- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran.
DOI:10.25259/SNI_390_2019Copyright: © 2019 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Abolfazl Rahimizadeh, Zahed Malekmohammadi, Walter L. Williamson, Shaghayegh Rahimizadeh, Mahan Amirzadeh, Naser Asgari. Rivaroxaban-induced acute cervical spine epidural hematoma: Report of a case and review. 25-Oct-2019;10:210
How to cite this URL: Abolfazl Rahimizadeh, Zahed Malekmohammadi, Walter L. Williamson, Shaghayegh Rahimizadeh, Mahan Amirzadeh, Naser Asgari. Rivaroxaban-induced acute cervical spine epidural hematoma: Report of a case and review. 25-Oct-2019;10:210. Available from: http://surgicalneurologyint.com/surgicalint-articles/9723/
Background: Spontaneous spinal epidural hematomas (SEHs) due to the utilization of factor Xa inhibitors are rare.
Case Description: A 66-year-old female presented with a Brown-Sequard syndrome attributed to a cervical epidural hematoma secondary to the utilization of rivaroxaban, one of the factor Xa inhibitors. Following a cervical laminectomy for the evacuation of the hematoma, the patient completely recovered.
Conclusion: A spinal hemorrhagic event should be suspected in patients receiving factor Xa inhibitor drugs. Here, we had an elderly female on rivaroxaban experienced the acute onset of neck/back pain associated with a Brown-Sequard syndrome. A literature review showed that this is the seventh example of SEH occurring as a result of the use of anticoagulation drugs (OACDs; e.g., including Xa inhibitors).
Keywords: Anticoagulant, Factor Xa inhibitors, Rivaroxaban, Spinal epidural hematoma
Factor Xa inhibitor drugs, the newer oral anticoagulants, are increasingly utilized for the prevention of stroke in nonvalvular atrial fibrillation and the prevention/treatment of DVT and pulmonary emboli.[
A 66-year-old female presented acutely with neck pain/back pain and a classic Brown-Sequard syndrome of 1 day’s duration. The patient was taking rivaroxaban (15 mg, daily) and low-dose aspirin for atrial fibrillation. An emergent cervical MRI disclosed a dorsal-lateral C3-C6 cervical epidural mass. It was isointense on T1 weighted and hyperintense on T2-weighted MRIs; these findings were compatible with an acute cervical/SHE [
Etiology of SEH with Xa inhibitors
Factor Xa inhibitors are newer oral anticoagulant drugs which block thrombin formation, prevent conversion of fibrinogen to fibrin, and, hence, inhibit thrombus formation.[
Literature review of SEH occurring with factor Xa
A review of literature revealed that factor Xa inhibitor- induced SEH is mostly seen in the elderly and more so in females rather than males [
Treatment of SEH due to factor Xa
The management of SEH depends on the volume of the hematoma and the rapidity/severity of the neurological symptoms/signs.[
Optimal surgical timing
Early recognition and surgical intervention for SEHs with neurologic compromise remain key to achieving a favorable outcome.[
Optimal time for restarting anticoagulant
In one study, the optimal timing for readministration of Xa anticoagulants was 2–3 weeks postoperatively.[
For patients receiving factor Xa inhibitors, SEH should be included in the differential diagnosis where patients develop acute spinal/back pain and the onset of a significant neurological deficit. Performing immediate MR scans to document the location and severity of the SEH are critical. While those with lesser symptoms/signs may be managed conservatively, patients with significant neurological deficits may warrant urgent/emergent clot removal.
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