Spinal Cord Hemorrhage Treatment & Management

Updated: Feb 19, 2019
  • Author: Morteza Sadeh, MD, PhD, MS; Chief Editor: Helmi L Lutsep, MD  more...
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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 or prothrombin complex concentrate 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. The optimal treatment to reverse the effects of the new oral anticoagulants is unknown.

Another potential medical treatment, drug therapy for cord edema, is unproved.

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Surgical Care

Depending on etiology (deduced from history, lab work, and imaging) and clinical findings (such as the presence or progression of neurological deficits), surgery may be indicated for hemorrhage affecting the spinal cord. Surgery would not be expected to reverse the damage already caused by infarction.

In general, surgery should be strongly considered in spinal subdural hemorrhage and epidural hemorrhage. Patients with these conditions may benefit from immediate decompressive operation if associated neurological signs and symptoms are present (e.g., weakness, paresthesiae, loss of sphincter control, positive Babinski, etc.). [24, 25]  

It should be noted, however, that even emergency surgery cannot guarantee full return of function, and management decisions are made on a case-by-case basis. If coagulopathy is present, it may need to be corrected, and the patient may require medical stabilization.

Spinal vascular lesions may be approached by catheter-based interventional techniques, such as embolization or coiling.

Endovascular embolization for AVF or combined embolization followed by surgical resection for AVM may be indicated for patients with spinal SAH. [1] The decision of embolization vs. surgery or whether or not to perform any intervention is complex and depends on the presence of neurologic symptoms, acuity of symptom presentation and hemorrhage, location of the AVM (ventral vs. dorsal; proximity to critical spinal cord tracts), and location and number of feeding arteries and draining veins, presence of nidus, and any associated fistulas.  

Even if significant obliteration is achieved by endovascular embolization, an AVM may still require operative resection.  In the case of partial embolization, surgery is usually performed. The long-term clinical outcome of patients treated for AVMs (by endovascular intervention, surgery, or both) varies according to the nidus versus fistulous type of AVM. Patient outcomes are usually better in the latter type, which may depend on the degree of obliteration, and inherent hemodynamic differences between the two types. [26]

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Consultations

The following consultations may prove helpful:

  • Neurosurgeon – acute
  • Neurologist – acute
  • Interventional neuroradiologist – acute
  • Hematologist – acute (if indicated)
  • Urology – as needed
  • Rehabilitation physician – long term
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