Spinal epidural hematoma – A rare and debilitating complication of thrombolytic therapy

Abstract

Thrombolytic therapy directed to the achievement of early reperfusion in cases with acute ST elevation myocardial infarction can have significant complications which can be due to bleeding or in the form of allergic reactions. Sometimes these complications can cause mortality or significant and incapacitating morbidity which may at times surpass the risk possessed by the disease itself. We are reporting an interesting case of 63-year-old male, who presented to us with acute anterior wall myocardial infarction and developed acute onset paralysis following intravenous administration of streptokinase and heparin. MRI spine revealed spinal epidural hematoma. Patient was advised urgent surgical evacuation of hematoma, but opted for conservative management. Patient had significant residual neurological deficits at follow-up. In conclusion, spinal epidural hematoma is a rare complication following thrombolysis for acute ST elevation myocardial infarction. Though rare, high index of suspicion is required by physicians, as prompt treatment may lead to complete recovery, which otherwise can lead to debilitating neurological sequel.

Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke

“…However, most of the case reports describe spontaneous epidural hematoma after administration of both intravenous alteplase and heparin. [423][424][425] The only case describing epidural hematoma after intravenous alteplase that does not specifically mention simultaneous administration of heparin was published in 1996 by Connolly et al 426 Although the authors do not specifically mention administration of heparin, heparinization was the standard of care at many centers at the time. Moreover, the hematoma occurred in a delayed fashion 10 days after intravenous alteplase.…”

Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy

“…The majority of published reports involve spontaneous spinal or epidural hematomas after thrombolytic therapy. [52][53][54][55][56][57][58][59][60][61][62][63][64][65][66][67][68] Recent cases involve thrombolysis for myocardial infarction. Bleeding has been reported at all spinal levels-cervical, thoracic, and lumbar.…”

Spontaneous Epidural Hematoma of the Cervical Spine Following Thrombolysis in a Patient with STEMI—Two Medical Specialties Facing a Rare Dilemma

“…9 As regard to the clinical entity itself, SSEH is an emergency, and it is rapidly presented with severe back pain and signs of compression of the spinal cord/neurologic deficits requiring immediate surgical treatment. 2,5,10 It may also be presented with breathing distress and paraplegia. 11 Furthermore, it has been stated that even the initial symptoms of Guillain-Barre syndrome can be similar to a case of SSEH located at the cervicothoracic junction.…”

“…Spontaneous spinal epidural hematoma (SSEH) is a rare and severe complication of the procedure. 2 Several SSEH risk factors have been reported, such as hypertension, anticoagulant use, straining, lifting, and even sneezing, although it is unknown, whether these also predict SSEHs in STEMI patients. SSEH confers significant morbidity, as over 50% of patients are traditionally reported to retain at least some level of sensorimotor deficiency.…”