Atypical Presentation of an Epidural Hematoma in a Patient Receiving Rivaroxaban After Total Hip Arthroplasty

Abstract

The authors report a case of a 69-year-old woman who presented with a spontaneous spinal epidural hematoma (SSEH) 10 days after a total hip arthroplasty. The patient had been receiving 10 mg/d of rivaroxaban for 5 days for venous thromboembolism prophylaxis. She had a sudden onset of severe neck pain, followed by quadriplegia below C4. A dorsal SSEH was revealed by computed tomography. While preparing for the emergency evacuation of the SSEH, the neurological symptoms resolved spontaneously in 4 hours. The 1-month follow-up magnetic resonance imaging confirmed that the SSEH had completely resolved. The pathogenesis of SSEH is unclear, but anticoagulant therapy is a known risk factor. It is a relatively rare disorder. Only 1 case of SSEH has been reported, and that patient was receiving a nonsteroidal anti-inflammatory drug besides rivaroxaban, which is another known risk factor for bleeding disorders. [Orthopedics. 2016; 39(3):e558-e560.].

Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy

“…However, no details regarding risk factors or frequency are reported. A review of the literature noted 7 neuraxial hematomas associated with rivaroxaban [125][126][127][128][129][130][131][132][133][134] (Table 10). Three of the patients had undergone a neuraxial block.…”

“…However, in 2 of the cases, an alternate agent of thromboprophylaxis was used immediately postoperatively, and the hematomas occurred after hospital discharge. 126,127 In the remaining case, the epidural catheter was removed 18 hours after the first dose of rivaroxaban, a shorter time interval than the 26 hours (2 elimination half-lives as is recommended by the manufacturer in elderly patients (rivaroxaban [full prescribing information], available at https://www.xarelto-us.com/shared/product/ xarelto/prescribing-information.pdf, accessed March 4, 2017). 125 If a neuraxial block is considered in patients treated with prophylactic rivaroxaban (≤10 mg/d), a time interval of 22 to 26 hours should be observed between the last dose of rivaroxaban and the subsequent neuraxial puncture and/or catheter manipulation/ withdrawal.…”

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

“…e acute presentation, however, represents an important diagnostic challenge [15] especially as a mimicker of cerebrovascular accidents [18]. Even though no direct trauma is involved in spontaneous spinal hematomas, some activities have been associated with onset such as stretch exercises [19] and Valsalva maneuvers during trumpet playing [20] and defecation [3], for example, which might have been the case in our patient as well. Even though new reversal agents have been recently approved for dabigatran, apixaban, and rivaroxaban [16], the lack of their widespread use makes it essential to identify the best evidence-supported choice for surgical timing of evacuation.…”

“…Since the first description of a case of SH associated with the use of a DOAC (rivaroxaban) in 2012 [1], there have been a total of 10 other reports describing both SSEH and spinal subdural hematomas (SSDHs) in association with different DOACs [2][3][4][5][6][7][8][9]. As the use of DOACs continues to increase [10], more similar cases are expected to complicate treatment with these agents.…”

Acute spontaneous thoracic epidural hematoma, triggered by weight-lifting training, in a retired sportsman: case report and literature review

“…Old age, uncontrolled arterial hypertension, and anticoagulant therapy are main risk factors for SSEH:~3% of the patients were hypertensive, and 17-30% linked to anticoagulation [16,27,31]. Scattered case studies associated SSEH with anti-platelet drugs (mainly clopidogrel) [32].…”