AN UNFORESEEN CATASTROPHIC CONSEQUENCE OF ENOXAPARIN: A RARE CASE OF ACUTE QUADRIPLEGIA AND APHASIA SECONDARY TO SPINAL EPIDURAL HEMATOMA

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Spontaneous spinal epidural hematomas (SSEH) are a rare but catastrophic consequence of anticoagulation that causes an acute onset of neurological deficits. Here we present the first case of a patient presenting with quadriplegia and aphasia due to SSEH. CASE PRESENTATION: A 60 year-old African-American woman with a history significant for hypertension and prior DVT was admitted after a syncopal event. On presentation, she was found to be in respiratory distress with hypotension due to massive pulmonary embolism accompanied by lower extremity DVT. She required tissue plasminogen activator (tPA) administration followed by therapeutic anticoagulation with enoxaparin. On day 3 of hospitalization she acutely developed quadriparesis and aphasia. An MRI of the cervical spine showed fluid in the posterior paraspinal musculature from the midline skull base to C5 and in the right posterior paraspinal musculature from C7 into the upper thoracic spine with moderate cord compression. These findings were consistent with a spontaneous spinal epidural hematoma. The patient underwent urgent temporary IVC filter placement. Anticoagulation was reversed with protamine sulfate and the patient was taken to the OR for hematoma evacuation and cervical spine decompression. Post-intervention, the patient had a full neurological recovery, and was discharged without complications on post operative day 7. DISCUSSION: SSEH is a rare entity that if not diagnosed and treated promptly can lead to detrimental outcomes including death. It is characterized by an accumulation of blood in the vertebral epidural space that compresses the spinal cord or spinal nerve roots. It is typically attributed to coagulopathies and arteriovenous malformations. Standard therapy is decompressive laminectomy, with only 50% of patients exhibiting full neurological recovery. To our knowledge, this is the first case of a patient presenting with quadriplegia and aphasia due to a spontaneous cervical spine epidural hematoma from anticoagulation. The added complexity of this patient, in which she also had a lower extremity DVT that required IVC filter placement and reversal of her anticoagulation for surgical decompression, adds to the distinctiveness of this case. CONCLUSIONS: Due to the broad nature of clinical presentation of SSEH, ranging from severe neck pain to aphasia and quadriplegia, it is of utmost importance for clinicians to quickly diagnose and treat this devastating condition. After identification, resources and care teams must rapidly be mobilized in order for evacuation and decompression. In patients who experience this rare disorder due to therapeutic anticoagulation with enoxaparin and who have a deep venous thrombosis, rapid placement of IVC filter followed by protamine reversal and emergent laminectomy and decompression within 12 hours of symptom onset can potentially allow full recovery of neurological deficits. Reference #1: Spinal epidural hematoma. J Am Acad Orhop Surg. 2010 Aug; 18(8):494-502. Reference #2: Spontaneous Spinal Epidural Hematoma in a Patient on Rivaroxaban: Case Report and Literature Review. J Emerg Med. 2017 Oct;53(4):536-539. Reference #3: Spontaneous spinal epidural hematoma: the importance of preoperative neurological status and rapid intervention. J Clin Neurosci. 2015; 22(1) 123 DISCLOSURES: No relevant relationships by Shahrzad Abdollahi, source=Admin input No relevant relationships by Hadiatou Barry, source=Web Response no disclosure on file for Jennifer Frabizzio; No relevant relationships by Rajesh Patel, source=Web Response No relevant relationships by Andrew Tran, source=Web Response