Emergent Reversal of Direct Oral Anticoagulants Permitting Neurosurgical Intervention for Nonhemorrhagic Pathology: Case Report

Abstract Direct oral anticoagulants (DOACs) are becoming the medication of choice for the management of venous thromboembolism and stroke prevention in atrial fibrillation because of simplified dosing, a more predictive pharmacokinetic profile, and better clinical outcomes when compared with traditional vitamin K antagonists. Recently, reversal agents for DOACs have been approved by the US Food and Drug Administration for use for in managing life-threatening or uncontrolled bleeding; however, for acute nonhemorrhagic conditions requiring surgical intervention, such as acute hydrocephalus requiring ventriculostomy, there is little evidence to help guide appropriate management for patients on DOACs. The authors report the use of andexanet alfa to counteract rivaroxaban treatment in a 28-year-old woman who developed herniation syndrome and acute hydrocephalus from a cerebellar tumor. They describe how appropriate timing of administration of the DOAC reversal agent may permit urgent neurosurgical intervention.