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Internal iliac artery aneurysm rupture secondary to anticoagulation causing sciatica
European Geriatric Medicine 1 (2010) 172–173
European geriatric medicine: EGM clinical case
Internal iliac artery aneurysm rupture secondary to anticoagulation causing sciatica D. Sivapathasuntharam *, C. Oclee-Brown, P. Reynolds Department of Medicine, Kent and Sussex Hospital, Mount Ephraim, Tunbridge Wells TN4 8AT, Kent, United Kingdom
A R T I C L E I N F O
Article history: Received 24 April 2010 Accepted 6 May 2010 Available online 18 June 2010
Keywords: Internal iliac artery aneurysm Sciatica Anti-coagulation Elderly Acute coronary syndromes
1. Introduction In this report we discuss the case of an elderly gentleman who acutely presented with a common medical symptom, was treated with conventional therapy but then subsequently developed an unusual but significant complication. 2. Case report An 89-year-old man presented with chest pain lasting three hours associated with dyspnoea and dizziness. He had a history of asthma, prostate cancer and osteoarthritis. He had previously been independent and mobile. On examination, he was haemodynamically stable, chest and cardiovascular examinations were normal. An electrocardiogram showed sinus rhythm with no acute changes. D-Dimers were elevated and initial troponin I was 0.08 mg/L (N < 0.03 mg/L). Arterial blood gas examination on air revealed pH 7.425, pCO2 5.17 (kPa) and pO2 9.09 (kPa). Treatment for a possible pulmonary embolism was commenced but this was stopped when CT pulmonary angiography showed no evidence of pulmonary embolism. As a repeat troponin at 12 hours rose to 0.25 mg/L (N < 0.03 mg/L), treatment was commenced for the acute coronary * Corresponding author. Department of Ageing and Health, 9th floor, North Wing, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, United Kingdom. Tel.: +44 0207 1882515; fax: +44 0207 9282339. E-mail address: [email protected] (D. Sivapathasuntharam).
syndrome; with aspirin, low molecular weight heparin and clopidogrel. On Day 3 of admission, he developed pain in the left buttock and left hip joint which was initially attributed to osteoarthritis. By Day 5, he was unable to extend and flex both his left hip and knee. Loss of power was, in part, attributed to pain, which impeded accurate neurological examination. Analgesia was given and anticoagulation stopped. Once pain was controlled, repeat examination confirmed inability to extend and flex the left hip and knee, power graded 0/5. He had loss of left plantar flexion, reduced sensation over his left thigh, an absent left ankle jerk but normal perianal tone and peripheral pulses. Plain radiographs showed degenerative lumbar scoliosis. MRI of his spine was unremarkable. On Day 10, his haemoglobin dropped three units with no obvious focus for blood loss. CT abdomen was performed which showed an aneurysm of the left internal iliac artery measuring 7.8 by 5.8 cm with an oblique longitude dimension in excess of 8 cm and considerable surrounding thrombus and possible localised rupture (Fig. 1). The location could cause compression on the sciatic nerve. There was also a localised retroperitoneal haemorrhage into the left iliopsoas muscle. He was transferred to a tertiary referral centre and underwent percutaneous left internal iliac embolisation. Further neurological review concluded that his signs and symptoms were compatible with lumbosacral plexus compression. EMG demonstrated axonal loss in his left quadraceps, iliopsoas and tibialis anterior. Attempts at gaining some functional improvement in that limb were unsuccessful. On discharge, he had a significant disability and needed considerable assistance with his activities of daily living. 3. Discussion Aneurysms of the internal iliac arteries are rare, they have an incidence of < 1% of all aorto-iliac aneurysms [1]. The incidence of rupture and mortality of these aneurysms is high [1]. As these aneurysms occur within the pelvis, they can expand to large sizes before becoming symptomatic [1]. Eighteen percent of internal iliac artery aneurysms cause neurological symptoms and 8% cause hip or buttock pain [2]. Other symptoms include abdominal pain (32%), urological symptoms (28%), groin pain (11%) and gastrointestinal symptoms (8%) [2].
1878-7649/$ – see front matter ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. doi:10.1016/j.eurger.2010.05.005
[(Fig._1)TD$IG]
D. Sivapathasuntharam et al. / European Geriatric Medicine 1 (2010) 172–173
173
Recent prescription of anti-thrombotic therapy should raise suspicions further. Earlier detection may have reduced the degree of functional impairment experienced by our patient, thus preserving his independence. This case re-iterates the difficulties of applying conventional treatment regimes to older patients in whom the risks potentially outweigh the benefits. Although this was a rare presentation, it adds to the evidence-base that older patients are a high risk group. Although patients should never be denied potentially life saving treatments on grounds of age alone, careful consideration should be made when prescribing even common therapeutic regimes. Learning points Older patients are a high-risk group and conventional therapy may be associated with significant complications. Acute sciatic pain or leg weakness may be related to an iliac artery aneurysm and in the context of anticoagulation may suggest a haemorrhage.
Fig. 1. The arrow demonstrates the aneurysm with thrombus.
Conflict of interest statement Nothing declared.
Our patient was asymptomatic prior to admission. It is plausible that extensive anticoagulation may have contributed to the enlargement or rupture of a previously undiagnosed internal iliac artery aneurysm. It is extremely rare for aneurysms in the pelvis to present as severe sciatica although this is not the first documented case [3,4,5]. Our case appears to be unique in that the clinical picture was possibly associated with anti-thrombotic therapy. Older patients with acute coronary syndromes still have a high risk of death and adverse outcome and often they have a greater treatment benefit than their younger counterparts [6]. However, in spite of the growing elderly population, current evidence remains limited and insufficient to guide management in this cohort with the same certainty that exists in a younger group [6]. Several studies have highlighted an increased bleeding risk associated with conventional triple anti-thrombotic therapy [7–9]. Advanced age is an independent predictor for bleeding. A new therapy for managing acute coronary syndromes is fondaparinux, a synthetic factor X inhibitor. It has been shown to reduce mortality, ischaemic events and major bleeding compared to heparin even in patients who are over 65 years of age [10]. This therapy could be considered more, particularly in the older high-risk patient. 4. Conclusions It is important to consider rare causes of sciatica and leg weakness, particularly when the symptoms present acutely.
References [1] Parry DJ, Kessel D, Scott DJA. Simplifying the internal iliac artery aneurysm. Ann R Coll Surg Engl 2001;83:302–8. [2] Dix FP, Titi M, Al-Khaffaf H. The isolated Internal Iliac artery aneurysm – a review. Eur J Vasc Endovascular Surg 2005;30:119–29. [3] Geelen JA, de Graaff R, Biemans RG, Prevo RL, Koch PW. Sciatic nerve compression by an aneurysm of the internal iliac artery. Clin Neurol Neurosurg 1985;87:219–22. [4] Gardiner MD, Mangwani J, Williams WW. Aneurysm of the common iliac artery presenting as a lumbosacral plexopathy. J Bone Joint Surg Br 2006;88: 1524–6. [5] Dudeney S, O’Farrell D, Bouchier-Hayes D, Byrne J. Extraspinal causes of sciatica. A case report. Spine 1998;23:494–6. [6] Alexander KP, Newby LK, Cannon CP, Armstrong PW, Gibler WB, Rich MW, et al. Acute coronary care in the elderly. Part 1: non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 2007;115:2549–69. [7] Patrono C, Garcia Rodriguez LA, Landolfi R, Baigent C. Low-dose aspirin for the prevention of atherothrombosis. N Eng J Med 2005;353:2373–83. [8] Orford JL, Fasseas P, Melby S, Burger K, Steinhubl SR, Holmes DR, et al. Safety and efficacy of aspirin, clopidogrel and warfarin after coronary stent placement in patients with an indication for anticoagulation. Am Heart J 2004;147:463–7. [9] Bursely K, Eisenberg MJ, Zhang X, Pilote L. Bleeding complications associated with combination of aspirin, thienopyridine derivatives and warfarin in elderly patients following acute myocardial infarction. Arch Intern Med 2005;165:784–9. [10] Mehta S, Boden W, Eikelboom J, Flather M, Steg PG, Avezum A, et al. Antithrombotic therapy with fondaparinux in relation to interventional management strategy in patients with ST- and non-ST-segment elevation acute coronary syndromes: an individual patient-level combined analysis of the fifth and sixth organization to assess strategies in ischemic syndromes (OASIS 5 and 6) randomized trials. Circulation 2008;118:2038–46.
European geriatric medicine: EGM clinical case
Internal iliac artery aneurysm rupture secondary to anticoagulation causing sciatica D. Sivapathasuntharam *, C. Oclee-Brown, P. Reynolds Department of Medicine, Kent and Sussex Hospital, Mount Ephraim, Tunbridge Wells TN4 8AT, Kent, United Kingdom
A R T I C L E I N F O
Article history: Received 24 April 2010 Accepted 6 May 2010 Available online 18 June 2010
Keywords: Internal iliac artery aneurysm Sciatica Anti-coagulation Elderly Acute coronary syndromes
1. Introduction In this report we discuss the case of an elderly gentleman who acutely presented with a common medical symptom, was treated with conventional therapy but then subsequently developed an unusual but significant complication. 2. Case report An 89-year-old man presented with chest pain lasting three hours associated with dyspnoea and dizziness. He had a history of asthma, prostate cancer and osteoarthritis. He had previously been independent and mobile. On examination, he was haemodynamically stable, chest and cardiovascular examinations were normal. An electrocardiogram showed sinus rhythm with no acute changes. D-Dimers were elevated and initial troponin I was 0.08 mg/L (N < 0.03 mg/L). Arterial blood gas examination on air revealed pH 7.425, pCO2 5.17 (kPa) and pO2 9.09 (kPa). Treatment for a possible pulmonary embolism was commenced but this was stopped when CT pulmonary angiography showed no evidence of pulmonary embolism. As a repeat troponin at 12 hours rose to 0.25 mg/L (N < 0.03 mg/L), treatment was commenced for the acute coronary * Corresponding author. Department of Ageing and Health, 9th floor, North Wing, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, United Kingdom. Tel.: +44 0207 1882515; fax: +44 0207 9282339. E-mail address: [email protected] (D. Sivapathasuntharam).
syndrome; with aspirin, low molecular weight heparin and clopidogrel. On Day 3 of admission, he developed pain in the left buttock and left hip joint which was initially attributed to osteoarthritis. By Day 5, he was unable to extend and flex both his left hip and knee. Loss of power was, in part, attributed to pain, which impeded accurate neurological examination. Analgesia was given and anticoagulation stopped. Once pain was controlled, repeat examination confirmed inability to extend and flex the left hip and knee, power graded 0/5. He had loss of left plantar flexion, reduced sensation over his left thigh, an absent left ankle jerk but normal perianal tone and peripheral pulses. Plain radiographs showed degenerative lumbar scoliosis. MRI of his spine was unremarkable. On Day 10, his haemoglobin dropped three units with no obvious focus for blood loss. CT abdomen was performed which showed an aneurysm of the left internal iliac artery measuring 7.8 by 5.8 cm with an oblique longitude dimension in excess of 8 cm and considerable surrounding thrombus and possible localised rupture (Fig. 1). The location could cause compression on the sciatic nerve. There was also a localised retroperitoneal haemorrhage into the left iliopsoas muscle. He was transferred to a tertiary referral centre and underwent percutaneous left internal iliac embolisation. Further neurological review concluded that his signs and symptoms were compatible with lumbosacral plexus compression. EMG demonstrated axonal loss in his left quadraceps, iliopsoas and tibialis anterior. Attempts at gaining some functional improvement in that limb were unsuccessful. On discharge, he had a significant disability and needed considerable assistance with his activities of daily living. 3. Discussion Aneurysms of the internal iliac arteries are rare, they have an incidence of < 1% of all aorto-iliac aneurysms [1]. The incidence of rupture and mortality of these aneurysms is high [1]. As these aneurysms occur within the pelvis, they can expand to large sizes before becoming symptomatic [1]. Eighteen percent of internal iliac artery aneurysms cause neurological symptoms and 8% cause hip or buttock pain [2]. Other symptoms include abdominal pain (32%), urological symptoms (28%), groin pain (11%) and gastrointestinal symptoms (8%) [2].
1878-7649/$ – see front matter ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. doi:10.1016/j.eurger.2010.05.005
[(Fig._1)TD$IG]
D. Sivapathasuntharam et al. / European Geriatric Medicine 1 (2010) 172–173
173
Recent prescription of anti-thrombotic therapy should raise suspicions further. Earlier detection may have reduced the degree of functional impairment experienced by our patient, thus preserving his independence. This case re-iterates the difficulties of applying conventional treatment regimes to older patients in whom the risks potentially outweigh the benefits. Although this was a rare presentation, it adds to the evidence-base that older patients are a high risk group. Although patients should never be denied potentially life saving treatments on grounds of age alone, careful consideration should be made when prescribing even common therapeutic regimes. Learning points Older patients are a high-risk group and conventional therapy may be associated with significant complications. Acute sciatic pain or leg weakness may be related to an iliac artery aneurysm and in the context of anticoagulation may suggest a haemorrhage.
Fig. 1. The arrow demonstrates the aneurysm with thrombus.
Conflict of interest statement Nothing declared.
Our patient was asymptomatic prior to admission. It is plausible that extensive anticoagulation may have contributed to the enlargement or rupture of a previously undiagnosed internal iliac artery aneurysm. It is extremely rare for aneurysms in the pelvis to present as severe sciatica although this is not the first documented case [3,4,5]. Our case appears to be unique in that the clinical picture was possibly associated with anti-thrombotic therapy. Older patients with acute coronary syndromes still have a high risk of death and adverse outcome and often they have a greater treatment benefit than their younger counterparts [6]. However, in spite of the growing elderly population, current evidence remains limited and insufficient to guide management in this cohort with the same certainty that exists in a younger group [6]. Several studies have highlighted an increased bleeding risk associated with conventional triple anti-thrombotic therapy [7–9]. Advanced age is an independent predictor for bleeding. A new therapy for managing acute coronary syndromes is fondaparinux, a synthetic factor X inhibitor. It has been shown to reduce mortality, ischaemic events and major bleeding compared to heparin even in patients who are over 65 years of age [10]. This therapy could be considered more, particularly in the older high-risk patient. 4. Conclusions It is important to consider rare causes of sciatica and leg weakness, particularly when the symptoms present acutely.
References [1] Parry DJ, Kessel D, Scott DJA. Simplifying the internal iliac artery aneurysm. Ann R Coll Surg Engl 2001;83:302–8. [2] Dix FP, Titi M, Al-Khaffaf H. The isolated Internal Iliac artery aneurysm – a review. Eur J Vasc Endovascular Surg 2005;30:119–29. [3] Geelen JA, de Graaff R, Biemans RG, Prevo RL, Koch PW. Sciatic nerve compression by an aneurysm of the internal iliac artery. Clin Neurol Neurosurg 1985;87:219–22. [4] Gardiner MD, Mangwani J, Williams WW. Aneurysm of the common iliac artery presenting as a lumbosacral plexopathy. J Bone Joint Surg Br 2006;88: 1524–6. [5] Dudeney S, O’Farrell D, Bouchier-Hayes D, Byrne J. Extraspinal causes of sciatica. A case report. Spine 1998;23:494–6. [6] Alexander KP, Newby LK, Cannon CP, Armstrong PW, Gibler WB, Rich MW, et al. Acute coronary care in the elderly. Part 1: non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 2007;115:2549–69. [7] Patrono C, Garcia Rodriguez LA, Landolfi R, Baigent C. Low-dose aspirin for the prevention of atherothrombosis. N Eng J Med 2005;353:2373–83. [8] Orford JL, Fasseas P, Melby S, Burger K, Steinhubl SR, Holmes DR, et al. Safety and efficacy of aspirin, clopidogrel and warfarin after coronary stent placement in patients with an indication for anticoagulation. Am Heart J 2004;147:463–7. [9] Bursely K, Eisenberg MJ, Zhang X, Pilote L. Bleeding complications associated with combination of aspirin, thienopyridine derivatives and warfarin in elderly patients following acute myocardial infarction. Arch Intern Med 2005;165:784–9. [10] Mehta S, Boden W, Eikelboom J, Flather M, Steg PG, Avezum A, et al. Antithrombotic therapy with fondaparinux in relation to interventional management strategy in patients with ST- and non-ST-segment elevation acute coronary syndromes: an individual patient-level combined analysis of the fifth and sixth organization to assess strategies in ischemic syndromes (OASIS 5 and 6) randomized trials. Circulation 2008;118:2038–46.