eMedicine Specialties > Neurology > Neurological Emergencies

Spinal Cord Hemorrhage: Treatment & Medication

Author: Richard M Zweifler, MD, Chief of Neurology, Sentara Healthcare, Norfolk, VA
Contributor Information and Disclosures

Updated: Dec 4, 2008

Treatment

Medical Care

Medical therapies for spinal cord hemorrhage are limited.

  • If the bleed is caused by a coagulopathy, reversal of the bleeding tendency is crucial. Examples include fresh frozen plasma and vitamin K for warfarin-induced bleeds, protamine sulfate for heparin-induced bleeds, platelet transfusions for thrombocytopenia, specific clotting factor concentrates or fresh frozen plasma for clotting factor deficiencies such as hemophilia and Christmas disease.
  • Another potential medical treatment, drug therapy for cord edema, is unproved.

Surgical Care

  • Depending on etiology, surgery may be indicated for hematomyelia.
  • In general, surgery should be performed in spinal subdural hemorrhage and epidural hemorrhage.
  • Treatment of spinal subarachnoid hemorrhage consists of bed rest and surgical resection of extramedullary angiomas, when present.
  • Spinal angiomas also can be approached by catheter-based interventional techniques, such as embolization or coiling.
  • Focal radiation therapy, as in the gamma knife or cold photon knife, is also a consideration with spinal arteriovenous malformations.

Consultations

  • Neurosurgeon
  • Interventional neuroradiologist
  • Radiation oncologist
  • Hematologist
  • Rehabilitation physician (physical medicine and rehabilitation, neurology)

Medication

The goal of pharmacotherapy is to inhibit the effect of anticoagulants in patients taking such medications. Attempts to treat spinal cord swelling (edema) with mannitol or corticosteroids have not been tested in randomized, double-blind studies. If spinal cord trauma can be taken as a situation similar to cord compression, high-dose corticosteroids may be beneficial.

Antidotes (blood modifiers)

Anticoagulated patients may require a blood modifier.


Protamine sulfate

Neutralizes heparin effects by forming a salt.

Adult

Dose administered depends upon duration of time since heparin administration
Immediately: Administer 1-1.5 mg/100 U of heparin
30-60 min: Administer 0.5-0.75 mg/100 U of heparin
Over 2 h: Administer 0.25-0.375 mg/100 U of heparin
If heparin was administered by deep SC injection, give 1-1.5 mg protamine/100 U of heparin; do not exceed 50 mg IV over 10 min

Pediatric

Not established

IV administration physically incompatible with certain antibiotics, including several cephalosporins and penicillins

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Heparin rebound associated with anticoagulation and bleeding may occur


Phytonadione (AquaMEPHYTON, Mephyton, Vitamin K)

Promotes liver synthesis of clotting factors that in turn inhibit warfarin effects.

Adult

2.5-10 mg/dose SC or IM (rarely, 25-50 mg may be required); repeat after 6-8 h if PT has not normalized

Pediatric

1-2 mg/dose IM/SC; repeat after 6-8h if PT has not normalized

Antagonizes effects of warfarin sodium and dicumarol

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Monitor PT closely

More on Spinal Cord Hemorrhage

Overview: Spinal Cord Hemorrhage
Differential Diagnoses & Workup: Spinal Cord Hemorrhage
Treatment & Medication: Spinal Cord Hemorrhage
Follow-up: Spinal Cord Hemorrhage
Multimedia: Spinal Cord Hemorrhage
References
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References

  1. Aminoff MJ. Vascular disorders of the spinal cord. In: Davidoff RA, ed. Handbook of the Spinal Cord. New York: Marcel Dekker; 1987:259-97.

  2. Barth A, Bougousslavsky J, Caplan LR. Spinal stroke syndromes. In: Barth A, Caplan LR, eds. Stroke Syndromes. 1995. New York: Cambridge University; 395-402.

  3. Geldmacher DS, Bowen BC. Spinal cord vascular disease. In: Bradley WG, Daroff RB, Fenichel GM, Marsden CD, eds. Neurology in Clinical Practice Principles of Diagnosis and Management. 4th ed. Philadelphia, Pa: Butterworth-Heimann; 2004:1313-22.

  4. Karavelis A, Foroglou G, Petsanas A, Zarampoukas T. Spinal cord dysfunction caused by non-traumatic hematomyelia. Spinal Cord. May 1996;34(5):268-71. [Medline].

  5. Russell NA, Benoit BG. Spinal subdural hematoma. A review. Surg Neurol. Aug 1983;20(2):133-7. [Medline].

  6. Toole JF. Spinal cord vascular anatomy and diseases. In: Toole JF, ed. Cerebrovascular Disorders. 4th ed. Baltimore, Md: Lippincott Williams & Wilkins; 1990:519-34.

  7. Weisberg LA. Vascular diseases of the spinal cord. In: Rowland LP, ed. Merritt's Textbook of Neurology. 10th ed. Baltimore, Md: Lippincott Williams & Wilkins; 2001:271.

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Further Reading

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Keywords

spinal cord hemorrhage, hematomyelia, spinal subarachnoid hemorrhage, SAH, spinal epidural hemorrhage, EDH, subdural hemorrhage, SDH, subarachnoid space, bleeding in the spinal cord, intramedullary hemorrhage, spinal angioma

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Contributor Information and Disclosures

Author

Richard M Zweifler, MD, Chief of Neurology, Sentara Healthcare, Norfolk, VA
Richard M Zweifler, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Medical Association, American Stroke Association, Royal Society of Medicine, and Stroke Council of the American Heart Association
Disclosure: Nothing to disclose.

Medical Editor

Rodrigo O Kuljis, MD, Esther Lichtenstein Professor of Psychiatry and Neurology, Director, Division of Cognitive and Behavioral Neurology, Department of Neurology, University of Miami School of Medicine
Rodrigo O Kuljis, MD is a member of the following medical societies: American Academy of Neurology and Society for Neuroscience
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Howard S Kirshner, MD, Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center
Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association
Disclosure: Boehringer Ingelheim Honoraria Speaking and teaching; BMS/Sanofi Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Novartis Consulting fee Review panel membership

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health and Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Boston Scientific Honoraria Speaking and teaching; Concentric Medical None Review panel membership; Northstar Neuroscience  Review panel membership; ev3 Consulting fee Review panel membership

 
 
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