Spinal Cord Hemorrhage Medication

Updated: Feb 19, 2019
  • Author: Morteza Sadeh, MD, PhD, MS; Chief Editor: Helmi L Lutsep, MD  more...
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Medication

Medication Summary

The primary goal of pharmacotherapy for patients with hemorrhage affecting the spinal cord is to reverse the effect of anticoagulants (in individuals taking such medications), with the goal of limiting any additional bleeding. Such agents and their antidotes are described in Table 2.

Table 2. Commonly used anticoagulants and antiplatelet agents, and the antidotes used to reverse their effects. Antidotes may be used in patients who have had a hemorrhage, are actively bleeding, in preparation for surgical intervention, or are at high risk for further hemorrhage. (Open Table in a new window)

Anticoagulant/antiplatelet agent Antidote
Heparin (UFH and LMWH) Protamine sulfate
Warfarin

Vitamin K, fresh frozen plasma (FFP), prothrombin protein concentrate (PPC), Factor VII concentrate

Note: PPC and Factor VII have effects within minutes; FFP and Vitamin K require hours–days to take full effect.
Direct factor X inhibitors (Fondaparinaux, Apixaban)

Four factor PCC

Oral activated charcoal

Andexanet alfa
Novel oral anticoagulants (NOAC)

Four factor PPC

Oral activated charcoal

Idarucizumab (Praxbind) for dabigatran reversal

+/- platelet transfusion for clopidogrel and ticagrelor

Attempts to treat spinal cord hemorrhage with medications such as mannitol or corticosteroids have not been tested in randomized, double-blind studies.  

If spinal cord hemorrhage presents a situation similar to spinal cord injury, high-dose corticosteroids (e.g., methylprednisolone) might be beneficial, but this needs to be weighed against possible side effects.

Inpatient and outpatient medications - additional

Spasticity secondary to spinal cord hemorrhage is treated in similar ways to spasticity secondary to other causes of traumatic spinal cord injury, or multiple sclerosis. Drugs include baclofen, tizanidine, and diazepam.

Pain following spinal cord hemorrhage (other than pain secondary to spasticity), is treated similarly to other neuropathic pain syndromes such as those in multiple sclerosis. Drugs may include gabapentin, pregabalin, amitriptyline, and/or carbamazepine.

Bladder complications of spinal cord hemorrhage also receive treatment similar to those of spinal cord injury / multiple sclerosis. Consultation with a urologist may be necessary. Drug therapy with anticholinergic agents may be beneficial for reflex uninhibited bladder (i.e., failure to store), and intermittent self-catheterization is essential in patients with inability to void (i.e., failure to empty).

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Antidotes (blood modifiers)

Class Summary

Anticoagulated patients may require a blood modifier.

Protamine

Neutralizes heparin effects by forming a salt.

Phytonadione (AquaMEPHYTON, Mephyton, Vitamin K)

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

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