2. Case report
History
Mr.Kiriganitha
75 years
Warakapola
c/o sudden painful swelling of Right calf for 1 day
No history of recent trauma to leg
No history of fever
No history of injuries to LL or wounds
No evidence of filarasis
Admitted to BH warakapola on 13/01/2011
Transferred to TH Kegalle on 14/01/2011 admitted to
ETU at 4pm
3. Past medical history
no past history of bleeding disorders
no history of haematological malignancies
Not a known diabetic(but on admission FBS was
180mg/dl)
No hypertension,CVA,TIA
No chest pain, no IHD,No exertional dyspnoea
Good exercise tolerance
Past surgical History
History of head injury following fallen from bicycle on
ground 1 year back-scalp laceration sutured under LA-no
intractable bleeding
4. Family history
No bleeding discrasia
Social history
A farmer, father of a daughter, living with daughter’s family
On Examination
Pt.In pain
GCS 15/15
Afebrile
not dyspnoeic
Mild pallor+
CVS-PR 80/min regular, good volume
BP-130/80mmHg
Heart in dual rhythm no murmurs
Capillary refilling time<2s
5. Respiratory –B/L equal breath sounds
Few fine crepts on bases
No rhonchi
Abdomen –soft
R/LL-swallen,erythematous calf which is tender and warm to touch
Investigations
Hb-10.7g/dl PCV-36%
WBC-10,800 N 67% L 28% M 5% E 2%
BT-3min CT-4min
Platelet count-307*1000/ul
BU-45 Na+138 K+3.8
ECG-no ischaemia
USS R/LL-?intra muscular collection of blood,no evidence of DVT
6. VS opinion to do urgent fasciotomy of R/LL for
compartmental release
On 14/01/11 at 5pm Sub Arachnoid Block given(single
attempt) under strict aseptic conditions under LA via a 25G
pencil point spinal needle, Heavy Bupivacaine 2.3cc
introduced intrathecally after observing a free flow of clear
CSF.
Spinal level achieved-L1
Compartmental release done making 2 surgical incisions on
either side of the R/LL. muscle haematoma found. clots
removed. the exact bleeder not found. tight bandage
applied.
Recovery uneventful.
7. Bleeding from wound site found in the night of the same day.
Re exploration done on the following day.15/01/2011 at 12.30pm
after transfusion of 1U of blood.
Pre op BP-120/60mmHg PR-80/min
SAB given in 3rd attempt under absolute aseptic procedure under
LA with Heavy Bupivacaine 1.8cc.
CSF was blood stained.?traumatic puncture
Clots were removed and haemostasis achieved. Pt. Kept in the
recovery room for 10min.post op BP-100/60 mmHg ,no other
complains and sent to the ward.
8. At 7.30pm,Pt.was complaining severe backache.
Managed as ?positional backache and had been given pain relief,
not informed seniors ,were not suspicious about symptoms.
Following day Pt. complained of urine retention +weakness of B/L
LL
O/E of LL
Tone
Power-Grade 1 (flicker of movements only)
Reflexes
Sensory level-mid thigh(L2)
9. Seen by CA- Spinal Haematoma need to be excluded .Need
Urgent MRI
Urgent investigations sent .
Hb-8.3g/dl
BT-2 1/2min
CT-1 1/2min
Platelet count-312*1000
PT-12.6s
INR-1
VP informed-need urgent MRI to exclude spinal haematoma
10. Could not get the MRI done on the same day.
Neurosurgical opinion-to start on Methyl Prednisolone until MRI is
available.
MRI on the following day (at Radiology Unit SBCH):
MRI Thoraco-lumbar spine:-Subdural haematoma at L3-T12 with
cord compression
Transferred to Neurosurgical unit Kandy
Neurosurgical opinion-Ct. IV Methyl Prednisolone
No need of surgical evacuation
Conservative Mx only
Haematological referral to exclude;
Acquired factor XIII deficiency
Acquired VWD
Acquired platelet dysfunction
Acquired fibrinogen disorder
11. APTT-28s(normal)
Haematologist opinion to do 2nd line invetigations;
Thrombin time
Clot stabilizing time
D.D. ?Acquired factor XIII deficiency
?Acquired fibrinogendeficiency
/dysfibrinogenemia
Pt, was started on Cryoprecipitate before completing Ix as
oozing from wound site
GCS level + spastic paraplegia-CT brain:frontal
ischaemia + cerebral atrophy.......... ?stupor
Now-regain GCS with slight movements of LL, On
physiotherapy......sensory level came down to below knee...
12. Causes for epidural haematoma
Predisposing factors:
Pre-existing coagulopathy
Spinal vascular malformation
Hypertension
Therapeutic thrombolysis
Use of antiplatelet or anticoagulant therapy
Administration of any kind of neuro-axial anaesthesia
13. Haemorrhagic complications after epidural
anaesthesia- 1:150 000-1:190 000
After spinal anaesthesia- <1:220 000
Very infrequent complication but very serious
consequences
permanent paraplegia
14. Reasons for epidural haematoma
Anatomical abnormalities
Eg:spinal haemangiomas,vascular lymphomas
Traumatic puncture with multiple attempts
Coagulation disorders( 54%) -2ndory to defect in haemostatic
mechanism eg:Leukaemia,Haemophilia,Thrombocytopenia,
cryoglobulinaemia,haemorrhagic diathesis, polycythaemia
Anticoagulant therapy(Acute or Chronic)(30%)
Among these newest anticoagulants - the very potent platelet
aggregation inhibitors (e.g., ticlopidin),thrombin antagonists
(e.g., melagatran), and factor Xa inhibitors (e.g., fondaparinux)
15.
16. a) T1 scan revealing Isointense linear biconvex mass compressing on the lower thoracic
spinal cord and cauda equina (arrow heads). (b) Same lesion showing heterogenous signal
of hyperintensity (arrow heads) and hypointensity (arrow) on T2 scan
17. severe Lumbar pain(absence of pain does not exclude
haematoma)
Motor impairment –flaccid paralysis (if cephalad
migration of haematoma occurs-spastic paralysis)
Sensory loss with sensory level below the level of
compressed spinal segment
Sphincter disturbance-Urine retention
18. Surgical decompression by laminectomy is the
definitive treatment
OUTCOME
1. Severity at presentation 2. Time from presentation to
surgery
Onset of symptoms Surgery
Within 12 hrs-60%recovery rate
>24 hrs-10% recovery rate
>8hrs known to be associated with worse prognosis
Also if it is Sub Arachnoid Haemorrhage
Or there were pre op neurological deficits
19. • Recognize symptoms
Early • Ix of choice-MRI
diagnosis
• Urgent neurosurgical
Aggressive intervention
treatment
20. Protocol proposal
Detection and management of epidural haematomas related to
anaesthesia in the UK: a national survey of current practice†
(i) Patients with epidural infusions running should
have observations that include assessment of motor
block made at least every 4 h.
(ii) These observations should continue for at least 24
h after removal of the epidural catheter.
(iii) There should be a designated person responsible
for investigating signs suggestive of epidural
haematoma.
21. (iv) If significant deterioration in motor function
occurs in the absence of a recent bolus dose of local
anaesthetic being administered, the designated person
should be contacted immediately.
(v) If motor block is attributed to a recent bolus dose
of epidural drugs, reassessment should occur within 2
h.
(vi) If an epidural infusion is running, it should be
turned off, alternative analgesia instigated as necessary
,and a reassessment of the patient’s motor function
should be made after a defined interval. The motor
block would be expected to resolve if due to overdose
or catheter migration. If motor power does not
improve, remediable causes, including epidural
haematoma or abscess, must be excluded.
22. (vii) Once an epidural haematoma is suspected, an
MRI scan should be organized immediately, as this is a
potential neurosurgical emergency. A protocol should
be agreed in advance with the diagnostic imaging
service.
(viii) If MRI scanning is not available in the local
hospital or there will be a delay, then the patient
should be referred to a neurosurgical unit to be
scanned. It may be appropriate to arrange a protocol
with local neurosurgical units to minimize delays in
investigation and treatment.