Delayed diagnosis of spinal subarachnoid hemorrhage in association with warfarin administration: a case report and literature review

Abstract

Spinal subarachnoid hemorrhage is a life-threatening condition often associated with markedly high morbidity and mortality rates. However, diagnosis is difficult because of its atypical symptoms. We herein describe a 52-year-old Chinese man who had been receiving warfarin therapy since having undergone mechanical mitral valve replacement surgery 3 years previously. Two days before admission to our hospital, he suddenly developed low back pain, urinary incontinence, and paraplegia. He was diagnosed with acute myelitis at a local hospital, but he subsequently developed a slight headache and was transferred to our hospital 2 days later. The patient was suspected to have subarachnoid hemorrhage based on his computed tomography (CT) findings. On the third day after admission, a CT scan showed both subarachnoid and cerebral hemorrhage. Blood tests revealed an international normalized ratio ranging from 1.44 to 1.86 and a prothrombin time of 16.5 to 21.3 s. We performed a lumbar puncture and obtained bloody cerebrospinal fluid. The patient also underwent spinal CT and angiography, which confirmed the diagnosis of spontaneous spinal subarachnoid hemorrhage. Because his general condition was poor, he underwent conservative treatment, and his neurologic function slightly improved after discharge.