Nontraumatic spinal subdural hematoma complicating direct factor Xa inhibitor treatment (rivaroxaban): a challenging management

Non-traumatic Spinal Subdural Hemorrhage Associated With Rivaroxaban Use

Spinal subdural hematoma (SSDH) is a rare medical emergency that can cause permanent neurological deficits. The disease is characterized by sudden onset back pain, sensorimotor changes, and bladder and autonomic dysfunction. This is often associated with the use of anticoagulants, blood dyscrasias, and recent spinal procedures. We present a case of a 63-year-old male maintained on rivaroxaban for nonvalvular atrial fibrillation clinically presenting with abrupt onset back pain that rapidly progressed to sensorimotor deficits and bladder dysfunction. Rivaroxaban, a selective inhibitor of factor Xa, has been approved by the Food and Drug Administration (FDA) for the reduction of stroke risk and systemic embolism in nonvalvular atrial fibrillation. We postulate that rivaroxaban played a major role in triggering the spinal hemorrhage. This case highlights the very limited documented cases of spontaneous subdural spinal hemorrhages associated with rivaroxaban use.

Non-traumatic Spontaneous Spinal Subdural Hematoma in a Patient with Acute Paraplegia

Acute non-traumatic spinal subdural hematoma (SSDH) is a rare clinical condition in the emergency medicine practice and difficult to diagnose during the primary physical examination. It mostly occurs at thoracal vertebra levels due to trauma, use of anticoagulants, medical procedures such as acupuncture, arteriovenous malformations, hematological disorders or space-occupying lesions. Here, we discussed an elderly female patient who was not on anticoagulant and described sudden loss of muscle strength and sensation in both lower extremities. Initial laboratory and imaging including brain computerized tomography (CT) and magnetic resonance imaging (MRI) were in normal range. Her secondary examination revealed anesthesia under the T4 dermatome level. Cervical spine-MRI imaging revealed a subdural hematoma significantly compressing the spinal cord on the C7-T1 dermatome segments. Any emergency neurosurgical intervention was not considered and the patient was interned in the neurosurgical clinic for conservative treatment and further examination. Patient , with no progress seen in consecutive MRI scans, was discharged after offering an outpatient check-up. We recommend secondary physical examination in emergency department (ED). In the case of appearance of sensory deficits of certain dermatomes, spine-MR imaging may lead to put the diagnose early in ED.

Retrospective study of functional outcomes and disability after non-ischaemic vascular causes of spinal cord dysfunction

Objective: Describe demographic characteristics, functional outcomes and disability following rehabilitation for non-ischemic vascular spinal cord dysfunction (SCDys).Design: Retrospective, open cohort, case series.Setting: Tertiary rehabilitation unit, Victoria, Australia.Participants: Patients with non-ischemic vascular SCDys admitted over a 21-year-period (01/01/1995-31/12/2015) were identified using International Classification of Diseases codes.Outcome Measures: Demographic characteristics, etiology, neurologic classification, length of stay (LOS), and complications. On admission and discharge, the following were collected: functional independence measure (FIM) motor subscale, details on bowel, bladder, mobility, living arrangement, and support services.Results: 36 patients (female 58%; mean age 69 ± 16 years) were identified. The main causes of non-ischemic vascular SCDys were epidural hematoma (39%), dural arteriovenous fistula (17%), and arteriovenous malformation (11%). 22 cases (61%) were iatrogenic. Most (86%) had incomplete paraplegia. Urinary tract infection was the most common complication (64%). Median LOS in rehabilitation was 68 days. Significant improvement in FIM motor scores was observed from admission (median 25, interquartile range [IQR] 20-38) to discharge (median 69, IQR 38-77) (P < 0.001). On discharge, 4 patients (11%) walked >100 m unaided, 6 (17%) walked >100 m with assistive device, 10 (28%) walked >10 m with assistive device, 15 (41%) were wheelchair dependent and 1 (3%) patient remained non-mobile. 20 patients (56%) were discharged home, 8 (22%) to nursing home, and 8 (22%) transferred to another hospital.Conclusion: Most patients returned home with significantly improved functional outcomes compared to rehabilitation admission, but with the majority having ongoing major disabilities based on FIM motor scores.

Risk Factor Analysis and Surgical Outcomes of Acute Spontaneous Spinal Subdural Hematoma. An Institutional Experience of Four Cases and Literature Review

OBJECTIVE

Spontaneous spinal subdural hematoma (SSSDH) is exceedingly rare, with significant morbidity in most patients. Acute neurologic deficit in the context of a SSSDH is considered a neurosurgical emergency. We performed a literature review and compared the results with our institutional experience to evaluate the risk factors and neurologic outcomes of SSSDH.

METHODS

We retrospectively collected the medical, radiologic, and surgical information of 4 patients with SSSDH who were operated on in our neurosurgical unit. A literature review of surgically managed patients with SSSDH and their neurologic outcomes was performed. Ordered logistic regression statistics were used to study the risk factors influencing the postoperative Domenicucci grade.

RESULTS

A total of 112 patients were evaluated, with a female/male ratio of 1.3:1. Mean patient age was 60.25 years. Our analysis of the data showed that the cohort of patients presenting with bladder dysfunction in addition to paraparesis were found to have worse neurologic outcomes postoperatively. Adjusted analysis identified 3 clinical characteristics that influenced surgical outcome: cervical SSSDH (P = 0.029), neurologic deficit (P < 0.001), and anticoagulation medication (P < 0.001).

CONCLUSIONS

This review shows that patients aged ≥60 years and on anticoagulation are at an increased risk of sustaining a spontaneous subdural spinal hematoma without history of trauma. To our knowledge, this is also the first study to show a presenting symptom of bladder dysfunction as a significant risk factor for poor surgical outcome in SSSDH. Our study supports surgical evacuation of acute SSSDH in the presence of these risk factors.

Massive Acute Spinal Subdural Hematoma Causing Sudden Onset Paraplegia in a Patient on Anticoagulation

Spinal subdural hematoma (SSDH) is a rare but known entity that can cause severe and irreversible motor, sensory, and autonomic dysfunction if not decompressed in a timely manner. We present here a 74-year-old female on anticoagulation who developed sudden onset back pain with rapidly progressive paraplegia. On neurologic exam, she was completely flaccid in the bilateral lower extremities with absent sensation from the umbilicus down. Imaging demonstrated a massive extra-axial spinal hematoma from T12 to S1 that initially was believed to be epidural in origin. She was taken emergently to the operating room for a T11-L5 decompressive laminectomy, and dural opening demonstrated a thick subdural clot encasing the conus and cauda equina confirming the subdural pathology. Despite decompression and partial evacuation of the subdural hematoma, she did not recover neurologic function.

[Efficacy and safety of tranexamic acid sequential rivaroxaban on blood loss in elderly patients during lumbar interbody fusion]

Objective

To investigate the effect and safety of tranexamic acid sequential rivaroxaban on perioperative blood loss and preventing thrombosis for elderly patients during lumbar interbody fusion (LIF) with a prospective randomized controlled study.

Methods

Between April and October 2019, the elderly patients with lumbar degenerative diseases requiring LIF were included in the study, among which were 80 patients met the selection criteria. According to the antifibrinolysis and anticoagulation protocols, they were randomly divided into a tranexamic acid sequential rivaroxaban group (trial group) and a simple rivaroxaban group (control group) on average. Finally, 69 patients (35 in the trial group and 34 in the control group) were included for comparison. There was no significant difference in general data ( P>0.05) such as gender, age, body mass index, disease duration, diseased segment, type of disease, and preoperative hemoglobin between the two groups. The operation time, intraoperative blood loss, drainage within 3 days after operation, perioperative total blood loss, and proportion of blood transfusion patients were compared between the two groups, as well as postoperative venous thrombosis of lower extremities, pulmonary embolism, and bleeding-related complications.

Results

The operations of the two groups completed successfully, and there was no significant difference in the operation time ( P>0.05); the intraoperative blood loss, drainage within 3 days after operation, and perioperative total blood loss in the trial group were significantly lower than those in the control group ( P<0.05). The proportion of blood transfusion patients in the trial group was 25.71% (9/35), which was significantly lower than that in the control group [52.94% (18/34)] ( χ ²=5.368, P=0.021). Postoperative incision bleeding occurred in 4 cases of the trial group and 3 cases of the control group, and there was no significant difference in bleeding-related complications between the two groups ( P=1.000). There was 1 case of venous thrombosis of the lower extremities in each group after operation, and there was no significant difference in the incidence between the two groups ( P=1.000). Besides, no pulmonary embolism occurred in the two groups.

Conclusion

Perioperative use of tranexamic acid sequential rivaroxaban in elderly LIF patients can effectively reduce the amount of blood loss and the proportion of blood transfusion patients without increasing the risk of postoperative thrombosis.

Spontaneous Spinal Epidural Hematoma in a Patient on Apixaban for Nonvalvular Atrial Fibrillation

Background

With the rise in the use of direct oral anticoagulants (DOACs), more hemorrhagic complications are being encountered. Since the first description of a case of spontaneous spinal epidural hematoma (SSEH) related to the utilization of DOACs in 2012, there have been few reports describing a similar association. However, no cases so far have reported an association between SSEHs and apixaban. Case Description: A 76-year-old lady, with a history of nonvalvular atrial fibrillation, presented with a new onset of progressive left lower and upper extremity weakness. She reported back pain and numbness in the left leg up to the knee along with numbness in the left arm up to the shoulder. A CT scan of the neck was suggestive of an epidural hematoma extending from C2-C3 level to C6-C7. As the patient was on apixaban at the time, surgical treatment was delayed for two days to decrease the risk of intraoperative bleeding. Nine days later, she was discharged. Her physical exam was almost unchanged from that on presentation, except for resolution of pain and minimal improvement in motor power in her left lower extremity from 1/5 to 2/5 distally.

Conclusions

Spinal hematomas represent surgical emergencies with earlier intervention portending better outcome. Based on the few case reports that point to DOACs as a potential culprit, it appears that a high suspicion index resulting in earlier SSEH diagnosis and intervention is crucial for improved neurological outcome and recovery. Prompt diagnosis remains a challenge, especially that SSEH can mimic cerebrovascular accidents.

Perioperative Management of Patients Receiving New Anticoagulants

There is an increased use of oral anticoagulants for the prevention of venous and arterial thrombosis. Vitamin-K antagonists have been used for decades as the main oral anticoagulants but they have the draback a complex therapeutic management, slow onset of action and by a different oral intake caused by dietary vitamin K intake. New non-vitamin K antagonist oral anticoagulants (NOACs) have been developed to overcome the limitations of warfarin. Their management is easier as it requires a fixed daily dose without coagulation monitoring. Although their therapeutic profile is safe, proper attention should be paid in case of unexpected need for the reversal of their coagulation effect and in case a patient needs to have a scheduled surgery. For non-acute cardiac surgery, discontinuation of NOACs should start at least 48 hours prior surgery. Intracranial bleedings associated with NOACs are less dangerous comparing to those warfarin-induced. NOACs need to be stopped ≥24 hours in case of elective surgery for low bleeding-risk procedures and ≥48 hours for high bleeding-risk surgery in patients with normal renal function and 72 hours in case of reduced CrCl < 80. The therapy with NOACs should be resumed from 48 to 72 hours after the procedure depending on the perceived bleeding, type of surgery and thrombotic risks. There are some available NOAC reversal agents acting within 5 to 20 minutes. In case of lack of reversal agent, adequate diuresis, renal replacement therapy and activated charcoal in case of recent ingestion should be considered.

Management of Spinal Emergencies in Patients on Direct Oral Anticoagulants

OBJECTIVE

Spine surgeons increasingly encounter acute spinal pathologies in patients treated with direct oral anticoagulants (DOACs), but only limited data on the management of these patients are currently available.

METHODS

We retrospectively analyzed patients who presented to our department with acute spinal pathology during treatment with DOAC and who required urgent surgical therapy. Patient characteristics and treatment modalities were studied, with specific focus on the management of hemostasis and surgical therapy. Furthermore, we analyzed 19 cases of spinal emergencies during DOAC treatment reported in the literature.

RESULTS

A total of 12 patients were identified and included in the present analysis. Patients suffered from acute spinal cord compression caused by spinal tumor manifestation (n = 5), empyema (n = 4), degenerative spinal stenosis (n = 1), hematoma (n = 1), and vertebral body fracture/dislocation (n = 2). All patients underwent emergency surgical treatment. Prohemostatic substances were administered perioperatively in 10 patients (83%) and included administration of prothrombin complex concentrates (83%), tranexamic acid (17%), and transfusion of platelets (8%). A total of 9 patients (75%) showed postoperative improvement of neurologic symptoms, and the in-hospital mortality in this patient cohort was 17%.

CONCLUSIONS

Emergency spine surgery is feasible and should be considered in patients on treatment with DOAC. The (low) risk of intraoperative bleeding complications has to be weighed against the risk of permanent disability if surgical decompression is delayed. Administration of prothrombin complex concentrates and tranexamic acid may improve the coagulation before surgery, especially in cases of unavailable specific antidotes.

Spontaneous spinal subdural haematoma in a patient on apixaban

A 68-year-old man on apixaban presented to the emergency department with back pain following a long-haul flight. Investigations for pulmonary embolus and aortic dissection were negative and he was discharged with analgesia for mechanical back pain. He presented three more times with worsening back pain, third time with urinary retention and the fourth time with lower limb weakness and loss of coordination. He was found to have a spinal subdural haematoma on MRI and transferred to a tertiary centre, where he was managed conservatively and discharged for rehabilitation with good neurological recovery.

Spontaneous Spinal Epidural Hematoma in a Patient on Rivaroxaban: Case Report and Literature Review

BACKGROUND

Spinal hematomas (SHs) are rare yet potentially debilitating causes of acute back pain. Although spontaneous SHs have been described in the setting of anticoagulation with warfarin or enoxaparin, few cases of spontaneous SH on direct oral anticoagulants (DOACs) have been reported.

CASE REPORT

We report a case of spontaneous spinal epidural hematoma in a patient on rivaroxaban. A 72-year-old man on rivaroxaban and aspirin presented with a 4-day history of nontraumatic back pain. In the emergency department he developed lower-extremity weakness and numbness, followed by urinary incontinence. Magnetic resonance imaging revealed spinal epidural hematoma at T11-L2. The patient underwent emergent decompression and hematoma evacuation and was discharged home 8 days later with complete resolution of symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early recognition and surgical intervention for SHs with neurologic compromise is key to favorable outcome. Optimal timing of surgery in patients on DOACs requires an assessment of the risk of intraoperative or postoperative bleeding, an assessment of the patient's symptom progression, as well as an understanding of the pharmacokinetics of the DOAC used and possible reversal options available. We also review all published cases of spontaneous SHs in patients on DOACs and report on their management and outcomes.

Spontaneous Spinal Epidural Hematoma from Rivaroxaban

Spontaneous spinal epidural hematoma (SSEH) is a rare diagnosis. One known risk factor is anti-coagulation medication. We present a case of SSEH in a 74-year-old male on rivaroxaban therapy who clinically presented with an intermittently resolving and then worsening neurological exam. Due to the extremely high morbidity and mortality associated with this diagnosis, it is important to be aware of the various presentations and adverse effects related to novel anticoagulation.

Iatrogenic Spinal Subdural Hematoma due to Apixaban: A Case Report and Review of the Literature

In the last decade, the clinical relevance for developing safer oral anticoagulants prompted the development of new classes of drugs that have shown a lower risk of life-threatening bleeding events as compared to standard warfarin. Nontraumatic spinal subdural hematoma is an uncommon urgent complication that can be associated with the use of these agents. An unusual case of spinal subdural hematoma related to apixaban treatment for nonrheumatic atrial fibrillation is reported here.

Neurosurgery in a patient at peak levels of rivaroxaban: taking into account all factors

We present a patient who underwent urgent neurosurgery for acute onset paraplegia due to a spontaneous subdural spinal hematoma less than 5 hours after she had taken rivaroxaban. The Key Clinical Question was whether early high-risk surgery on a patient taking direct oral anticoagulants is feasible. Prothrombin complex concentrate (PCC) and tranexamic acid were administered and perioperative hemostasis was good. There is scant data on neurosurgical procedures performed within 12 hours after the intake of a direct oral anticoagulant. With the hemostatic support of high-dose PCC, early surgery after administration of rivaroxaban seems feasible in case of an emergency indication, but should only be considered when delaying surgery is esteemed hazardous to the patient. More experience is needed to allow balancing risks and benefits of urgent vs delayed intervention and on the optimal hemostatic support in the absence of a specific antidote.

Spinal subarachnoid and subdural hematoma presenting as a Brown-Séquard-like myelopathy following minor trauma in a patient on dabigatran etexilate

Dabigatran etexilate is a relatively new anticoagulant from the class of direct thrombin inhibitors which is administered orally and does not require routine blood work monitoring. Dabigatran may be attractive to both clinicians and patients because of both its convenience and efficacy; however, clinical complications are still being elucidated. Here, we present a previously unreported case of spinal subarachnoid and subdural hematoma presenting as a Brown-Séquard-like myelopathy in a patient after minor trauma in the setting of Dabigatran anticoagulation.

Rivaroxaban-Induced Nontraumatic Spinal Subdural Hematoma: An Uncommon Yet Life-Threatening Complication

In the last decade, the desire for safer oral anticoagulants (OACs) led to the emergence of newer drugs. Available clinical trials demonstrated a lower risk of OACs-associated life-threatening bleeding events, including intracranial hemorrhage, compared to warfarin. Nontraumatic spinal hematoma is an uncommon yet life-threatening neurosurgical emergency that can be associated with the use of these agents. Rivaroxaban, one of the newly approved OACs, is a direct factor Xa inhibitor. To the best of our knowledge, to date, only two published cases report the incidence of rivaroxaban-induced nontraumatic spinal subdural hematoma (SSDH). Our case is the third one described and the first one to involve the cervicothoracic spine.