Poster 482 Spinal Intramedullary Hematoma in a Man With a History of Spinal Astrocytoma Resection and Lower Extremity DVT Who Was on Long-Term Warfarin: A Case Report

Case Description: A 51-year-old man who underwent subtotal resection of spinal astrocytoma at level T7-T9 in April 2007 which resulted in T10 motor and sensory ASIA D classification. Patient developed a deep venous thrombosis (DVT) in lower left extremity, diagnosed by Doppler ultrasound, 8 months after spinal surgery. Patient had been treated with warfarin since December 2007 secondary to the DVT and increased DVT risk associated with cancer. Anticoagulation was initiated and managed by a hematologist/oncologist with International Normalized Ratio (INR) values obtained weekly, then monthly once INR values were stable. INR values for the 2 years previous to this event ranged from 1.8-2.8. Patient developed acute onset of complete, bilateral, lower extremity paralysis in January 2012. Thirty hours after onset of paralysis, patient presented to an emergency department where thoracic MRI revealed intramedullary hematoma extending from the site of the previous surgery (T8) to T10. Documented INR was 2.2. Patient underwent thoracic laminectomy at level T9-T10 with exposure of previous T8 decompression, intramedullary exploration and evacuation of intramedullary hemorrhage. Setting: Tertiary care hospital. Results or Clinical Course: Patient had complete loss of motor function and sensation from level T10 resulting in conversion of incomplete ASIA D to complete ASIA A classification that has persisted at 6 weeks follow-up. Discussion: This is the first reported case, to our knowledge, of an intramedullary hematoma that developed at a previous spinal tumor resection site in a patient on chronic, therapeutic anticoagulation. Conclusions: The risk of spontaneous spinal hemorrhage in one with previous spinal tumor resection and who requires anticoagulation is unknown. However, given the significant consequences of an intramedullary hemorrhage and the increased risk of spontaneous hemorrhage associated with warfarin anticoagulation, risks versus benefits of anticoagulation should be carefully assessed and discussed with a patient, and frequently re-evaluated.