Spinal epidural hematoma onset with Horner syndrome.

A 72 yrs old woman, receiving anticoagulant therapy for atrial fibrillation, came to our attention with right Horner Syndrome (HS) (miosis, ptosis and anhidrosis, Fig. 1A) and right arm hypo esthesia. Cervical Magnetic Resonance Imaging (MRI) revealed a subacute C6-T1 spinal epidural hematoma (Fig. 1B and C), causing compression and anterior dislocation of the spinal cord. Apraclonidine drops (0.5%) administered in the affected eye dilated the pupil mildly, indicating intact postganglionic fibers. The anticoagulant therapy was interrupted for one month with improvement of the neurological signs. HS results from interruption of the oculosympathetic pathway (first, second and third-order neuron lesions). The most common causes of HS are cerebral vascular accident, trauma, tumor and carotid artery dissection (1). HS may occurs by damaging the sympathetic fibers descending from the ipsilateral hypothalamus through the brain stem and cervical cord to C8-T2 (first and second-order neuron lesions). Diagnosis of spinal hematoma should be considered in patients with HS taking anticoagulant therapy because an early discontinuating of the therapy may significantly improve the prognosis (2).