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LETTER TO EDITOR
Year : 2022  |  Volume : 70  |  Issue : 4  |  Page : 1674-1675

Spontaneous Spinal Epidural Hematoma in a Patient on Rivaroxaban: A Case Report


1 Department of Neurosurgery, “Korgialenio Benakio” Red Cross Hospital of Athens, Athens, Greece
2 Department of Anesthesiology, “Korgialenio Benakio” Red Cross Hospital of Athens, Athens, Greece

Date of Submission15-Jul-2019
Date of Decision04-Nov-2019
Date of Acceptance13-Jul-2020
Date of Web Publication30-Aug-2022

Correspondence Address:
Stylianos Pikis
Department of Neurosurgery, “Korgialenio Benakio” Red Cross Hospital of Athens, P.O. Box 11526, Athens
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.355150

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How to cite this article:
Barkas K, Petrosyan T, Mantziaris G, Papigki E, Pikis S. Spontaneous Spinal Epidural Hematoma in a Patient on Rivaroxaban: A Case Report. Neurol India 2022;70:1674-5

How to cite this URL:
Barkas K, Petrosyan T, Mantziaris G, Papigki E, Pikis S. Spontaneous Spinal Epidural Hematoma in a Patient on Rivaroxaban: A Case Report. Neurol India [serial online] 2022 [cited 2022 Oct 7];70:1674-5. Available from: https://www.neurologyindia.com/text.asp?2022/70/4/1674/355150




Sir,

Spontaneous spinal epidural hematoma (SSEH) occurs with an incidence of 0,1/100000 per year and accounts for less than 1% of all spinal epidural space occupying lesions.[1],[2] Although anticoagulant medications have been reported as the second most common predisposing factor responsible for spinal hematoma development,[3] rivaroxaban-associated SSEH has been rarely described.[2]

We report on a 72-year-old male who presented in the Emergency room due to progressive, left hemiparesis. He reported sudden onset of severe neck pain at rest followed by progressive weakness of his left upper and lower limbs 6 h prior to admission. His past medical history was significant for rivaroxaban ingestion due to atrial fibrillation and hypertension. Physical examination revealed left upper limb plegia, left lower limb paresis (3/5), and urinary retention. Noncontrast head computerized tomography (CT) scan was unremarkable [Figure 1]a. Cervical spine CT scan was significant for a dorsal, epidural, hemorrhagic, space occupying lesion extending from C2 to C4 [Figure 1]a, [Figure 1]b. Cervical spine magnetic resonance image demonstrated spinal cord compression due to a left, dorsal, epidural hematoma extending from the C2 to the C4 [Figure 1]c, [Figure 1]d. Admission INR was 2,13. After administration of 2000 Units of four-factor pro-thrombin complex concentrate (PCC) the patient underwent left-sided C2 and C3 hemi-laminectomy, fenestration at the C4 and hematoma evacuation. Histopathologic examination confirmed the hematoma diagnosis. Postoperatively, his symptoms improved. He was discharged on postoperative day 9 with left upper limb paresis (3/5) and instructions for physiotherapy.
Figure 1: (a) Coronal, contrast enhanced, cervical spine, and head computerized tomography (CT) scan and (b) axial, contrast enhanced cervical spine CT scan demonstrating a hemorrhagic, extradural, space occupying lesion (SOL) at the C2 through C4 levels. (c) Saggital, T2 weighted (d), and axial, Gradient-echo, cervical spine magnetic resonance image significant for spinal cord compression due to an epidural SOL

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SSEH most commonly affects males in their fourth and fifth decade of life.[1],[3],[4],[5] It usually presents with acute pain at the hematoma level followed by neurologic deterioration with or without sphincter disturbance.[3] SSEH occurs due to bleeding from an epidural artery, vein, or from an epidural vascular malformation[1] and is most commonly located in the dorsal cervico-thoracic and thoraco-lumbar regions[1],[3]

Treatment of rivaroxaban-associated SSEH should be individualized and based on patient presentation, symptom progression, time of last dose of rivaroxaban, and patient co-morbidities. The anticoagulation forum suggests treatment with andexanet alfa in patients with rivaroxaban-associated major bleeding in whom a reversal agent is warranted. If andexanet alfa is not available, treatment with four-factor PCC 2000units is suggested.[6]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Figueroa J, DeVine JG. Spontaneous spinal epidural hematoma: Literature review. J Spine Surg 2017;3:58-63.  Back to cited text no. 1
    
2.
Goldfine C, Glazer C, Ratzan R. Spontaneous Spinal Epidural Hematoma from Rivaroxaban. Clin Pract Cases Emerg Med 2018;2:151-4.  Back to cited text no. 2
    
3.
Kreppel D, Antoniadis G, Seeling W. Spinal hematoma: A literature survey with meta-analysis of 613 patients. Neurosurg Rev 2003;26:1-49.  Back to cited text no. 3
    
4.
Tewari MK, Pandey AK. Spontaneous spinal extradural haematoma. Neurol India 1999;47:159.  Back to cited text no. 4
    
5.
Cetinalp NE, Oktay K, Ozsoy KM. Spontaneous spinal epidural hematoma mimicking a cerebrovascular disease. Neurol India 2017;65:1434-5.  Back to cited text no. 5
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6.
Cuker A, Burnett A, Triller D, Crowther M, Ansell J, Van Cott EM, et al. Reversal of direct oral anticoagulants: Guidance from the anticoagulation forum. Am J Hematol 2019;94:697-709.  Back to cited text no. 6
    


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