- Department of Neurosurgery, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia.
- Department of Undergraduate Program in Medicine, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia.
Andre Marolop Pangihutan Siahaan, Department of Neurosurgery, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia.
DOI:10.25259/SNI_608_2022Copyright: © 2022 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, transform, 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: Andre Marolop Pangihutan Siahaan1, Steven Tandean1, Bahagia Willibrordus Maria Nainggolan2. Spontaneous epidural hematoma induced by rivaroxaban: A case report and review of the literature. 16-Sep-2022;13:420
How to cite this URL: Andre Marolop Pangihutan Siahaan1, Steven Tandean1, Bahagia Willibrordus Maria Nainggolan2. Spontaneous epidural hematoma induced by rivaroxaban: A case report and review of the literature. 16-Sep-2022;13:420. Available from: https://surgicalneurologyint.com/surgicalint-articles/11871/
Background: Trauma is the most frequent reason for epidural bleeding. However, numerous investigation had discovered that anticoagulants such as rivaroxaban could cause epidural hematoma. Here, we present a case of epidural hematoma in young man who got rivaroxaban as treatment of deep vein thrombosis.
Case Description: A 27-year-old male with a history of deep vein thrombosis and one month of rivaroxaban medication presented with seizure and loss of consciousness following a severe headache. A CT scan of the head revealed epidural bleeding, and emergency blood clot removal was performed. As a reversal, prothrombin complex was utilized.
Conclusion: Rivaroxaban has the potential to cause an epidural hemorrhage. Reversal anticoagulant should be administered before doing emergency surgery.
Keywords: Case report, Epidural hematoma, Prothrombin complex concentrate, Rivaroxaban, Spontaneous epidural hematoma
Rivaroxaban is a factor Xa inhibitor that may have a more steady and predictable anticoagulant effect than warfarin.[
A 27-year-old man presented with a sudden onset seizure and a loss of consciousness following a severe headache. The neurological examination revealed a GCS of 9/15 with unequal pupils (L>R) and left hemiparesis. He was prescribed rivaroxaban 15 mg twice daily for 1 month after being diagnosed with DVT. There was no history of trauma, abnormalities of vascular, bleeding disorder, infection, or cancer, according to the patient’s medical history.
The laboratory detected a rise in D-dimer (1500, compared to 500 as a standard). The prothrombin time, INR, activated partial thromboplastin time, and thrombin time were all within the normal range. On head CT, a biconvex, hyperdense lesion consistent with epidural hemorrhage was observed on the left frontal and parietal, with a volume of 50 cc and midline shift [
To remove the epidural hematoma, an emergency craniotomy was performed. There was no evidence of a fractured skull, but the duramater revealed extensive and diffuse bleeding. There was no indication of infection, vascular abnormality, or cancer. Closure was accomplished following dura tenting and meticulous blood control. For reversal, 50 units/kg of prothrombin complex concentrate (PCC) were administered in three doses as a reversal agent. First dose was administered during surgery, second dose was administered after surgery, and third dose was administered 24 h after surgery.
On the following day, the patient regained consciousness. At 1-year follow-up, the patient was doing well and has no neurologic deficit.
The most common cause of epidural hematoma is trauma.[
Anticoagulant treatment is standard for DVT. Heparin is the preferred drug, but it requires frequent monitoring and has multiple drug and food interactions.[
In the EINSTEIN trial, it was determined that the risk of bleeding was significantly lower with rivaroxaban than with warfarin therapy. Intracerebral bleeding was the leading cause of fatal bleeding, which rivaroxaban appears to reduce.[
After 1 month of rivaroxaban treatment for DVT, the patient in this case developed epidural hematoma. Numerous studies reported rivaroxaban-related epidural hematoma.[
Commonly epidural hematomas are caused by damage to the middle meningeal artery or its terminal arterial branches (in around 55% of patients), the middle meningeal vein (in 30% of instances), and diploic veins or a ruptured dural venous sinus in the remaining 15%. However, this condition could be worse in the event of a diastatic fracture, in which distinct blood clots are present.[
Few studies have reported the incidence of spontaneous epidural spinal bleeding after rivaroxaban administration. Approximately 10–20 mg of rivaroxaban per day is associated with nontraumatic spinal hematoma incidence.[
A significant disadvantage of rivaroxaban therapy is the limited knowledge of monitoring methods for bleeding complications. Some of these assessments are quantitative, while others only provide qualitative data. In addition, it is essential to note that the availability of Xa antifactor tests was limited in Indonesia.[
A study suggests administering activated charcoal (50 g) to intubated intracranial hemorrhage patients with enteral access and/or those at low risk of aspiration who present within 2 h of oral direct factor Xa inhibitor ingestion.[
A study reported anticoagulation reversal strategies should be established without delaying surgical management. In elective surgery, discontinuing rivaroxaban at least 24 h before the procedure is sufficient to normalize the risk of bleeding associated with the drug. In emergency surgery, anti-Factor Xa levels had to be measured. The risk of drug-induced bleeding decreases with each hour between the last rivaroxaban dose and surgery.[
Despite the fact that rivaroxaban, a factor Xa inhibitor seems to be a better medication, doctors need to be familiar with its clinical profile, reversal medications, and management strategies in the event of substantial bleeding. Without postponing surgical care, anticoagulation reversal techniques should be developed using andexanet alfa. In contrast, PCC may be used as an anticoagulant reversal if andexanet alfa was not accessible.
The authors certify that they have obtained all appropriate patient consent.
There are no conflicts of interest.
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