(Kiosk 3) Spontaneous Hemorrhage Throughout the Central Nervous System with Conus Medullaris Infarct After Stretching Exercises in an Elderly Male on Anticoagulation

Case Diagnosis: 83 yo male with a history of Atrial fibrillation treated with apixaban, sick sinus syndrome s/p pacemaker placement, carotid artery stenosis, and significant alcohol use presenting with severe back pain and progressive lower extremity weakness.

Case Description or Program Description: Patient reports he was performing toe-touch stretching exercises and later that day experienced sudden severe back pain radiating into both legs when arising from a chair, prompting presentation to a local hospital. The next day, he developed worsening back and leg pain with progressive weakness and numbness, ultimately resulting in complete loss of lower extremity motor and sensory function below the umbilicus and waxing/waning mental status. MRI revealed intracranial hemorrhages, subarachnoid and subdural hemorrhage throughout the cervical, thoracic, and lumbar spine with severe mass effect on cauda equina nerve roots at L1-L2, as well as signal abnormality concerning for cord infarct in the lower thoracic cord and conus. He underwent T8-S1laminectomy with decompression and evacuation of subdural hematoma and was eventually discharged to an inpatient rehabilitation facility.

Setting: Level one trauma center, inpatient rehabilitation facility

Assessment/Results: Evaluation at the inpatient rehabilitation facility was consistent with a T11 ASIA Impairment Scale A paraplegia. He had flaccid lower extremity paralysis and a reflexive anal sphincter consistent with a high conus medullaris syndrome, as well as cognitive deficits in setting of interventricular and bilateral cerebral (and cerebellar) subarachnoid hemorrhages and small posterior fossa subdural hemorrhages. He was able to discharge home with family with supervised use of a power wheelchair, on a clean intermittent catheterization program for neurogenic bladder and upper motor neuron bowel program.

Discussion (relevance): This case highlights the potential for massive neurological hemorrhage for patients on anticoagulation and is one of the first to demonstrate intracranial, subarachnoid, and subdural hemorrhage within the spine on apixaban specifically.

Conclusions: The sudden onset of a neurologic deficit with initiation of a home exercise program in the setting of therapeutic anticoagulation warrants prompt evaluation. In rare circumstances, extensive spontaneous CNS hemorrhage can be considered.