Key result
Andexanet alfa achieves craniotomy hemostasis for rivaroxaban reversal but precedes multiple postoperative cerebral infarctions.
Why the study?
Rapid anticoagulant reversal is essential during severe bleeding, but the optimal timing for resuming anticoagulation after reversal agent administration remains unclear.
Case Report (n=1)
No
This case highlights that cardiogenic cerebral infarction can occur as early as 10 hours after surgery following factor Xa inhibitor reversal with andexanet alfa in traumatic acute subdural hematoma, suggesting a potential need for early anticoagulant resumption in high-risk patients.
Answers are grounded in this paper and cite their sources.
Potential early thrombosis after andexanet alfa in subdural hematoma warrants vigilance; leaves open optimal resumption timing in high-risk AF.
Background: Anticoagulants prevent thrombosis in patients with atrial fibrillation (AF) and venous thromboembolism but increase the risk of hemorrhagic complications. If severe bleeding occurs with anticoagulant use, discontinuation and rapid reversal are essential. However, the optimal timing for resuming anticoagulants after using reversal agents remains unclear. Here, we report early cerebral infarction following the use of andexanet alfa (AA), a specific reversal agent for factor Xa inhibitors, in a patient with traumatic acute subdural hematoma (ASDH). The possible causes of thromboembolic complication and the optimal timing for anticoagulant resumption are discussed. Case Description: An 84-year-old woman receiving rivaroxaban for AF presented with impaired consciousness after a head injury. Computed tomography (CT) revealed right ASDH. The patient was administered AA and underwent craniotomy. Although the hematoma was entirely removed, she developed multiple cerebral infarctions 10 h after the surgery. These infarctions were considered cardiogenic cerebral embolisms and rivaroxaban was therefore resumed on the same day. This case indicates the possibility of early cerebral infarction after using a specific reversal agent for factor Xa inhibitors. Conclusion: Most studies suggest that the safest time for resuming anticoagulants after using reversal agents is between 7 and 12 days. The present case showed that embolic complications may develop much earlier than expected. Early readministration of anticoagulant may allow for adequate prevention of the acute thrombotic syndromes.
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Nagai et al. (2023) conducted a case report in Traumatic acute subdural hematoma with atrial fibrillation on rivaroxaban (n=1). Andexanet alfa was evaluated on Hemostasis and postoperative thromboembolic complications (cerebral infarction). Andexanet alfa achieved intraoperative hemostasis in an 84-year-old woman on rivaroxaban with acute subdural hematoma, but multiple cerebral infarctions occurred 10 hours post-surgery.
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