gms | German Medical Science

Objective: Rivaroxaban is a direct inhibitor of factor Xa and is one of the novel oral anticoagulants (NOACs). The use of NOACs has increased over the last years and is expected to continue to rise. Although, there are several advantages in using rivaroxaban, its lack of specific antidotes may present neurosurgeons with a major challenge in managing patients requiring emergency neurosurgical intervention. Here, we report on one patient treated with rivaroxaban and, due to severe traumatic brain injury (TBI) requiring urgent decompressive craniectomy (DC).

Methods: A 79-year-old woman was admitted to our neurosurgical department after a fall on the staircase. The patient had been treated with rivaroxaban (Xarelto®) 20 mg/day due to permanent atrial fibrillation. At the time of admission the patient had a Glasgow Coma Scale (GCS)-Score of 13. The examination of motor function revealed a right-sited hemiparesis. The radiological trauma work-up with computed tomography (CT) showed a left-sited acute subdural hematoma (aSDH) with midline-shift, a left-sited traumatic subarachnoid hemorrhage (tSAH) fronto-parietal, and a left-sited temporal contusion. The initial blood testing revealed a highly elevated peak-level of rivaroxaban (> 433 ng/ml) with strong therapeutic anticoagulant activity measured by anti-factor-Xa-activity level > 1.14 IU/ml. We started the reversal of rivaroxaban activity with intra-venous (i.v.) bolus application of 1 g tranexamic acid (TXA) followed by continuous i.v. application of TXA in a dosage of 20 mg/kg. Furthermore, prothrombin complex concentrates (PCC) were administered with a dosage of 50 IE/kg.

Results: The surgical treatment was performed with DC in a standardized fashion. During the surgery diffuse bleeding occurred from the left temporal brain surface, which could not be managed surgically. The intra-op blood analysis revealed persistent anticoagulant effect of rivaroxaban despite the decrease of rivaroxaban-level after reversal (198 ng/ml, anti factor-Xa-activity level: > 1.14 IU/ml). In this case, in accordance with our guidelines we decided to apply 2 mg recombinant activated factor VII (NovoSeven®) as ultimo ratio treatment. Thereafter the bleeding was controlled and DC was finished successfully. A CT-scan performed postoperatively showed a complete removal of aSDH with consecutive decrease of midline-shift. The blood analysis showed a decreased anticoagulant effect of rivaroxaban (rivaroxaban-level: 34 ng/ml, anti factor-Xa-activity level: 0.33 IU/ml).

Conclusion: The staggered reversal of direct factor-Xa-inhibitor rivaroxaban as shown in our institutional protocol, provides a sufficient approach to evaluate and manage patients treated with this anticoagulant in the setting of urgent neurosurgical interventions.