Images in Cardiovascular Medicine
Spontaneous Spinal Epidural Hematoma Following Transcatheter Aortic Valve Replacement
2020 Volume 2 Issue 3 Pages 205-206
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2020 Volume 2 Issue 3 Pages 205-206
An 84-year-old man was referred to hospital for symptomatic severe aortic valve stenosis. He had no history of vascular malformation, coagulation disorders, or anticoagulant therapy. Echocardiography showed an aortic valve area of 0.73 cm2 and a mean gradient of 57 mmHg. Transcatheter aortic valve replacement (TAVR) using a balloon expandable valve was performed under dual antiplatelet therapy (100 mg aspirin and 75 mg clopidogrel) according to the then-current recommendations of consensus-based international guidelines. A total of 5,000 units of heparin were given during TAVR, with subsequent reversal using protamine. Immediately after TAVR, he had no neurological abnormalities. Five hours later, however, the patient developed paraplegia in both legs with vesicorectal disturbances. Magnetic resonance imaging of the thoracic (T) spine showed that an epidural hematoma, located at T7–T10, had pressed on and displaced the spinal cord (Figure). Spontaneous spinal epidural hematoma (SSEH) was diagnosed. Laminoplasty of T7–T11 and evacuation of the hematoma were performed. The vesicorectal disturbances improved, whereas the paresis in the lower limbs persisted after 8 months of rehabilitation.
(A) Sagittal and (B) axial T1-weighted, and (C) sagittal and (D) axial T2-weighted magnetic resonance imaging of the thoracic spine showing an epidural hematoma (white arrows).
SSEH, defined as blood in the epidural space without known traumatic or iatrogenic cause, is a rare condition with an incidence of 0.1/100,000 patients per year.1 Risk factors include arteriovenous malformation, anticoagulant therapy, underlying coagulopathy, and vertebral hemangioma. Generally, neurological deficits after TAVR are indicative of procedure-related stroke. When patients present with bilateral neurological symptoms, however, clinicians should also consider SSEH in the differential diagnosis. Moreover, to minimize the risk of bleeding complications, anti-thrombotic regimens should be determined considering the risk-benefit balance of bleeding and embolic complications.
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