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Low risk of traumatic intracranial hematoma expansion with factor Xa inhibitors without andexanet reversal.
World Neurosurg. 2020 Jun 16 [Online ahead of print]WN

Abstract

BACKGROUND

Andexanet alfa, a novel anticoagulation reversal agent for Factor Xa inhibitors, was recently approved. Traumatic intracranial hemorrhage presents a prime target for this drug. The ANNEXA-4 study established the efficacy of andexanet alfa in reversing Factor Xa inhibitors. However, the association between anticoagulation reversal and traumatic intracranial hemorrhage progression is not well understood.

OBJECTIVE

To determine progression rates of patients with traumatic intracranial hemorrhage on Factor Xa inhibitors prior to hospitalization who were managed without the use of Andexxa.

METHODS

A retrospective cohort study was performed between 2016 and 2019 at a single institution. An institutional traumatic brain injury (TBI) registry was queried. Patients with recorded use of apixaban or rivaroxaban <18 hours before injury were included. The primary study outcome was <35% increase in hemorrhage volume or thickness on repeated head computed tomography (CT) scans.

RESULTS

We identified 25 patients meeting the inclusion criteria. Two patients were excluded due to lack of necessary CT data. Twelve patients (52%) were receiving apixaban, and 11 (48%) rivaroxaban. On admission CT, 14 patients had subdural hematoma (SDH), 6 had traumatic intraparenchymal hemorrhage (IPH), and 3 had subarachnoid hemorrhage (SAH). Anticoagulation reversal was attempted in 17 (74%) patients, primarily using 4-factor prothrombin complex concentrate (4F-PCC). Twenty patients (87%) were adjudicated as having excellent or good hemostasis on repeat imaging.

CONCLUSIONS

Our results indicate that patients on Factor Xa inhibitors with complicated mild TBI have a similar intracranial hemorrhage progression rate to patients who are not anticoagulated or anticoagulated with a reversible agent. The hemostatic outcomes in our cohort were similar to those reported after Andexanet administration.

Authors+Show Affiliations

Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. Electronic address: mstipple@bidmc.harvard.edu.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

32561488

Citation

Maragkos, Georgios A., et al. "Low Risk of Traumatic Intracranial Hematoma Expansion With Factor Xa Inhibitors Without Andexanet Reversal." World Neurosurgery, 2020.
Maragkos GA, Nelton EB, Richter S, et al. Low risk of traumatic intracranial hematoma expansion with factor Xa inhibitors without andexanet reversal. World Neurosurg. 2020.
Maragkos, G. A., Nelton, E. B., Richter, S., & Stippler, M. (2020). Low risk of traumatic intracranial hematoma expansion with factor Xa inhibitors without andexanet reversal. World Neurosurgery. https://doi.org/10.1016/j.wneu.2020.06.069
Maragkos GA, et al. Low Risk of Traumatic Intracranial Hematoma Expansion With Factor Xa Inhibitors Without Andexanet Reversal. World Neurosurg. 2020 Jun 16; PubMed PMID: 32561488.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Low risk of traumatic intracranial hematoma expansion with factor Xa inhibitors without andexanet reversal. AU - Maragkos,Georgios A, AU - Nelton,Emmalin B, AU - Richter,Sven, AU - Stippler,Martina, Y1 - 2020/06/16/ PY - 2020/03/23/received PY - 2020/06/03/revised PY - 2020/06/08/accepted PY - 2020/6/21/entrez KW - Andexanet alpha KW - anticoagulation KW - intracranial hemorrhage JF - World neurosurgery JO - World Neurosurg N2 - BACKGROUND: Andexanet alfa, a novel anticoagulation reversal agent for Factor Xa inhibitors, was recently approved. Traumatic intracranial hemorrhage presents a prime target for this drug. The ANNEXA-4 study established the efficacy of andexanet alfa in reversing Factor Xa inhibitors. However, the association between anticoagulation reversal and traumatic intracranial hemorrhage progression is not well understood. OBJECTIVE: To determine progression rates of patients with traumatic intracranial hemorrhage on Factor Xa inhibitors prior to hospitalization who were managed without the use of Andexxa. METHODS: A retrospective cohort study was performed between 2016 and 2019 at a single institution. An institutional traumatic brain injury (TBI) registry was queried. Patients with recorded use of apixaban or rivaroxaban <18 hours before injury were included. The primary study outcome was <35% increase in hemorrhage volume or thickness on repeated head computed tomography (CT) scans. RESULTS: We identified 25 patients meeting the inclusion criteria. Two patients were excluded due to lack of necessary CT data. Twelve patients (52%) were receiving apixaban, and 11 (48%) rivaroxaban. On admission CT, 14 patients had subdural hematoma (SDH), 6 had traumatic intraparenchymal hemorrhage (IPH), and 3 had subarachnoid hemorrhage (SAH). Anticoagulation reversal was attempted in 17 (74%) patients, primarily using 4-factor prothrombin complex concentrate (4F-PCC). Twenty patients (87%) were adjudicated as having excellent or good hemostasis on repeat imaging. CONCLUSIONS: Our results indicate that patients on Factor Xa inhibitors with complicated mild TBI have a similar intracranial hemorrhage progression rate to patients who are not anticoagulated or anticoagulated with a reversible agent. The hemostatic outcomes in our cohort were similar to those reported after Andexanet administration. SN - 1878-8769 UR - https://www.unboundmedicine.com/medline/citation/32561488/Low_risk_of_traumatic_intracranial_hematoma_expansion_with_factor_Xa_inhibitors_without_andexanet_reversal L2 - https://linkinghub.elsevier.com/retrieve/pii/S1878-8750(20)31327-9 DB - PRIME DP - Unbound Medicine ER -
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