared to non-OAC ICH. There was no statistically significant relationship to OAC use for lobar (OAC-ICH: 423 of 1,107/38.2% vs non-OAC ICH: 1,884 of 5,152/36.6%; RR 1.02, 95% CI 0.89-1.17, p = 0.75, I 2 = 53%, p for heterogeneity = 0.04) or brainstem ICH (OAC-ICH: 36 of 546/6.6% vs non-OAC ICH: 172 of 2,626/6.5%; RR 1.04, 95% CI 0.58-1.87, p = 0.89, I 2 = 59%, p for heterogeneity = 0.04). The risk for intraventricular extension (OAC-ICH: 436 of 840/51.9% vs non-OAC ICH: 1,429 of 3,508/40.7%; RR 1.26, 95% CI 1.16-1.36, p < 0.001, I 2 = 0%) was significantly increased in patients with OAC-ICH. We found few data on ICH morphology in OAC-ICH vs non-OAC ICH. CONCLUSION: The overrepresentation of cerebellar ICH location and intraventricular extension in OAC-ICH might have mechanistic relevance for the underlying arteriopathy, pathophysiology, or bleeding pattern of OAC-ICH, and should be investigated further.

Rare case of losartan-induced cough complicated by rectus sheath haematoma: in a patient on rivaroxaban therapy.

Spontaneous rectus sheath haematomas and cough secondary to losartan are individually rare conditions. Abdominal wall haematomas present with abdominal pain and abdominal mass. Most patients are managed conservatively; Surgery or embolisation is indicated for shock, infection, rupture into the peritoneum or intractable pain. This is a man aged 65 years presented with dry cough and right-sided abdominal pain. He started losartan a few weeks prior to the onset of cough and had been on rivaroxaban for prior deep venous thrombosis. The right side of his abdomen was distended, bruised and tender. His haemoglobin dropped from 13.3to 9.5 g/dL. CT abdomen/pelvis showed a large 14.5×9.1×4.5 cm haematoma within the right lateral rectus muscle. His only risk factor for developing rectus sheath haematoma was cough in the setting of anticoagulation. Dry cough due to angiotensin receptor blockers is rare, but can have very serious consequences.

Intracerebral Hematoma Occurring During Warfarin Versus Non-Vitamin K Antagonist Oral Anticoagulant Therapy.

The neuroradiological findings and its outcomes of intracerebral hemorrhage (ICH) were compared between the non-vitamin K antagonist oral anticoagulant (NOAC) therapy and warfarin therapy. In the latest 3 years, 13 cases of nonvalvular atrial fibrillation on NOAC therapy were admitted for ICH. For comparison, 65 age- and gender-comparable patients with ICH on warfarin therapy were recruited. Three NOACs had been prescribed: dabigatran (n = 4), rivaroxaban (n = 2), and apixaban (n = 7). The average ages were 76 ± 9 and 78 ± 8 years in the warfarin (n = 65) and NOAC groups (n = 13), respectively. There was no difference in the clinical features, including the CHADS2 score or HAS-BLED score: 2.62 ± 1.31 versus 2.62 ± 1.33, or 1.09 ± 0.43 versus 1.00 ± 0.41, for the warfarin and NOAC groups, respectively. The volume of ICH <30 ml was found in 84.6% of the patients on NOACs, but it was found in 53.8% of the patients on warfarin (p = 0.0106). The expansion of hematoma was limited to 7 patients (10.8%) of the warfarin group. A lower hospital mortality and better modified Rankin Scale were observed in the NOAC group than in the warfarin group: 1 (7.7%) versus 27 (41.5%; p = 0.0105) and 3.2 ± 1.4 versus 4.5 ± 1.6 (p = 0.0057), respectively. In conclusion, ICH on NOAC therapy had smaller volume of hematoma with reduced rate of expansion and decreased mortality compared with its occurrence on warfarin.

Spontaneous rectus sheath hematoma during rivaroxaban therapy.

Rivaroxaban is an oral anticoagulant agent that directly inhibits Factor Xa and interrupts both the intrinsic and extrinsic pathway of the coagulation cascade and is currently indicated for use in patients for atrial fibrillation and prophylaxis of deep venous thrombosis. The present case reports of spontaneous rectus sheath hematoma during rivaroxaban therapy for atrial fibrillation in a 75-year-old woman.

Treatment with novel oral anticoagulants in a real-world cohort of patients undergoing cardiac rhythm device implantations.

AIMS: The safety and efficacy of novel oral anticoagulants in patients with atrial fibrillation undergoing pacemaker or implantable cardioverter-defibrillator interventions have not been clearly defined. Therefore, we compared the incidence of bleeding and thrombo-embolic complications following cardiac rhythm device (CRD) implantations under dabigatran vs. rivaroxaban in a real-world cohort. METHODS AND RESULTS: We analysed 176 consecutive procedures performed in 93 patients treated peri-interventionally with dabigatran and 83 patients with rivaroxaban, respectively. Post-operative bleeding complications and thrombo-embolic events occurring within 30 days were compared. There were no significant differences in baseline characteristics between patients in the dabigatran and the rivaroxaban group. Most of the patients in both the groups received dual chamber or cardiac resynchronization devices (71 vs. 78%) as opposed to single-chamber systems (29 vs. 22%). In the dabigatran group, two (2%) bleeding complications (two pocket haematomas) were observed in comparison with four (5%, three pocket haematomas and one pericardial effusion) in the rivaroxaban group (P = 0.330). Three complications in the rivaroxaban group necessitated surgical intervention as opposed to none in the dabigatran group (P = 0.064). One case of a transient ischaemic attack occurred in the dabigatran group (P = 0.343). CONCLUSION: Bleeding and thrombo-embolic complications in patients treated with dabigatran or rivaroxban are rare. Further and larger studies are warranted to define the optimal anticoagulation management in patients with a need for oral anticoagulation and CRD interventions.

How safe is thromboprophylaxis in abdominoplasty?

BACKGROUND: Deep vein thrombosis and its most dangerous outcome, pulmonary embolism, are complications with a high incidence in hospitalized patients. In plastic surgery, abdominoplasty is the aesthetic surgery more frequently associated with deep vein thrombosis condition. This study aimed to test the efficacy and safety of oral rivaroxaban for the prevention of venous thromboembolism after abdominoplasty in patients considered to be at risk. METHODS: In a randomized, double-blind study, 40 patients undergoing abdominoplasty were assigned to receive either oral rivaroxaban (10 mg) or oral placebo once daily for 10 days, beginning 6 to 8 hours after surgery. RESULTS: The study was interrupted after 27 operations due to systematic complications. The population operated on was composed of women with a mean age of 38 years. Most patients were Caucasian (85 percent) and had a mean body mass index of 28. The average overall rate of complications was 29.6 percent (large hematomas requiring drainage), and all complications were seen in the study group, with none in the control group. CONCLUSIONS: Plastic surgery procedures in which large detachment is planned in patients with a moderate risk of deep venous thrombosis should be evaluated with regard to the risk and benefit of thromboembolism prophylaxis. Other measures must be applied and eventually contraindicate a surgical procedure. Further research is needed to complement the data from this work.

Acquired haemophilia complicated with gastrointestinal bleeding and spontaneous iliopsoas muscle haematoma in a woman with chronic C hepatitis under treatment with pegylated IFN alpha 2a and ribavirin.

Acquired haemophilia A is a very rare (1-2 cases per million people) but often life-threatening haemorrhagic disorder characterized by antibodies directed against coagulation factor VIII. We report the case of a 55-year old woman under treatment with Pegylated alpha 2a interferon (IFN) and Ribavirin for chronic viral C hepatitis, who developed a progressive severe haemorrhagic syndrome diagnosed as acquired haemophilia based on supplementary laboratory data (prolonged activated partial thromboplastin time, extremely low factor VIII level - 1%, high titre of factor VIII inhibitor - 30 Bethesda U/ml).The onset was insidious, about three months before presenting to our unit. Antiviral therapy had been stopped three weeks before current admission. Emergency intensive treatment included: haemostatic agents - rFVII (Novoseven), FEIBA (Factor VIII Inhibitor Bypassing Activity), vitamin K, adrenostazin, cryoprecipitate, fresh frozen plasma, as well as immunosuppressive therapy (high dose corticotherapy and cyclophoshamide), immunoglobulins (Humaglobin), prophylactic PPI and antibiotics. The evolution was slowly favourable with the remission of the haemorrhagic syndrome and regression of the iliopsoas muscle haematoma. Clinicians should be aware that acquired forms of haemophilia do exist, representing a rare diagnosis and a therapeutic challenge. To our knowledge, this is the first reported case of acquired haemophilia in Romania, in a patient with chronic viral C hepatitis under antiviral treatment.

Transient stabbing headache from an acute thalamic hemorrhage.

Stabbing headache can be encountered in both primary and secondary forms, but has been infrequently reported among patients with stroke, and is not known to be associated with a small well-circumscribed brain lesion. A 95-year-old woman taking warfarin presented with the sudden onset of stabbing headache strictly in the right frontal and supraorbital regions, along with gait imbalance and dysarthria. Neuroimaging revealed a small left thalamic hematoma. This association of an acute thalamic lesion with stabbing headache in the contralateral trigeminal distribution is discussed, along with a brief review of stabbing headache occurring in cerebrovascular disease.

Interaction between warfarin and the herbal product Shengmai-yin: a case report of intracerebral hematoma.

A 71-year-old man was stable on warfarin (2.25 mg daily) therapy with an international normalized ratio (INR) of 1.8-2.2 after a heart valve replacement surgery. Recently, he consumed the liquid-like herbal product called shengmai-yin (10 mL daily) against medical advice. Seven days after the daily consumption of shengmai-yin, he was admitted to the intensive care unit because of consciousness disturbance [Glasgow Coma Scale (GCS) score 7] with an INR of 5.08. Head computed topography revealed intracerebral hematoma in the left temporoparietal region. Both warfarin therapy and the herbal product were withdrawn. At the same time, therapy with intravenous vitamin K1 40 mg was started. On the second day of admission, craniectomy was performed to remove the intacerebral hematoma under general anesthesia. He remained confused and restless for 2 days, but then showed progressive recovery in the consciousness level as well as motor and verbal functions. Shengmai-yin contains herbal ingredients that can interact with warfarin. The Drug Interaction Probability Scale (DIPS) indicated that warfarin and shengmai-yin were highly probable causes of intracerebral hematoma. Patients on warfarin therapy should be discouraged from taking herbal medicines, especially preparations that are already known to have antiplatelet and antithrombotic effects.

Síndrome dolorosa miofascial do músculo psoas: complicação do tratamento intervencionista: relato de caso / Psoas muscle miofascial painful syndrome: complication of the interventional treatment: case report

JUSTIFICATIVA E OBJETIVOS: A infiltração anestésica do músculo psoas para tratamento da síndrome dolorosa miofascial apresenta reconhecida eficácia, tendo como complicações estabelecidas a infecção local e o hematoma. O objetivo do presente estudo foi relatar um caso de síndrome dolorosa miofascial do músculo psoas com complicação decorrente do tratamento intervencionista.RELATO DO CASO: Paciente do sexo feminino, 49 anos, com queixa de dor lombar e abdominal há cinco anos, com piora há dois anos. Na consulta relatou dor lombar, com irradiação para a região inguinal esquerda, contínua, com intensidade 8 pela escala analógica visual (EAV), apesar do uso de fórmula contendo fluoxetina, meloxicam e amitriptilina. A hipótese diagnóstica foi de síndrome dolorosa miofascial do psoas, sendo realizada infiltração anestésica do músculo, com alívio imediato e completo da dor. Dezoito dias após o procedimento a paciente apresentou dor de intensidade 6 e com história clínica compatível com hematoma subagudo. Trinta e cinco dias após o primeiro exame, a ressonância nuclear magnética (RNM) mostrou regressão total da coleção intramuscular, com persistência apenas de tênue área de edema e realce mio-fibrilar. Realizou-se infiltração muscular com toxina botulínica medicamentosa com duloxetina (60 mg/dia), sendo obtida a remissão total do quadro doloroso. CONCLUSÃO: O caso mostrou a eficácia da infiltração do músculo psoas com anestésico local e corticoide como medida terapêutica indicada para relaxamento muscular imediato, com desativação dos pontos-gatilho e consequente alívio da dor, acelerando assim o processo de recuperação e mostrou que o hematoma é uma complicação que pode ser resolvida com tratamento clínico.

BACKGROUND AND OBJECTIVES: Anesthetic infiltration of the psoas muscle to treat painful myofascial syndrome is recognized as effective and has as established complications local infection and hematoma. This study aimed at reporting a case of psoas muscle painful myofascial syndrome with a complication caused by the interventional treatment.CASE REPORT: Female patient, 49 years old, with lumbar and abdominal pain complaint for five years which has worsened in the last two years. Patient reported lumbar pain, with irradiation to the left inguinal region, continuous, with intensity 8 according to visual analog scale (VAS), in spite of using a formula with fluoxetine, meloxicam and amitriptyline. Diagnostic hypothesis was painful psoas myofascial syndrome. The muscle was infiltrated with anesthetics with immediate and complete pain relief. Eighteen days after the procedure, patient presented pain of intensity 6 and with clinical history compatible with sub-acute hematoma. Thirty-five days after the first exam, MRI has shown total regression of the intramuscular collection with persistence of just a subtle area of edema and myo-fibrillary enhancement. Muscle was infiltrated with botulinic toxin drug with duloxetine (60 mg/day), with total remission of pain. CONCLUSION: This case has shown the efficacy of infiltrating the psoas muscle with local anesthetics and steroid as therapeutic measure indicated for immediate muscle relaxation, with deactivation of trigger-points and consequent pain relief, thus accelerating the recovery process, and has shown that hematoma is a complication which may be solved with clinical treatment

Interaction between Warfarin and the Herbal Product Shengmai-Yin: A Case Report of Intracerebral Hematoma

A 71-year-old man was stable on warfarin (2.25 mg daily) therapy with an international normalized ratio (INR) of 1.8-2.2 after a heart valve replacement surgery. Recently, he consumed the liquid-like herbal product called shengmai-yin (10 mL daily) against medical advice. Seven days after the daily consumption of shengmai-yin, he was admitted to the intensive care unit because of consciousness disturbance [Glasgow Coma Scale (GCS) score 7] with an INR of 5.08. Head computed topography revealed intracerebral hematoma in the left temporoparietal region. Both warfarin therapy and the herbal product were withdrawn. At the same time, therapy with intravenous vitamin K1 40 mg was started. On the second day of admission, craniectomy was performed to remove the intacerebral hematoma under general anesthesia. He remained confused and restless for 2 days, but then showed progressive recovery in the consciousness level as well as motor and verbal functions. Shengmai-yin contains herbal ingredients that can interact with warfarin. The Drug Interaction Probability Scale (DIPS) indicated that warfarin and shengmai-yin were highly probable causes of intracerebral hematoma. Patients on warfarin therapy should be discouraged from taking herbal medicines, especially preparations that are already known to have antiplatelet and antithrombotic effects.

Interaction between Warfarin and the Herbal Product Shengmai-Yin: A Case Report of Intracerebral Hematoma

A 71-year-old man was stable on warfarin (2.25 mg daily) therapy with an international normalized ratio (INR) of 1.8-2.2 after a heart valve replacement surgery. Recently, he consumed the liquid-like herbal product called shengmai-yin (10 mL daily) against medical advice. Seven days after the daily consumption of shengmai-yin, he was admitted to the intensive care unit because of consciousness disturbance [Glasgow Coma Scale (GCS) score 7] with an INR of 5.08. Head computed topography revealed intracerebral hematoma in the left temporoparietal region. Both warfarin therapy and the herbal product were withdrawn. At the same time, therapy with intravenous vitamin K1 40 mg was started. On the second day of admission, craniectomy was performed to remove the intacerebral hematoma under general anesthesia. He remained confused and restless for 2 days, but then showed progressive recovery in the consciousness level as well as motor and verbal functions. Shengmai-yin contains herbal ingredients that can interact with warfarin. The Drug Interaction Probability Scale (DIPS) indicated that warfarin and shengmai-yin were highly probable causes of intracerebral hematoma. Patients on warfarin therapy should be discouraged from taking herbal medicines, especially preparations that are already known to have antiplatelet and antithrombotic effects.

Preoperative use of alpha tocopherol does not increase the risk of hematoma in the face lift patient: a preliminary report.

BACKGROUND: Antiplatelet therapy and nutritional supplements are factors that may increase the risk of hematoma after routine face lift. This has led to the often-repeated instruction "do not take any vitamins, herbs, aspirin, and any medications that may increase bleeding for 10 days before your face lift operation." At odds and diametrically opposed to this goal is combating the increased risk of deep venous thrombosis and venous thromboembolism associated with surgery. METHODS: On the basis of clinical observations, the author has incorporated the routine use of preoperative oral alpha tocopherol (vitamin E) into his preoperative instructions. The cohort included 146 patients scheduled for elective face lift enrolled in this study from February of 2007 to April of 2008. Aspirin and clopidogrel were stopped before surgery. Patients were instructed to take 400 IU of alpha tocopherol daily 3 weeks before surgery. RESULTS: No hematoma developed in any of the 146 patients. The time for routine drainage was not prolonged. No clinically evident case of deep vein thrombosis or venous thromboembolism occurred. The clinical impression was that increased bruising was not observed. CONCLUSIONS: A recent landmark article has documented the efficacy of alpha tocopherol in the prevention of venous thromboembolism in over 39,000 patients. The addition of this readily available, over-the-counter medication may have profound effects in the prevention of a potentially devastating complication in the elective cosmetic surgery patient. Future prospective studies may further elucidate the efficacy of alpha tocopherol in the prevention of venous thromboembolism.

Reversal of the International Normalized Ratio with recombinant activated factor VII in central nervous system bleeding during warfarin thromboprophylaxis: clinical and biochemical aspects.

Major bleeding is a frequent and hazardous complication associated with thromboprophylaxis using vitamin-K antagonists (VKA). Suggested regimens for control of highly elevated International Normalized Ratio (INR) and hemorrhagic events during VKA treatment include administration of vitamin K, infusion of fresh frozen plasma (FFP) or a prothrombin complex concentrate (PCC). In contrast, this communication present the first report on the efficacious use of recombinant factor VIIa (rFVIIa) as additional therapy in seven patients presenting with central nervous system (CNS) bleeding emergencies. Pre-treatment INRs ranged from 1.7 to 6.6, and 10 min after a single dose of rFVIIa (10-40 microg/kg) all INRs were

Medical therapy for intracerebral hematoma with the gamma-aminobutyric acid-A agonist muscimol.

BACKGROUND AND PURPOSE: No therapy has been rigorously proven effective for intracerebral hematoma, although surgery is frequently used for some types of lobar hemorrhages. Since intracerebral mass causes significant ischemia in surrounding brain, we reasoned that anti-ischemia therapy might improve outcome after experimental hematoma. METHODS: We stereotaxically injected varying doses of bacterial collagenase into the caudate nucleus of rats. Four hours later we administered intravenously 2 mg/kg muscimol, a potent agonist of the gamma-aminobutyric acid-A receptor (n = 20); 1 mg/kg MK-801, an antagonist of the N-methyl-D-aspartate receptor (n = 17); or saline (n = 28). Forty-eight hours after collagenase injection we rated each animal using a standard rodent neurological examination. The ratings were compared with the amounts of injected collagenase by the quantal bioassay procedure. Brains were then prepared for histomorphometry and brain volumes estimated. RESULTS: We found that the ED50 for collagenase (amount of enzyme that renders 50% of the subjects abnormal) was 0.77 +/- 0.09 U in saline-treated subjects. Treatment with muscimol significantly increased the ED50 to 1.2 +/- 0.21 U, for a potency ratio of 1.55 +/- 0.34 (t = 1.7, P < .05). MK-801 did not affect outcome. Volume of hematoma was significantly correlated with amount of injected collagenase (n = 33, r = .64, P < .001). Volumes of basal ganglia and white matter were significantly reduced by hemorrhage, and muscimol partially ameliorated this. CONCLUSIONS: We conclude that muscimol significantly improves neurological outcome after intracerebral hematoma.