Spontaneous spinal epidural hematoma and spinal cord infarction following orthotopic liver transplantation: Case report and review of the literature
A 65-year-old female with hepatitis C-related cirrhosis and HCC presented for OLT. The patient previously underwent treatment for HCC with multiple transarterial chemoembolizations, radiofrequency ablation, and laparoscopic hepatic wedge resection for masses in the right lobe of the liver. Her past history was significant for hypertension and uterine cancer requiring total abdominal hysterectomy with bilateral salpingo-oopherectomy. Prior to transplantation, the patient was neurologically intact.\nWhen a suitable donor organ became available, the patient was taken to the operating room for OLT using conventional techniques and veno-venous bypass. Surgery was complicated, however, by donor liver edema after reperfusion. Secondary to edema and with inability to obtain adequate hemostasis, the abdomen was packed and temporarily closed. Posttransplant Doppler ultrasound was performed and ruled out inferior vena cava (IVC) outflow obstruction. The patient was resuscitated in the intensive care unit and then taken back to the operating room the following day. Approximately 1 L of hematoma was evacuated from the abdomen after which careful inspection showed excellent hemostasis. The abdomen was then closed in standard fashion. The patient was extubated. She did have a fluctuating coagulopathy and thrombocytopenia (INR 1.7 and platelets 21,000 on posttransplant day one); this is not abnormal for patients postliver transplantation.\nOn posttransplant day 5 she developed respiratory distress and subsequently suffered a cardiac arrest with pulseless electrical activity. Cardiopulmonary resuscitation (CPR) was administered with eventual conversion to ventricular fibrillation, which was then treated with electrical defibrillation using 300 J. Following the cardiac arrest, the patient required reintubation and suffered from aspiration pneumonitis. Hypotension required the administration of vasopressive medications. Left lower extremity edema prompted a Doppler ultrasound that showed an occlusive deep venous thrombosis (DVT). This warranted the placement of a retrievable IVC filter, during which a nonocclusive thrombus in the infrarenal IVC was noted.\nWhen the patient's mental status improved on posttransplant day 10, it became clear that she was plegic in both lower extremities. Magnetic resonance imaging (MRI) of the cervical, thoracic, and lumbar spine [] demonstrated epidural hematoma located dorsally at the foramen magnum, and both ventrally and dorsally from C7 to T6. The hematoma was hyperintense on both T1- and T2-weighted sequences, consistent with extracellular methemoglobin (late subacute hemorrhage, >7 days). In the lower thoracic spine there was marked spinal cord edema consistent with infarction characterized by an increased T2 signal from T8-T12.\nDue to the age of the hematoma, the plegic deficit and presence of spinal cord infarction, and her life-threatening continued coagulopathy, the patient was not considered a candidate for surgery (e.g., decompressive laminectomy for evacuation of the hematoma). She did, however, receive an 8-day course of intravenous methylprednisolone as part of the routine posttransplant immunosuppresion. Although the patient slowly recovered (tracheostomy for prolonged ventilator-dependent respiratory failure with subsequent weaning from the ventilator), she remained plegic in both lower extremities 6 months posttransplantation.