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).
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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A 60-year-old female presented with gradual onset of worsening back pain, lower extremity weakness, and paresthesia (over 6-8 days). She was found to have a spinal arteriovenous malformation in the thoracic region. A sagittal T2 MRI section of thoracic spine showed a heterogeneous, non-enhancing intradural extra-medullary mass (red arrow) displacing the spinal cord in the thoracic spine spanning from lower cervical to T11. The mass may represent AVM with corresponding hemorrhage. The hemorrhage involved late subacute intramedullary with some chronic component.
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Spinal angiography in the same 60-year-old female patient as above further characterized the AVM and the feeding arteries which were successfully embolized. Also noted are the tortuous subarachnoid spinal veins (yellow arrows) which increased pressure on the cord and contributed to the development of Foix-Alajouanine syndrome.
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A 62-year-old male presented with a sudden onset of severe back pain, lower extremity weakness, and loss of sensation. A sagittal thoracic T2 MRI showed an intradural mass in the lower thoracic region, along with hemorrhage (red arrow). The hemorrhage contained both chronic and subacute and is contained to the subdural space.
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Spinal angiography on the same 62-year-old male patient showed a dissecting aneurysm of the recurrent radicular medullary branch of artery of Adamkiewicz originating from the left T10 and supplying the anterior spinal artery. It was subsequently treated via endovascular embolization.
Tables
- Table 1. Summary of intramedullary spinal cord hemorrhage etiologies, with history and associated clues, common imaging findings, and representative management. Adapted from Leep, Hunderfund, & Wijdicks (2009).
- 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.
| Etiology | History clues | Imaging findings | Management |
|---|---|---|---|
| Spinal trauma | MVA, falls, sports | Associated injury to bony and/or ligamentous structures | Spine stablization/decompression; debated rolde of steroids |
| Spinal AVM | Sudden onset of neurological deficits, severe back pain, and meningismus | Abnormal vessels with flow voids | Endovascular embolizations vs. surgical resection |
| Spinal cavernoma | Family or personal history of cavernomas | “Popcorn”-like lesions with associated hemosiderin rings | Possible surgery if recurrent bleeds |
| Coagulation deficits | History of warfarin, heparin, or other medications; elevated PTT or INR; sudden onset of deficits; genetic causes; liver or autoimmune disease; malignancy | Possible air-fluid levels | Anticoagulation reversal; correction of deficient coagulation factor(s); treatment of underlying problem |
| Spinal cord tumor | Progressive neurological deficits; known history of cancer (especially renal cell carcinoma) | Mass effect with spinal cord enlargement; contrast enhancement | Surgical resection; radiation for malignancy |
| 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 |
