Warfarin

Abstract

Retroclival epidural haematoma: case reportIn a report, a 78-year-old woman was described, who developed retroclival epidural haematoma during treatment with warfarin for atrial fibrillation.The woman presented to the emergency department with a 2-day history of weakness in all limbs. One month previously, she had been diagnosed with atrial fibrillation, and initiated on warfarin therapy [route and dosage not stated]. On admission to the emergency department, she was found to be haemodynamically stable, and her neurological examination demonstrated a Glasgow coma scale (GCS) score of 15, and quadriparesis without any sensory deficit or cranial nerve palsy. Deep tendon reflexes in all four limbs were found to be normoactive, and the plantar reflex was found mute. Laboratory investigations revealed a platelet count of 202000, prothrombin time of 26.1 seconds, and international normalised ratio of 2.23. Brain CT scan showed a retroclival hyperdense mass lesion compressing the brainstem. Sagittal images revealed that the lesion extended inferiorly from the dorsum sellae through the foramen magnum to the anterior arch of C1. A MRI and CT angiography showed no other apparent intracranial abnormalities. MRI of the lumbar spine revealed a lesion of low signal intensity on T2-weighted images and high signal intensity on T1-weighted images from L4 to S2 causing mass effect on the thecal sac. Based on these findings and clinical presentation a diagnosis of warfarin-induced retroclival epidural haematoma was made [time to reaction onset not clearly stated].The woman's anticoagulation treatment was reversed with fresh frozen plasma and Vitamin K supplements. Her treatment was switched to enoxaparin, and she was managed conservatively with methylprednisolone. Daily neurological examinations revealed progressive clinical improvement. Craniocervical and lumbar CT after 5 days revealed no progression of the haematoma and no significant increase in ventricular size was observed. She was discharged without any neurological deficit. After 3 weeks of discharge, MRI showed spontaneous resolution of the haematoma, and she remained free of any neurological deficit.