Management of severe traumatic brain injury in a rivaroxaban overdose: illustrative case

Abstract

Background: The management of rivaroxaban overdose in severe traumatic brain injury (sTBI) is undocumented. Reversal with andexanet alfa (AA) and prothrombin complex concentrates (PCCs) in cases of supratherapeutic doses remains unproven. Management is further complicated by the absence of real-time serum rivaroxaban concentration assays and drug-specific coagulation assays. This report details the use of plasma exchange (PLEX) in combination with PCC and AA to manage rivaroxaban overdose in sTBI.

Observations: A 36-year-old female presented with sTBI. Her admission international normalized ratio was 4.8 and thromboelastography reaction time was 85 seconds. Chromogenic low-molecular-weight heparin anti-Xa (AXA) concentration was < 0.1 units/mL. PCC and vitamin K were administered but failed to improve coagulopathy. Further history revealed a possible rivaroxaban overdose, and AA was administered. The second AXA prior to AA was > 1.8 units/mL. AXA remained > 1.8 units/mL 3 hours after AA. PLEX was urgently initiated prior to surgery for drug removal. Serum rivaroxaban concentrations pre- and post-PLEX were 534.6 and 256.8 ng/mL, respectively. A hemicraniectomy was performed without intraoperative or postoperative bleeding complications.

Lessons: Routine reversal strategies may be insufficient in achieving hemostasis in rivaroxaban overdose. PLEX reduced serum rivaroxaban concentration by 52%. PLEX can be an important adjunct to consider for medical and perioperative management of rivaroxaban overdose. https://thejns.org/doi/10.3171/CASE24475.

Keywords: direct-acting oral anticoagulants; overdose; plasma exchange; rivaroxaban; traumatic brain injury.

FIG. 1.

Initial noncontrast head CT scan obtained upon arrival in the emergency department, demonstrating 4.1 mm of midline shift and a left-sided acute SDH measuring 5.6 mm.

FIG. 2.

Timeline (in hours) of patient laboratory results and management. Expected mean trough rivaroxaban concentration 26–44 ng/mL (5th–95th percentile 6–137 ng/mL). INR normal range 0.9–1.1; partial thromboplastin time (PTT) normal range 25.5–35 seconds; TEG reaction (R) time normal range 22–44 seconds. OR = operating room.

FIG. 3.

Second noncontrast head CT (A–C) performed 6 hours after initial CT (preoperatively), demonstrating a worsening 7-mm acute left-sided SDH and multiple bilateral foci of intraparenchymal hemorrhage in the frontal lobes, resulting in a 9-mm midline shift.

FIG. 4.

Noncontrast CT (A–C) performed after left-sided decompressive hemicraniectomy, showing successful evacuation of left SDH and improvement of midline shift. Additionally, no progression of hemorrhage appears.