Extensive spontaneous cervical epidural hematoma due to oral anticoagulant (dabigatran) successfully treated with reversal agent idarucizumab alone

Abstract

Background: Dabigatran is an anticoagulant (novel oral anticoagulant) that is a direct thrombin inhibitor and only recently has a reversal agent, idarucizumab, been made available (2015).

Case description: An 86-year-old male taking dabigatran for atrial fibrillation, acutely presented with the spontaneous onset of neck pain and quadriparesis. When the MRI demonstrated a C2-T2 spinal epidural hematoma, the patient was given the reversal agent idarucizumab. Due to his attendant major comorbidities, he was managed nonoperatively. Over the next 7 days, the patient's neurological deficits resolved, and within 2 weeks, he had regained normal neurological function.

Conclusion: In this case, a C2-T2 epidural cervical hematoma attributed to dabigatran that was responsible for an acute, spontaneous quadriparesis was successfully treated with the reversal agent idarucizumab without surgical intervention being warranted.

Keywords: Anticoagulant reversal; Dabigatran; Idarucizumab; Pradaxa; Spinal epidural hematoma.

Figure 1:

Cervical spine MRI (a) T2-weighted sagittal view demonstrating extensive ventral epidural hematoma extending from the mid-body of C2 to the superior edge of T2. *Indicates focal area of possible active hemorrhage measuring 7 mm × 6 mm at the level of the C6-7 disc space. (b) T2-weighted axial view with arrow indicating severe spinal cord impingement corresponding with focal area of hemorrhage. Arrows in the figure represent the extent of the epidural hematoma from the mid-C2 vertebral body to T2.

Figure 2:

Cervical spine MRI obtained at 1 month follow-up with (a) T2-weighted sagittal view and (b) T2-weighted axial views demonstrating complete resolution of hematoma with resolution of previously demonstrated cord compression.