ACUTE PAINLESS PROGRESSIVE QUADRIPLEGIA ASSOCIATED WITH WARFARIN USE

To the Editor: A 68-year-old man with a history of hypertension, atrial fibrillation (on warfarin), hyperlipidemia, congestive heart failure, chronic obstructive pulmonary disease, and dementia presented to the emergency department after sustaining a fall in his home. He suffered a contusion of his right hip and left forehead without a loss of consciousness. Initial examination by the emergency department physician revealed no weakness or other neurological deficits. A computed tomography (CT) scan of his head showed only atrophy and chronic white matter ischemic changes. Cervical spine and right hip x-rays demonstrated no bony pathology. He was found to have an international normalized ratio (INR) of 7.1 and was admitted for observation. On the second hospital day, he complained of right arm weakness, and a neurological consultation was requested. He had no neck pain or tenderness on neck movements. Examination confirmed dementia (Mini-Mental State Examination score 5 18) and revealed dysarthria and a mild right hemiparesis. He had diffusely brisk deep-tendon reflexes with bilateral extensor plantar responses. A repeat CT scan of his head performed emergently showed no changes from the prior scan, and a magnetic resonance imaging (MRI) scan of his brain and cervical spine was suggested. At this time, the patient also became short of breath with a significant cough and was started on intravenous corticosteroids for a presumed exacerbation of chronic obstructive pulmonary disease. He was unable to tolerate any initial attempt at attaining an MRI scan. The following day, the patient was found to be quadriparetic. His INR was 2.4, and he was transfused with fresh frozen plasma to reverse the coagulopathy. His respiratory status declined further, requiring intubation and transfer to a medical intensive care unit. After intravenous sedation, an MRI scan of his brain and cervical spine was performed, showing findings consistent with acute hemorrhage in the cervical cord with edema tracking cranially into the medulla (Figure 1). The patient was treated with intravenous dexamethasone. His INR at the time was 1.0. One week later, he developed high fevers and died from ventilator-associated pneumonia and systemic fungemia. The family refused an autopsy. Intraspinal hemorrhage is a rare but serious complication of anticoagulant therapy. It has been recommended that intraspinal hemorrhage be suspected in any patient taking anticoagulant agents who complains of local or referred spinal pain associated with limb weakness, sensory deficits, or urinary retention. To our knowledge, this is the first report of a patient with an intramedullary spinal cord hematoma without pain as the presenting symptom. The slowly progressive weakness with initial negative clinical examination and imaging studies suggested an evolving cervical hematoma. Although underlying vascular malformations cannot be excluded, the imaging studies were not suggestive. It was also not possible to exclude trauma as a contributing factor. Presence of cognitive impairment may prevent adequate communication of pain in older adults, although the patient was able to describe his clinical presentation and communicate his other needs and was not in discomfort while moving his neck and head. Nonetheless, cognitively impaired older people are at high risk for falling,