Intracranial Hemorrhage in Patient Treated with Rivaroxaban
This is an 84 year-old right-handed female with a past medical history of atrial fibrillation on rivaroxaban 20 mg daily, Alzheimer’s dementia, hypertension, diabetes, and chronic obstructive pulmonary disease. The patient had fallen down 6 steps at home as witnessed by her husband. Her last rivaroxaban dose was about 8 hours prior to the fall. She became unresponsive 2 hours after the fall without tonic or clonic activity and was intubated in the field for airway protection. In addition she received 1 gram of levatiracetam and 1 mg of lorazepam.\nPhysical examination was significant for left forehead and right lower extremity ecchymoses. On computed tomography (CT) scan at time of presentation in the emergency room, she was found to have diffuse scattered acute subarachnoid hemorrhage and intraventricular hemorrhage (). Repeat head CT less than 24 hours after initial event showed stable acute subarachnoid hemorrhage and intraventricular hemorrhage. Laboratory evaluation at admission showed prothrombin time of 11.7 seconds, activated partial thromboplastin time of 24.7 seconds, and platelet count of 157,000 per mm3. At 3 hours post event, she received four units of fresh frozen plasma and 10 mg of Vitamin K slow intravenous push. The patient’s hospitalization was complicated by intubation, pneumonia, and gastrostomy tube placement. Rivaroxaban was held during the hospitalization. Levetiracetam was initiated for seizure prophylaxis and was tapered off after two weeks. She was able to recover to her prior neurological baseline. Warfarin anti-coagulation was started 2-3 weeks after onset of the hemorrhage.