Spinal epidural hematoma associated with streptokinase treatment for myocardial infarction

Spontaneous psoas hematoma in a case of acute myocardial infarction following streptokinase infusion

INTRODUCTION

Cardiovascular disorders are the major cause of mortality and morbidity globally as well as in India. In India, where resources are limited and majority of patients pay out of their own pocket, thrombolysis is still done for majority of STEMI cases.

CASE SCENARIO

A 48-year-old male patient, nonhypertensive and nondiabetic, came to the ER with history of retrosternal chest pain suggestive of angina at rest. An Electrocardiogram (ECG) revealed ST-segment elevation in the anterior leads. Patient was diagnosed with Acute STEMI and thrombolysis was initiated with STK. The following day, the patient complained of pain in his left groin. On examination, there was a swelling and tenderness in left lower abdomen and inability to extend the hip. A CT scan was done, which showed Psoas muscle hematoma.

CONCLUSION

Spontaneous bleed into psoas muscle is a very rare complication of thrombolysis that may require surgical exploration.

Remote spinal epidural haematoma after spinal anaesthesia presenting with a 'spinal lucid interval'

An obstetric patient who had no significant risk factors developed a spinal epidural haematoma remote from the site of needle puncture (for administration of spinal anaesthesia). The clinical deficits were manifest after recovery from the motor blockade had started a phenomenon that we have termed as a 'spinal lucid interval'. The patient developed flaccid paraplegia with a sharp sensory level and urinary retention. The patient underwent emergency laminectomy and evacuation of the haematoma. She gradually recovered near normal power and was ambulant independently and had normal sphincter function at follow-up.

Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition)

The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with neuraxial blockade is unknown. Although the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics, recent epidemiologic surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient populations.Overall, the risk of clinically significant bleeding increase with age,associated abnormalities of the spinal cord or vertebral column, the presence of an underlying coagulopathy, difficulty during needle placement,and an indwelling neuraxial catheter during sustained anticoagulation( particularly with standard heparin or low-molecular weight heparin). The need for prompt diagnosis and intervention to optimize neurologic outcome is also consistently reported. In response to these patient safety issues, the American Society of Regional Anesthesia and Pain Medicine (ASRA) convened its Third Consensus Conference on Regional Anesthesia and Anticoagulation. Practice guidelines or recommendations summarize evidence-based reviews. However, the rarity of spinal hematoma defies a prospective randomized study, and there is no current laboratory model. As a result,the ASRA consensus statements represent the collective experience of recognized experts in the field of neuraxial anesthesia and anticoagulation. These are based on case reports, clinical series, pharmacology,hematology, and risk factors for surgical bleeding. An understanding of the complexity of this issue is essential to patient management.

Vertebral artery dissection as an extremely rare cause of spinal epidural hematoma: case report and review of the literature

OBJECTIVE

To present a patient with a cervico-thoracic ventrally located epidural hematoma caused by dissection and subsequent bleeding of the cervical portion of the vertebral artery.

SUMMARY AND BACKGROUND DATA

Non traumatic epidural hematoma is a rare entity. The etiology usually is not clarified: a venous origin is usually suspected although an arterial source is also possible.

CLINICAL REPORT

A 32-year-old woman presented with a ventrally located cervico-thoracic epidural hematoma caused by non traumatic dissection and dissecting aneurysm rupture of the cervical portion of the vertebral artery. The dissection was demonstrated by magnetic resonance imaging and digital subtraction angiography. The patient had no neurological symptoms and was treated by conservative methods. Follow up imaging showed healing of the vertebral artery and resorption of the epidural hematoma.

CONCLUSION

Dissection of the cervical portion of the vertebral artery with subsequent perivascular bleeding is not well recognized as a possible cause of a spinal epidural hematoma. Even though this entity and the underlying cause may be rare, we suggest a vigilant search for vertebral artery injury in cases of ventrally located cervical and upper thoracic epidural hematoma.

Spinal Epidural Haematoma Related to Oral Anticoagulant Overdose

The most important complication during the treatment of oral anticoagulants is bleeding and it is seen most commonly in the skin, urinary system, gastrointestinal tract and central nervous system. Spinal epidural bleeding related to oral coagulant overdose is a rare complication and it may require urgent surgical treatment depending on the neurological clinical chart. This paper describes a patient with spinal epidural haematoma defined by imaging methods due to paraparesis which developed during oral coagulant usage and its treatment.