A fatal case of overwarfarinization leading to complete paraplegia with hematomyelia

Background: Warfarin is a commonly prescribed anticoagulant medication used for thromboprophylaxis in patients at an increased risk of thromboembolic events. However, warfarin administration can lead to hemorrhage due to its narrow therapeutic range. Hemorrhage may occur in unusual anatomical sites and can result in mortality. Case Presentation: We report the case of an 84-year-old male patient diagnosed with non-valvular atrial fibrillation (AF) and hyperthyroidism, who presented with the sudden onset of lower back pain, bilateral lower limb weakness, and paraesthesia. He was diagnosed with an intramedullary epidural hematoma leading to spinal cord compression as a consequence of overwarfarinization. Following the administration of a new increased dose of oral warfarin, the patient experienced sudden onset back pain accompanied by complete paraplegia. After reversing the overwarfarinization to a therapeutic level, an emergency surgical procedure involving spinal decompression, clot removal, and posterior instrumentation was planned. However, the patient developed an onset of unstable tachyarrhythmia following the administration of anesthesia, leading to the discontinuation of the surgery. Due to substantial risks, the patient declined to undergo the surgical procedure. Despite a consistent neurological condition, he developed a disability and subsequently succumbed to death due to a respiratory infection within four weeks following the initial presentation of symptoms. Conclusions: This case represents a rare instance of intramedullary epidural hematoma resulting in spinal cord compression due to overwarfarinization, highlighting the need for awareness and urgent management.