Neurol Sci (2011) 32:687–689 DOI 10.1007/s10072-011-0508-5
CASE REPORT
Relapsed spontaneous spinal epidural hematoma associated with aspirin and clopidogrel Seong Hoon Lim • Bo Young Hong • Ye Rim Cho • Han Seung Kim • Jong In Lee Hye Won Kim • Young Jin Ko
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Received: 19 March 2010 / Accepted: 17 February 2011 / Published online: 8 March 2011 Ó Springer-Verlag 2011
Abstract An acute spontaneous spinal epidural hematoma (SSEH) is a rare spinal pathology. A 57-year-old man who had hypertension and had been on dual antiplatelet therapy with aspirin and clopidogrel for primary prevention presented with the sudden onset of mid back pain and monoplegia of the left lower extremity. Magnetic resonance imaging revealed an epidural hematoma, and the patient underwent emergency hemilaminectomy for evacuation. However, the symptoms worsened, and complete paraplegia developed. A second procedure to remove the recurrent hematoma was performed. No vascular malformation or other possible cause for SSEH was found other than the aspirin and clopidogrel medication. This case report describes relapsed SSEH caused by the combination of aspirin and clopidogrel medication and urges caution in prescribing dual antiplatelet agents. Keywords Aspirin Clopidogrel Spinal epidural hematoma Antiplatelet agent Paraplegia
Introduction A spontaneous spinal epidural hematoma (SSEH) is an infrequent cause of acute spinal cord compression and usually requires an emergency surgical evacuation [1]. Most cases of SSEH are caused by trauma, vascular
S. H. Lim B. Y. Hong Y. R. Cho H. S. Kim J. I. Lee H. W. Kim Y. J. Ko (&) Department of Rehabilitation Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, 505 Banpo-Dong, Seocho-Gu, Seoul 137-701, Republic of Korea e-mail:
[email protected]
malformation, or tumors [1]. Less common causes are anticoagulation, aspirin, hypertension, and clopidogrel [2, 3]. Currently, the combined regimen of clopidogrel and aspirin are often prescribed for patients with a history of cardiac disease or ischemic stroke [4–6]. In the present case report, we describe a patient with SSEH who had been treated with aspirin and clopidogrel for primary prevention. Rebleeding occurred after the first operation. The patient’s recovery was significantly impaired and he had a poor prognosis as a result of rebleeding that was likely caused by dual antiplatelet therapy.
Case report A 57-year-old man, who spontaneously developed low back pain and progressive weakness of the left lower limb, was admitted to the hospital. He had hypertension and had been prescribed a dihydropyridine calcium channel antagonist (cilnidipine) 5 mg, clopidogrel 75 mg, and aspirin 100 mg once a day for the past 3 years. The initial evaluation in the emergency room revealed normal vital signs. The manual muscle test showed weakness of the left lower limb and no muscle contraction of the anal sphincter (Table 1). Sensory examination revealed bilateral hypesthesia of the trunk and the left lower limb below the T10 dermatome including anal sensation. Routine laboratory and coagulation parameters such as platelet count, bleeding time, prothrombin time, and other coagulation factors were within normal limits. Magnetic resonance imaging revealed an epidural oval-shaped mass extending from T11 to L3 with welldefined contours compressing the spinal cord (Fig. 1). The dual antiplatelet agents were discontinued immediately after diagnosis. Surgical decompression with a left
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Neurol Sci (2011) 32:687–689
Table 1 The manual muscle test HD 1 R
L
HD 2 (POD 1)
HD 3 (POD 2)
HD 9
R
R
R
L
L
HD 50 L
R
L
Hip flexion
5/5
1/5
4/5
1/5
2/5
1/5
0/5
0/5
1/5
1/5
Knee extension
5/5
1/5
4/5
1/5
2/5
0/5
0/5
0/5
0/5
0/5
Ankle dorsiflexion
5/5
1/5
4/5
1/5
1/5
0/5
0/5
0/5
0/5
0/5
Long toe extension
5/5
1/5
4/5
1/5
1/5
0/5
0/5
0/5
0/5
0/5
Ankle plantar flexion
5/5
1/5
4/5
1/5
1/5
0/5
0/5
0/5
0/5
0/5
HD hospital day, POD postoperative day, R right, L left
hemilaminectomy from T11 to L3 and hematoma removal was urgently performed. No evidence of vascular malformation or other anatomical variations were detected during surgery. During the night of postoperative day 1, weakness of the right leg developed. Computerized tomography showed progression of the epidural hematoma extending from T11 to L4 (Fig. 2). Reoperation with total laminectomy and hematoma removal was performed. The neurological symptoms remained unchanged after the second operation (Table 1). The patient received comprehensive therapy for rehabilitation over the next 4 weeks, and although functional aspects improved, the strength of his lower limbs and the analgesic use remained unchanged.
Discussion The outcome of SSEH is usually good if it is diagnosed and treated early. Conservative treatment can be sufficient for SSEH [7]; however, in patients with neurological progression or severe symptoms at initial presentation, emergency surgical evacuation should be performed. Surgery performed within 26–36 h slows the progression, and small hematomas are associated with a good prognosis [8, 9].
Fig. 2 Spine computed tomography (CT) image shows a newly developed hematoma in the posterior epidural space
Fig. 1 Magnetic resonance (MR) sagittal images show a posterior epidural hematoma (white arrows) extending from T11 to L5 compressing the spinal cord. An iso-intensity is seen at the T1-
weighted image (a), and heterogeneous-intensity at the T2-weighted image (b). The convex shape of the hematoma is seen on the MR axial image (c). The hematoma was located in the epidural space
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In our case, although surgical evacuation was performed 17 h after onset of the initial symptoms, relapsed hemorrhage may have caused the poor outcome.
Neurol Sci (2011) 32:687–689
Antiplatelet therapy, such as aspirin or clopidogrel, is widely used for patients at risk for heart disease and ischemic stroke [5, 10]. Several previous reports have shown that dual antiplatelet therapy with clopidogrel and aspirin improves outcomes and provides effective prevention for patients at risk for several diseases [5, 11]. However, another study reported that dual antiplatelet therapy was associated with an increased risk of major bleeding [6, 12]. In our case, the prescription of clopidogrel in combination with aspirin may not have been appropriate for a patient with hypertension. The present case highlights the bleeding complications associated with inappropriate dual antiplatelet therapy. Moreover, relapsing hemorrhage may cause a disastrous outcome such as permanent neurological damage. In light of the recent popularity of antiplatelet medications, physicians need to be aware of critical side effects such as SSEH and should be cautious when prescribing dual antiplatelet therapy, particularly clopidogrel in combination with aspirin. Conflict of interest No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated.
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