Cauda equina syndrome due to Factor Xa inhibitor (Rivaroxaban): Case report and review of literature

Abstract

Background: Factor Xa inhibitors are widely used by the physicians to reduce the incidence of thrombosis in order to protect the cardiovascular function. Although complications of bleeding and spontaneous gastrointestinal sources have been reported before, there are very sporadic cases of spinal epidural haematoma causing neurological compromise.
Case presentation: We report a case of spontaneous spinal epidural haematoma (SSEH) in an 85-year-old female patient treated with Rivaroxaban, a new agent to prevent the incidence of thrombo-embolic events. Anticoagulant therapy is a recognised risk factor in the development of spontaneous bleeding and haematomas. The patient presented to the emergency department with sudden onset of severe back pain in the lumbar spine associated with paraplegia in the lower limbs. Magnetic resonance imaging (MRI) of the spine demonstrated a SSEH from T12 to L5 affecting the cauda equina. Rivaroxaban was discontinued and the patient was monitored as an inpatient. There was gradual improvement in the symptoms of the lower limbs.
Conclusion: This rare condition of incomplete cauda equina syndrome due to Rivaroxaban therapy has not been reported previously. Clinicians must have a high index of suspicion in patients on regular anti-coagulation regimen.

Keywords

Rivaroxaban / Epidural haematoma / Incomplete cauda equina syndrome

CONFLICTS OF INTEREST DISCLOSURE

We obtained verbally permission from the Mr IF son, a biomedical scientist working at the Tamale Teaching Hospital.

References

[1] Jackson R. Case of spinal apoplexym. Lancet. 1869; 2: 538-539.

[2] Lonjon MM, Paquis P, Chanalet S, et al. Nontraumatic spinal epidural haematoma: report of four cases and review of the literature. Neurosurgery. 1997; 41: 483-487. PMid:9257319. https://doi.org/10.1097/00006123-199708000-00035

[3] Akimoto T, Yamada T, Shinoda S, et al. Spontaneous spinal epidural hematoma as a potentially important stroke mimic. J Cent Nerv Syst Dis. 2014; 6: 15-20. PMid:24526842. https://doi.org/10.4137/JCNSD.S13252

[4] Mohammed N, Shahid M, Haque M, et al. Spontaneous spinal epidural haematoma mimicking acute coronary syndrome. Quant Imaging Med Surg. 2015; 5(6): 925-7.

[5] Shin JJ, Kuh SU, Cho YE. Surgical management of spontaneous spinal epidural haematoma. Eur Spine J. 2006; 15: 998-1004 PMid:16758110. https://doi.org/10.1007/s00586-005-0965-8

[6] Dziedzic T, Kunert P, Krych P, et al. Management and neurological outcome of spontaneous spinal epidural hematoma. J Clin Neurosci. 2015; 22: 726-729. PMid:25677879. https://doi.org/10.1016/j.jocn.2014.11.010

[7] Guzel A, Simsek O, Karasalihoglu S, et al. Spontaneous spinal epidural haematoma after seizure: a case report. Clin Pediatric. 2007; 46: 263-265. PMid:17416884. https://doi.org/10.1177/0009922806289427

[8] Holtas S, Heiling M, Lonntoft M. Spontaneous spinal epidural haematoma: findings at MR imaging and clinical correlation. Radiology. 1996; 199: 409-413. PMid:8668786. https://doi.org/10.1148/radiology.199.2.8668786

[9] Jaeger M, Jeannert B, Schaeren S. Spontaneous spinal haematoma during Factor Xa inhibitor treatment (Rivaroxaban). Eur Spine J. 2012; 21(Suppl 4): S433-S435 PMid:21874549. https://doi.org/10.1007/s00586-011-2003-3

[10] Serizawa Y, Ohshiro K, Tanaka K, et al. Spontaneous resolution of an acute spontaneous spinal epidural haematoma without neurological deficits. Intern Med. 1995; 34: 992-994. PMid:8563102. https://doi.org/10.2169/internalmedicine.34.992

[11] Lovblad KO, Baumgartner RW, Zambaz BD, et al. Nontraumatic spinal epidural haematomas MR features. Acta Radiol. 1997; 38: 8-13. PMid:9059394. https://doi.org/10.1080/02841859709171234

[12] Markham JW, Lynge HN, Stahlman GE. The syndrome of spontaneous spinal epidural haematoma. Report of three cases. J Neurosurg. 1967; 26: 334-342. PMid:6019740. https://doi.org/10.3171/jns.1967.26.3.0334

[13] Liu Z, Jiao Q, Yu J, et al. Spontaneous spinal epidural haematoma: analysis of 23 cases. Surg Neurol. 2008; 69: 253-260. PMid:17900669. https://doi.org/10.1016/j.surneu.2007.02.019

[14] EINSTEIN Investigators, Bauersachs R, Berkowitz SD, Brenner B, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med. 2010; 363(26): 2499-510. PMid:21128814. https://doi.org/10.1056/NEJMoa1007903

[15] ROCKET AF Study Investigators (2010) Rivaroxaban-once daily, oral, direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation: rationale and design of the ROCKET AF study. Am Heart J. 2010; 159(3): 340-7.e1. PMid:20211293. https://doi.org/10.1016/j.ahj.2009.11.025

[16] Ruschel LG, Monteiro do Rego FM, Milano JB, et al. Spontaneous intracranial epidural hematoma during rivaroxaban treatment. Rev Assoc Med Bras. 2015; 62(8): 721-724. PMid:27992010. https://doi.org/10.1590/1806-9282.62.08.721

[17] Ismail R, Zaghrini E, Hitti E. Spontaneous spinal epidural hematoma in a patient on Rivaroxaban: case report and literature review. J Emer Med. 2017; 53(4): 536-539. PMid:29079069. https://doi.org/10.1016/j.jemermed.2017.06.005

[18] Dargazanli C, Lonjon N, Gras-Combe G. Non-traumatic spinal subdural haematoma complicating direct factor Xa inhibitor treatment (Rivaroxaban): a challenging management. Eur Spine J. 2016; 25(suppl 1): 100-3. PMid:26228186. https://doi.org/10.1007/s00586-015-4160-2

[19] Castillo JM, Afanador HF, Manjarrez E, et al. Non-traumatic spontaneous spinal subdural haematoma in a patient with non-valvular atrial fibrillation during treatment with Rivaroxaban. Am J Case Rep. 2015; 16: 377-81. PMid:26090890. https://doi.org/10.12659/AJCR.893320

[20] Bamps S, Decramer T, Vandenbuscche N, et al. World Neurosurg. 2015; 83: 257-8. PMid:25463422. https://doi.org/10.1016/j.wneu.2014.10.012