Spinal subarachnoid hemorrhage in cortical superficial siderosis after apixaban and clopidogrel therapy

Excerpt

A 78-year-old man developed back pain without fever and headache. On admission, he showed pronounced positive Lasègue test without focal abnormalities. Due to atrial fibrillation and following coronar stenting he was on medication with apixaban (2, 5 mg bid) and clopidogrel (75 mg daily). Laboratory tests showed slight leukocytosis (11.600/µl) and elevated prostatic specific antigen (8 ng/dl; normal <4.4) due to controlled prostatic cancer. His computed tomography scan of the brain was normal, but magnetic resonance imaging (MRI) with T2* showed cortical superficial siderosis (CSS) (Fig. 1a). The MR angiography was normal. MRI of his spine demonstrated a marked hyperintense fluid level at the height of the second sacral vertebral body (Fig. 1b, c). The lumbar puncture revealed an extensively hemorrhagic cerebrospinal fluid. MRI of the additional spinal axis did not show an identifiable cause, thus a spinal subarachnoid hemorrhage in the context of CSS complicated by new anticoagulant therapy combined with platelet inhibition was diagnosed. A second lumbar puncture 7 days later after cessation of anticoagulant and antithrombotic therapy showed residual xanthochromia of the cerebrospinal fluid. With further conservative therapy the patient recovered within 3 weeks.

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