Hemorrhagic Transformation of Ischemic Stroke in Patient Treated With Rivaroxaban

Rivaroxaban (BAY 59-7939) is an oral factor Xa inhibitor used for stroke prevention in atrial fibrillation. There are currently no evidence based guidelines for treatment of hemorrhagic side effects of factor Xa inhibitors. We report a case of delayed hemorrhagic conversion of an ischemic infarct in a 60-year-old male treated with rivaroxaban for stroke prevention in a setting of paroxysmal atrial fibrillation. The patient presented with generalized discomfort and malaise as well as worsening of expressive aphasia from a prior infarct. In addition, right superior quadrantanopsia was present. CT head at 140 minutes and 8 hours following symptom onset revealed confluent petechiae and linear gyral hyperintensities of the left temporal lobe without mass effect, classified as type 2 Hemorrhagic Transformation (HI2). The patient received a single unit of fresh frozen plasma (FFP) and three doses of Vitamin K. He remained clinically stable without need for neurosurgical intervention, and was subsequently discharged with a plan to commence aspirin therapy five days after onset and switch to dabigatran two weeks later for management of paroxysmal atrial fibrillation. Hemorrhagic transformation in this case remained clinically stable following conservative therapy, likely due to pharmacological clearance of rivaroxaban. Prothrombin complex concentrates may be considered for emergent reversal of rivaroxaban. doi: http://dx.doi.org/10.4021/jh78w