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1/88. Spinal epidural hematoma and high thromboembolic risk: between Scylla and Charybdis.

    OBJECTIVE: To determine the optimal time for reinstitution of anticoagulant therapy after evacuation of spinal epidural hematoma in patients who have a high risk for cardiogenic embolization. MATERIAL AND methods: The clinical histories of all patients with a spinal epidural hematoma encountered at Mayo Clinic Rochester between 1975 and 1996 were reviewed. We present three cases of spontaneous spinal epidural hematoma and the management of anticoagulation in each case. RESULTS: Of the 17 patients identified, 3 received anticoagulant therapy at the onset of the hematoma and were at high risk for cardiogenic embolization. In two patients with a metallic heart valve and one patient with long-standing atrial fibrillation, anticoagulant therapy was discontinued for 5, 13, and 18 days, respectively, after decompressive laminectomy. Systemic embolization occurred in one patient with a previous history of embolization to the femoral artery. No systemic embolization occurred in the two patients with a metallic valve. CONCLUSION: Early resumption of warfarin therapy is indicated after a spinal surgical procedure; however, discontinuation of anticoagulation for several days seems safe while postoperative hemostasis is monitored.
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2/88. Abrupt exacerbation of acute subdural hematoma mimicking benign acute epidural hematoma on computed tomography--case report.

    A 75-year-old male was hit by a car, when riding a bicycle. The diagnosis of acute epidural hematoma was made based on computed tomography (CT) findings of lentiform hematoma in the left temporal region. On admission he had only moderate occipitalgia and amnesia of the accident, so conservative therapy was administered. Thirty-three hours later, he suddenly developed severe headache, vomiting, and anisocoria just after a positional change. CT revealed typical acute subdural hematoma (ASDH), which was confirmed by emergent decompressive craniectomy. He was vegetative postoperatively and died of pneumonia one month later. Emergent surgical exploration is recommended for this type of ASDH even if the symptoms are mild due to aged atrophic brain.
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3/88. Epidural hematoma following epidural catheter placement in a patient with chronic renal failure.

    PURPOSE: We report a case of epidural hematoma in a surgical patient with chronic renal failure who received an epidural catheter for postoperative analgesia. Symptoms of epidural hematoma occurred about 60 hr after epidural catheter placement. CLINICAL FEATURES: A 58-yr-old woman with a history of chronic renal failure was admitted for elective abdominal cancer surgery. Preoperative laboratory values revealed anemia, hematocrit 26%, and normal platelet, PT and PTT values. General anesthesia was administered for surgery, along with epidural catheter placement for postoperative analgesia. Following uneventful surgery, the patient completed an uneventful postoperative course for 48 hr. Then, the onset of severe low back pain, accompanied by motor and sensory deficits in the lower extremities, alerted the anesthesia team to the development of an epidural hematoma extending from T12 to L2 with spinal cord compression. Emergency decompressive laminectomy resulted in recovery of moderate neurologic function. CONCLUSIONS: We report the first case of epidural hematoma formation in a surgical patient with chronic renal failure (CRF) and epidural postoperative analgesia. The only risk factor for the development of epidural hematoma was a history of CRF High-risk patients should be monitored closely for early signs of cord compression such as severe back pain, motor or sensory deficits. An opioid or opioid/local anesthetic epidural solution, rather than local anesthetic infusion alone, may allow continuous monitoring of neurological function and be a prudent choice in high-risk patients. If spinal hematoma is suspected, immediate MRI or CT scan should be done and decompressive laminectomy performed without delay.
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ranking = 5
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4/88. Spontaneous chronic spinal epidural hematoma of the lumbar spine.

    We report an exceptional description of a spontaneous chronic spinal epidural hematoma presenting as lumbar radiculitis. The computed tomographic, magnetic resonance imaging, and intraoperative findings are presented. We discuss anatomical and pathophysiological considerations that could lead to such a condition. We estimate that spontaneous spinal epidural hematomas located in the ventral space are in fact premembranous or posterior longitudinal ligament hematomas.
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5/88. Spinal epidural hematoma caused by extradural arteriovenous malformation: a case report and review of the literature.

    About 330 cases of spinal epidural hematoma have been reported in the literature but few cases had pathologically proven extradural arteriovenous malformation. The authors report a case of spinal epidural hematoma caused by extradural arteriovenous malformation. The patient presented with a sudden onset of back pain followed by rapidly progressive neurological deficit. MRI was the procedure of choice for diagnosis of this lesion. Treatment was emergency surgical decompression. prognosis depends on the preoperative neurological deficit, operative interval and localization of the hematoma.
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6/88. Spinal haematoma following epidural anaesthesia in a patient with eclampsia.

    A patient with a twin pregnancy required a Caesarean section for severe pre-eclampsia. Her platelet count was 71 x 10(9).l-1. Epidural anaesthesia was performed after platelet transfusion. A spinal epidural haematoma was diagnosed postoperatively. A generalised tonic-clonic seizure sparing the lower limbs enabled early diagnosis to be made. The patient recovered with no permanent neurological damage after laminectomy and clot removal. The risks and benefits of regional techniques require careful consideration, and postoperative monitoring for recovery of neural blockade is essential.
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7/88. Epidural hematoma after minor oral trauma.

    A case report was presented in which a 15-year-old boy was beaten about the head with a baseball bat. Intraoral trauma and facial lacerations were repaired. Since results of the neurological examination were within normal limits, the patient was discharged. The next day, the patient became lethargic; however, the patient's mother did not bring the patient back to the hospital until the routine postoperative visit. At that time, the patient had right hemiparesis, was unable to speak, and was clearly obtunded. A carotid angiogram disclosed a left venous epidural hematoma in the parietal area. A craniotomy was performed with good results. The importance of follow-up neurologic examinations in cases of trauma to the face and head is stressed.
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ranking = 1
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8/88. Epidural hematoma following epidural analgesia in a patient receiving unfractionated heparin for thromboprophylaxis.

    BACKGROUND AND OBJECTIVES: The practice of providing postoperative epidural analgesia for patients receiving deep venous thromboprophylaxis with unfractionated heparin is common. This case report is intended to heighten awareness of comorbid risk factors for epidural hematoma and to bring attention to the new ASRA consensus guidelines on the management of neuraxial anesthesia in the presence of standard heparin. CASE REPORT: A 79-year-old woman with apparently normal coagulation and receiving no antiplatelet agents required an abdominoperineal resection for recurrent squamous cell carcinoma of the anus. Approximately 2 hours after her preoperative dose of 5,000 U unfractionated heparin, an epidural catheter was placed on the third attempt. Subcutaneous heparin was subsequently administered every 12 hours. Her international normalized ratio became slightly elevated during surgery while the partial thromboplastin time and platelet count remained normal. The catheter was removed on postoperative day 3, 6 hours after the last dose of heparin. The patient developed signs of an epidural hematoma requiring surgical evacuation on postoperative day 4. The presence of previously undiagnosed spinal stenosis may have contributed to her symptoms. CONCLUSION: Management of postoperative epidural analgesia in the patient receiving thromboprophylaxis with unfractionated heparin requires appropriate timing of epidural insertion and removal, monitoring of coagulation status and vigilance.
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ranking = 5
keywords = operative
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9/88. Spontaneous epidural hematoma following a shunt in an infant with congenital factor x deficiency. Case report and literature review.

    The authors describe a case of an infant with congenital factor x deficiency. The patient presented with a central nervous system hemorrhage followed by hydrocephalus. He underwent a ventriculoperitoneal shunt and, during the postoperative period, developed a spontaneous epidural hematoma, which was evacuated. The clinical and pathophysiological aspects of this case are discussed based on a literature review.
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ranking = 1
keywords = operative
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10/88. Delayed postoperative epidural hematoma formation after heparinization in lumbar spinal surgery.

    Treatment of thromboembolic disease in the postoperative lumbar spine patient is controversial. This case report describes an epidural hematoma with neurologic sequelae in an elderly patient who received intravenous heparin therapy over 2 weeks after lumbar decompression. Implications for treatment of thromboembolic disease in the postoperative lumbar spine is reviewed.
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ranking = 6
keywords = operative
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