Haemorrhagic stroke due to rivaroxaban and use of prothrombin complex concentrate as a reversal agent

Abstract

Background Oral anticoagulation for stroke prevention in atrial fibrillation significantly reduces the risk of thromboembolism; however, intracranial haemorrhage is a serious complication. The novel oral anticoagulants such as rivaroxaban have been shown to be as efficacious as conventional therapy but with a lower risk of bleeding, specifically intracranial bleeding events. Clinical details A 68-year-old male presented to the emergency department with sudden onset confusion, severe frontal headache, photophobia and word finding difficulty. His blood pressure was 224/169 mmHg on admission and he had an irregularly irregular pulse rate of 99 bpm. A computed tomography of the head confirmed a posterior parietal intracranial haemorrhage, which was attributed to recent (3 weeks prior) commencement of rivaroxaban 15 mg daily for stroke prevention in the context of normal renal function. Outcome Intravenous (IV) hydralazine, oral amlodipine and topical glyceryl trinitrate were given to control blood pressure. Prothrombin complex concentrate was used to reverse the effects of rivaroxaban and prevent further bleeding. The patient made an excellent recovery and was discharged with short-term outpatient rehabilitation services. Aspirin was recommenced for stroke prevention 2 weeks after the initial presentation. Conclusion While the new generation of oral anticoagulants offers many benefits in comparison to warfarin (such as fewer drug interactions, more standardised dosing and the lack of need for International Normalised Ratio (INR) monitoring), there still remains a risk of potentially fatal bleeding. Careful patient selection and regular follow-up are required to reduce these risks. Patients should be counselled on the bleeding risks associated with the use of novel anticoagulants.