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

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.