{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,29]],"date-time":"2026-01-29T22:59:31Z","timestamp":1769727571304,"version":"3.49.0"},"reference-count":62,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"23","license":[{"start":{"date-parts":[[2024,12,2]],"date-time":"2024-12-02T00:00:00Z","timestamp":1733097600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Cosmet Laser Ther"],"published-print":{"date-parts":[[2024,12,2]]},"abstract":"\n BACKGROUND<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>\n \n OBSERVATIONS<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>\n \n LESSONS<\/jats:title>\n 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.<\/jats:p>\n \n https:\/\/thejns.org\/doi\/10.3171\/CASE24475<\/jats:ext-link>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/case24475","type":"journal-article","created":{"date-parts":[[2024,12,2]],"date-time":"2024-12-02T01:51:35Z","timestamp":1733104295000},"source":"Crossref","is-referenced-by-count":0,"title":["Management of severe traumatic brain injury in a rivaroxaban overdose: illustrative case"],"prefix":"10.3171","volume":"8","author":[{"given":"Madeline J.","family":"Foertsch","sequence":"first","affiliation":[{"name":"Department of Pharmacy Services, University of Cincinnati Medical Center, Cincinnati, Ohio"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Henry T.","family":"Beckett","sequence":"additional","affiliation":[{"name":"University of Cincinnati College of Medicine, Cincinnati, Ohio"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lauren M.","family":"Dehne","sequence":"additional","affiliation":[{"name":"Department of Pharmacy Services, University of Cincinnati Medical Center, Cincinnati, Ohio"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stephanie","family":"Janusz","sequence":"additional","affiliation":[{"name":"Department of Pharmacy Services, University of Cincinnati Medical Center, Cincinnati, Ohio"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Simona","family":"Ferioli","sequence":"additional","affiliation":[{"name":"Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Laura B.","family":"Ngwenya","sequence":"additional","affiliation":[{"name":"Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Molly E.","family":"Droege","sequence":"additional","affiliation":[{"name":"Department of Pharmacy Services, University of Cincinnati Medical Center, Cincinnati, Ohio"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"7","key":"bib1","series-title":"J Neurol","first-page":"3849","article-title":"Incidence of intracranial bleeding in mild traumatic brain injury patients taking oral anticoagulants: a systematic review and meta-analysis","volume":"271","author":"Karamian","year":"2024","unstructured":"Karamian ASeifi AKaramian ALucke-Wold B. Incidence of intracranial bleeding in mild traumatic brain injury patients taking oral anticoagulants: a systematic review and meta-analysis. J Neurol. 2024;271(7):3849-3868."},{"issue":"1","key":"bib2","series-title":"Ann Emerg Med","first-page":"98","article-title":"What is the incidence of intracranial hemorrhage among anticoagulated patients with minor head trauma?","volume":"74","author":"Gottlieb","year":"2019","unstructured":"Gottlieb MThottathil SMHolton JP. What is the incidence of intracranial hemorrhage among anticoagulated patients with minor head trauma? Ann Emerg Med. 2019;74(1):98-100."},{"issue":"7","key":"bib3","series-title":"JAMA Health Forum","first-page":"e211693","article-title":"National trends in use of and spending on oral anticoagulants among US medicare beneficiaries from 2011 to 2019","volume":"2","author":"Troy","year":"2021","unstructured":"Troy AAnderson TS. National trends in use of and spending on oral anticoagulants among US medicare beneficiaries from 2011 to 2019. JAMA Health Forum. 2021;2(7):e211693."},{"issue":"3","key":"bib4","series-title":"J Am Heart Assoc","first-page":"e007338","article-title":"Evidence gaps in the era of non\u2013vitamin K oral anticoagulants","volume":"7","author":"Aronis","year":"2018","unstructured":"Aronis KNHylek EM. Evidence gaps in the era of non\u2013vitamin K oral anticoagulants. J Am Heart Assoc. 2018;7(3):e007338."},{"issue":"2","key":"bib5","series-title":"H\u00e4mostaseologie","first-page":"201","article-title":"How do I reverse oral and parenteral anticoagulants?","volume":"40","author":"Koscielny","year":"2020","unstructured":"Koscielny JRutkauskaite ESucker Cvon Heymann C. How do I reverse oral and parenteral anticoagulants? H\u00e4mostaseologie. 2020;40(2):201-213."},{"issue":"25","key":"bib6","series-title":"N Engl J Med","first-page":"2413","article-title":"Andexanet alfa for the reversal of factor xa inhibitor activity","volume":"373","author":"Siegal","year":"2015","unstructured":"Siegal DMCurnutte JTConnolly SJ, et al. Andexanet alfa for the reversal of factor xa inhibitor activity. N Engl J Med. 2015;373(25):2413-2424."},{"issue":"12","key":"bib7","series-title":"N Engl J Med","first-page":"1131","article-title":"Andexanet alfa for acute major bleeding associated with factor xa inhibitors","volume":"375","author":"Connolly","year":"2016","unstructured":"Connolly SJMilling TJEikelboom JW, et al. Andexanet alfa for acute major bleeding associated with factor xa inhibitors. N Engl J Med. 2016;375(12):1131-1141."},{"issue":"1","key":"bib8","series-title":"J Thromb Thrombolysis","first-page":"121","article-title":"Cost comparison of andexanet versus prothrombin complex concentrates for direct factor Xa inhibitor reversal after hemorrhage","volume":"49","author":"Frontera","year":"2020","unstructured":"Frontera JABhatt PLalchan R, et al. Cost comparison of andexanet versus prothrombin complex concentrates for direct factor Xa inhibitor reversal after hemorrhage. J Thromb Thrombolysis. 2020;49(1):121-131."},{"issue":"12","key":"bib9","series-title":"Cureus","first-page":"e20632","article-title":"Efficacy and safety of andexanet alfa for bleeding caused by factor xa inhibitors: a systematic review and meta-analysis","volume":"13","author":"Shrestha","year":"2021","unstructured":"Shrestha DBBudhathoki PAdhikari A, et al. Efficacy and safety of andexanet alfa for bleeding caused by factor xa inhibitors: a systematic review and meta-analysis. 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Pharmacotherapy. 2012;32(6):546-558."},{"issue":"4","key":"bib25","series-title":"Ann Pharmacother","first-page":"341","article-title":"Anti-xa oral anticoagulant plasma concentration assay in real life: rivaroxaban and apixaban quantification in emergency with LMWH calibrator","volume":"53","author":"Billoir","year":"2019","unstructured":"Billoir PBarbay VJoly LMFresel MChr\u00e9tien MHLe Cam Duchez V. Anti-xa oral anticoagulant plasma concentration assay in real life: rivaroxaban and apixaban quantification in emergency with LMWH calibrator. Ann Pharmacother. 2019;53(4):341-347."},{"issue":"1","key":"bib26","series-title":"J Physiol Pharmacol","first-page":"47","article-title":"Effects of direct oral anticoagulants on thromboelastographic parameters and fibrin clot properties in patients with venous thromboembolism","volume":"71","author":"Kopytek","year":"2020","unstructured":"Kopytek MZabczyk MNatorska JMalinowski KPUndas A. Effects of direct oral anticoagulants on thromboelastographic parameters and fibrin clot properties in patients with venous thromboembolism. J Physiol Pharmacol. 2020;71(1):47-53."},{"key":"bib27","series-title":"Front Cardiovasc Med","first-page":"991675","article-title":"The impact of direct oral anticoagulants on viscoelastic testing\u2014a systematic review","volume":"9","author":"Sahli","year":"2022","unstructured":"Sahli SDCastellucci CRoche TRR\u00f6ssler JSpahn DRKaserer A. The impact of direct oral anticoagulants on viscoelastic testing\u2014a systematic review. Front Cardiovasc Med. 2022;9:991675."},{"issue":"10","key":"bib28","series-title":"Pharmacotherapy","first-page":"780","article-title":"Reversal of apixaban and rivaroxaban with andexanet alfa prior to invasive or surgical procedures","volume":"42","author":"Bradshaw","year":"2022","unstructured":"Bradshaw PGKeegan SPDroege ME, et al. Reversal of apixaban and rivaroxaban with andexanet alfa prior to invasive or surgical procedures. Pharmacotherapy. 2022;42(10):780-791."},{"issue":"5","key":"bib29","series-title":"J Am Coll Cardiol","first-page":"594","article-title":"ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants","volume":"76","author":"Tomaselli","year":"2020","unstructured":"Tomaselli GFMahaffey KWCuker A, et al. ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants. J Am Coll Cardiol. 2020;76(5):594-622."},{"issue":"23","key":"bib30","series-title":"Am J Health Syst Pharm","first-page":"1722","article-title":"Administration of andexanet alfa for traumatic intracranial hemorrhage in the setting of massive apixaban overdose: a case report","volume":"80","author":"Jenniches","year":"2023","unstructured":"Jenniches DKerns AFDelBianco JStripp MPPhilp AS. Administration of andexanet alfa for traumatic intracranial hemorrhage in the setting of massive apixaban overdose: a case report. Am J Health Syst Pharm. 2023;80(23):1722-1728."},{"issue":"21","key":"bib31","series-title":"Blood","first-page":"3636","article-title":"A phase 2 randomized, double-blind, placebo-controlled trial demonstrating reversal of rivaroxaban-induced anticoagulation in healthy subjects by andexanet alfa (PRT064445), an antidote for Fxa inhibitors","volume":"122","author":"Mark","year":"2013","unstructured":"Mark CVandana MMichael K, et al. A phase 2 randomized, double-blind, placebo-controlled trial demonstrating reversal of rivaroxaban-induced anticoagulation in healthy subjects by andexanet alfa (PRT064445), an antidote for Fxa inhibitors. 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