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Case of the Month

Welcome to CNS Case of the Month Section.
The purpose of this Web area is to provide a forum for discussion and debate regarding the management of both ordinary and extraordinary cases. There are no right or wrong answers, but rather, there are various opinions on what should be the "standard of care." The answers given will be collected anonymously, and be presented in a graphical format at the end of each month. We will then see the spectrum of thought regarding the management of these patients.

We are always open to suggestions, and if you have a case or questions that you would like to have presented, please submit them to: info@1cns.org

Brian L. Hoh, MD
University of Florida
Ashok R. Asthagiri, MD
Associate Professor
Department of Neurological Surgery
University of Virginia
Maryam Rahman, MD MS
Assistant Professor
Department of Neurosurgery
University of Florida
Alexander A. Khalessi MD, MS
University of California San Diego
Wilson Z. Ray, MD
Assistant Professor in Neurosurgery
Department of Neurological Surgery
Washington University School of Medicine
Edward R. Smith, MD
Director, Pediatric Cerebrovascular Surgery
Department of Neurosurgery
Children's Hospital Boston / Harvard Medical School
Sameer Sheth, MD, PhD
Assistant Professor of Neurosurgery
Columbia University Medical Center
New York Presbyterian Hospital
August 2014: 75-year-old Man with Anterior Spinal Syndrome


  • 75-year-old man on apixaban (Eliquis) for atrial fibrillation presents with 48 hours of progressive bilateral leg weakness
  • Now with 24 hours of paraplegia but intact propioception and vibration sense
  • Loss of bowel/bladder control

Figure 1:
[Click to view larger image]
Click image to view larger picture.

1. The next best step in management would be:
    a. Posterior thoracic laminectomies and evacuation of hematoma
    b. Anterior thoracic approach and evacuation of hematoma
    c. Spinal angiogram
    d. Corticosteroids protocol
    e. ICU and induced-hypertension
2. The reversal of apixaban can be achieved with:
    a. Platelet transfusion
    b. Protamine
    c. Vitamin K
    d. Kcentra (4-factor Prothrombin complex concentrate)
    e. Fresh frozen plasma
3. The most likely diagnosis would be:
    a. Spinal cord cavernous malformation
    b. Hemorrhagic spinal ependymoma
    c. Hemorrhagic spinal cord hemangioblastoma
    d. Spinal AVM
    e. Spontaneous hemorrhage from anticoagulation
4. Which of the following describes you?
    a.   Resident/fellow
    b.   Private practice
    c.   Academics
5. I practice in one of the following locations.
    a.   I practice in one of the following states: WA, OR, CA, AK, HI
    b.   I practice in one of the following states: AZ, ID, NV, MT, WY, CO, NM, UT
    c.   I practice in one of the following states: ND, SD, NE, KS, OK, MN, IA, MO, WI, IL MI, IN, OH
    d.   I practice in one of the following states: TX, AR, AL, LA, KY, TN, MS, WV, NC, SC, GA, FL
    e.   I practice in one of the following states: ME, VT, NH, MA, RI, CT, NJ, NY, PA, DE, MD, DC, VA
    f.   I practice in Mexico or Canada
    g.   I practice in South America
    h.   I practice in Europe
    i.   I practice in Asia
    j.   I practice in Australia/Pacific Rim
    k.   I practice in Africa

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Pubmed References
Pubmed References
  • Fawole A, Daw HA, Crowther MA. Practical management of bleeding due to the anticoagulants dabigatran, rivaroxaban, and apixaban. Cleve Clin J Med. 2013 Jul;80(7):443-51. doi: 10.3949/ccjm.80a.13025.

  • Vascular diseases of the spinal cord.
    Rubin MN, Rabinstein AA.
    Neurol Clin. 2013 Feb;31(1):153-81. doi: 10.1016/j.ncl.2012.09.004. Review.
    PMID: 23186899 [PubMed - indexed for MEDLINE]

  • Spinal cord tumors: new views and future directions.
    Mechtler LL, Nandigam K.
    Neurol Clin. 2013 Feb;31(1):241-68. doi: 10.1016/j.ncl.2012.09.011. Review.
    PMID: 23186903 [PubMed - indexed for MEDLINE]