Neurosurgery in a patient at peak levels of rivaroxaban: taking into account all factors

Abstract

Essentials There is scant data on surgery shortly after intake of rivaroxaban.We performed neurosurgery using high dose PCCs and tranexamic acid.Intraoperative haemostasis was good and no transfusion was needed.There was no delayed postoperative haemotoma or thromboembolic complication. We present a patient who underwent urgent neurosurgery for acute onset paraplegia due to a spontaneous subdural spinal hematoma less than 5 hours after she had taken rivaroxaban. The Key Clinical Question was whether early high‐risk surgery on a patient taking direct oral anticoagulants is feasible. Prothrombin complex concentrate (PCC) and tranexamic acid were administered and perioperative hemostasis was good. There is scant data on neurosurgical procedures performed within 12 hours after the intake of a direct oral anticoagulant. With the hemostatic support of high‐dose PCC, early surgery after administration of rivaroxaban seems feasible in case of an emergency indication, but should only be considered when delaying surgery is esteemed hazardous to the patient. More experience is needed to allow balancing risks and benefits of urgent vs delayed intervention and on the optimal hemostatic support in the absence of a specific antidote.

Spontaneous spinal subdural haematoma in a patient on apixaban

“…A similar case to ours published in 2017 described a case of spontaneous, non-traumatic SSDH in a patient taking rivaroxaban 8. The patient developed flaccid paraplegia in her legs a few hours after taking rivaroxaban and the decision was made to perform urgent surgical decompression, after consulting with their haematology department regarding haemostasis concerns.…”

“…Owing to the promising results, the Food and Drug Administration approved andexanet alfa for reversal of bleeding in patients who are anticoagulated on rivaroxaban and apixaban in May 2018 16. There are scant studies regarding reversal of NOACs for urgent surgery either through the protocol using PCC and TXA, suggested by the authors of the prior case report,8 nor by andexanet alfa. Despite this, evidence-based clinical resource hubs such as UpToDate suggest using andexanet alfa as a first line reversal agent for all NOACs 17…”