Key result
Administration of andexanet alfa for the reversal of anticoagulation was followed by an acute ischemic stroke presenting as isolated homonymous hemianopia.
Why the study?
Reversal of anticoagulation with andexanet alfa in atrial fibrillation patients with severe bleeding may lead to ischemic stroke and visual loss, but this complication is not well described.
Case Report (n=1)
Reversal of factor Xa inhibitors with andexanet alfa in high-risk patients may induce a transient prothrombotic state, precipitating severe acute ischemic events that can present solely as visual symptoms.
Answers are grounded in this paper and cite their sources.
Visual symptoms after andexanet alfa warrant urgent stroke evaluation; case report leaves open prothrombotic risk in high-CHA₂DS₂-VASc AF patients.
Purpose: Clinical scoring systems have been developed (e.g., CHA2DS2-VASc and HAS-BLED) to aid in the perioperative management of anticoagulation therapy. The decision to continue, modify, or stop anticoagulation prior to surgical procedures requires multidisciplinary input and an individualised plan. Decisions both to continue or reverse anticoagulation can cause visual loss. Observations: We report the use of andexanet alfa (recombinant inactive factor Xa) as a reversal agent for anticoagulation in atrial fibrillation after surgical bleeding, which resulted in secondary homonymous hemianopsia and ischemic infarct. Conclusion and importance: Stroke is a major risk factor for atrial fibrillation, and anticoagulation in specific settings is evidence-based. Anticoagulation, however, increases the risk of haemorrhage and may require the use of a reversal agent (e.g., Andexanet alfa) in cases of severe bleeding. Unfortunately, reversal of anticoagulation in this setting can lead to an ischemic stroke and visual loss.
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Malekahmadi et al. (2026) conducted a case report in Atrial fibrillation on DOAC therapy with post-procedural hemorrhage (n=1). Andexanet alfa was evaluated. Administration of andexanet alfa for the reversal of anticoagulation was followed by an acute ischemic stroke presenting as isolated homonymous hemianopia.
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