Blood/Fluid Level in Warfarin Toxicity

A 64-year-old woman presented to the emergency department due to altered level of consciousness following a headache. She had undergone mitral valve replacement during the past month and was being treated with warfarin (5 mg/daily) afterwards. However, she was not following any clinic on a regular basis. She had a progressive headache that started a day before presentation. Headache was accompanied by nausea, vomiting, and lightheadedness. The patient’s consciousness had decreased gradually. On examination, her Glasgow coma scale (GCS) was 11/15. Her blood pressure was 150/80, but other vital signs were normal. Although she was uncooperative for neurologic assessment, gross motor movements were symmetrical and the reflexes were increased in her lower extremity. Other examinations, including pupillary reflexes were normal. The laboratory study was significant for prolonged prothrombin time (PT) and international normalization ratio (INR) (45seconds and 4.44 respectively).  Computed tomography (CT) scan showed several intracerebellar hemorrhages with blood/fluid level (Fig 1). The diagnosis of warfarin toxicity was made based on the clinical scenario. In order to reverse the

warfarin effect, fresh frozen plasma was prescribed and the patient was admitted to the neurologic intensive care unit.  She underwent neurosurgical operation after deterioration of her condition. The operation confirmed the diagnosis with several foci of hemorrhages. Unfortunately, after operation, there was no improvement in her condition and the patient died after a week in intensive care unit. “Blood/fluid level” is due to the separation of the plasma and sedimented blood that shows ongoing fibirnolysis and hypofibrinogenema [1-3]. It is illustrated by an  area of low CT attenuation above and high CT attenuation below by a discrete line of separation in an area of intraparenchymal hemorrhage [1]. Arteriovenous malformation, tumors and bleeding disorders can cause intraparenchymal hemorrhage due to blood/fluid level [1]. In a patient who is being treated with warfarin and who presents with headache, confusion, ataxia, nausea and vomiting with a CT scan showing blood/fluid level, warfarin toxicity should be considered.

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