Spinal intradural hematoma after intrathecal drug delivery system implantation in a patient with possible heparin-induced thrombocytopenia: a case report.

BACKGROUND

Intrathecal drug delivery systems (IDDSs) can provide analgesia for selected patients with refractory cancer pain. Neuraxial implantation in patients receiving antithrombotic therapy carries a risk of spinal bleeding. Heparin-induced thrombocytopenia (HIT) is mainly prothrombotic and should be diagnosed by combining clinical probability with laboratory testing.

CASE PRESENTATION: A 50-year-old woman with metastatic rectal adenocarcinoma, refractory cancer pain, previous lower-extremity venous thromboembolism, and chronic aspirin use underwent image-guided IDDS implantation after peri-procedural enoxaparin exposure. Enoxaparin 1.5 mg/kg was stopped 24 hours before implantation. On the same day, she developed acute left lower-extremity weakness (2/5) and blood-tinged cerebrospinal fluid from the intrathecal catheter. Platelets fell from 145 × 109/L to 40 × 109/L, and hemoglobin was 54 g/L. MRI showed a T12-S2 spinal intradural hematoma compressing the conus medullaris and cauda equina. A heparin-induced platelet activation assay on postoperative day 2 was reported as strongly positive. Management included transfusion support, corticosteroids, neurotrophic support, lumbar cerebrospinal fluid drainage, and hematological stabilization. Strength improved to 4/5 by postoperative day 6. Intrathecal analgesia was resumed on postoperative day 12, and the pain score decreased to 3/10.

CONCLUSION

This case describes spinal intradural hematoma with acute thrombocytopenia after peri-procedural enoxaparin exposure. The findings support possible HIT but do not show that HIT directly caused the hematoma. The event was likely multifactorial. Acute platelet decline after heparin exposure and new neurological deficits after a neuraxial procedure require prompt evaluation and multidisciplinary management.