Acute Spontaneous Spinal Epidural Hematoma in a Patient on a Direct Oral Anticoagulant (DOAC): A Case Report

Abstract

Acute spontaneous spinal epidural hematoma (SSEH) is a rare but serious condition that can mimic stroke or carotid artery dissection (CAD), potentially leading to misdiagnosis and inappropriate therapy. We report the case of a 75-year-old male with atrial fibrillation on Edoxaban who awoke with neck pain and, approximately 80 minutes later, developed sudden right-sided weakness. Neurological examination showed right upper limb (RUL) weakness (3/5 proximally, 0/5 distally), right lower limb (RLL) paralysis (0/5), hypotonia, but intact sensation, with a National Institutes of Health Stroke Scale (NIHSS) score of 6 - findings that supported conservative management in the absence of progressive deterioration. Initial CT head and CT angiogram were unremarkable, ruling out intracranial hemorrhage and carotid dissection. Aortic dissection was also excluded by CT aortogram. Although uncontrolled hypertension or other acute risk factors were not identified (blood pressure (BP) 157/81 mmHg), chronic anticoagulation likely contributed to SSEH. Cervical spine magnetic resonance imaging (MRI) performed on day 6 revealed a C3-C5 epidural hematoma compressing the cord. Neurosurgical consultation recommended conservative management due to improving strength and absence of worsening symptoms. Follow-up MRI at six weeks confirmed complete hematoma resolution with residual mild myelopathy. At discharge, after a 10-day hospital stay, the patient's neurological function had improved to 4/5 strength in the RUL and 3/5 in the RLL, and he was transferred for rehabilitation. This case underscores the importance of considering SSEH in anticoagulated patients with acute neck pain and hemiparesis, even when initial imaging for stroke or CAD is negative. Timely MRI and a multidisciplinary approach are crucial to avoid misdiagnosis and optimize outcomes.

Keywords: anticoagulant; atrial fibrillation; cervical spine; magnetic resonance imaging; mri diagnosis; spinal epidural hematoma; stroke.

Figure 1. Axial T2-weighted MRI of the cervical spine (A) showing a spinal epidural hematoma, and sagittal T2-weighted MRI (B) demonstrating cervical spinal cord compression with associated myelopathic signal changes.

MRI, magnetic resonance imaging

Figure 2. Axial T2-weighted MRI (A) showing resolution of the spinal epidural haematoma, and sagittal T2-weighted MRI (B) demonstrating residual, though reduced, myelopathic signal changes at the C4-C5 level.

MRI, magnetic resonance imaging