Spontaneous Spinal Epidural Haematoma Associated With Direct Oral Anticoagulants: A Descriptive Systematic Review

Direct oral anticoagulant (DOAC)-associated spontaneous spinal epidural haematoma (SSEH) is an uncommon but potentially devastating haemorrhagic complication that can cause acute spinal cord compression. Current evidence is limited to case reports, case series, and accompanying narrative reviews, with no comprehensive systematic synthesis of the available evidence. A systematic review was conducted in accordance with PRISMA 2020 guidelines. MEDLINE via PubMed was searched from database inception to March 2026 using predefined search terms, with additional studies identified through backward citation searching. Studies reporting atraumatic SSEH in adults receiving DOACs were included. Traumatic, iatrogenic, and non-epidural haemorrhages were excluded. Data extracted included patient demographics, DOAC type, clinical presentation, diagnostic pathway, management, and neurological outcomes. A descriptive synthesis was performed. A total of 17 studies comprising 21 patients met the inclusion criteria. Rivaroxaban and apixaban were the most frequently implicated DOACs. Patients typically presented with acute neck or back pain followed by rapidly progressive neurological deficits, with several cases initially mimicking acute stroke. MRI was the most frequently utilised imaging modality, while CT also identified the haematoma in several patients, either alone or before subsequent MRI. Management was predominantly surgical decompression, although four patients were managed conservatively. Complete or partial neurological recovery was reported in 18/21 patients. DOAC-associated SSEH is a rare but time-critical neurological emergency. Early recognition, prompt imaging, and timely intervention remain fundamental to optimising neurological outcomes. As the use of DOACs continues to increase, clinician awareness of this uncommon complication is essential to facilitate early diagnosis and appropriate management.