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Spontaneous Spinal Epidural Haematoma Associated With Direct Oral Anticoagulants: A Descriptive Systematic Review
Shivam Ghosh1, Adithya Shine1, Manujan Sundaralingam1
1Department of Surgery, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, GBR.
Cureus
|August 11, 2026
Summary
Direct oral anticoagulant (DOAC)-associated spontaneous spinal epidural haematoma (SSEH) is a rare neurological emergency. Early recognition and prompt treatment are crucial for good patient outcomes.
Area of Science:
- Neurology
- Hematology
Background:
- Direct oral anticoagulants (DOACs) are increasingly used for thromboprophylaxis and treatment.
- DOAC-associated spontaneous spinal epidural haematoma (SSEH) is a rare but severe complication causing spinal cord compression.
- Existing evidence is fragmented, necessitating a systematic synthesis.
Purpose of the Study:
- To systematically review and synthesize evidence on DOAC-associated SSEH.
- To describe patient demographics, clinical presentation, diagnostic methods, management strategies, and neurological outcomes.
Main Methods:
- A systematic review adhering to PRISMA 2020 guidelines was performed.
- MEDLINE via PubMed was searched from inception to March 2026, supplemented by citation searching.
- Studies on atraumatic SSEH in adult DOAC users were included; traumatic and iatrogenic cases were excluded.
Main Results:
- Seventeen studies involving 21 patients met the inclusion criteria.
- Rivaroxaban and apixaban were the most common DOACs implicated.
- Patients presented with acute pain and rapid neurological deficits; MRI and CT were key diagnostic tools.
- Most patients underwent surgical decompression, with 18/21 achieving neurological recovery.
Conclusions:
- DOAC-associated SSEH is a rare, time-critical neurological emergency.
- Early recognition, prompt imaging (MRI/CT), and timely intervention are vital for optimal neurological recovery.
- Increased clinician awareness of this complication is essential given rising DOAC use.
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