Anticoagulation Reversal in Intracerebral Hemorrhage: A Case Report on the Efficacy of Andexanet Alfa in an Apixaban-Treated Patient

Intracerebral hemorrhage (ICH) presents complex clinical challenges, particularly in patients receiving anticoagulation therapy. This case report discusses the management of acute ICH in a 60-year-old male patient on long-term apixaban therapy, who arrived at the emergency department with altered consciousness, right-sided hemiplegia, and mixed aphasia. Computed tomography (CT) imaging revealed a 70 ml left lenticular-capsular hematoma with significant mass effect, necessitating rapid intervention. Due to the patient's deteriorating neurological condition, andexanet alfa was administered as a reversal agent for apixaban, effectively reducing anti-factor Xa (FXa) activity and enabling an urgent left temporal craniotomy for hematoma evacuation. Postoperatively, the patient received ICU monitoring, blood pressure management, and supportive care, showing gradual improvement in consciousness and sensory aphasia over several days. Despite initial right hemiplegia and motor aphasia requiring rehabilitation, the patient showed excellent progress at one month, now walking independently and managing daily self-care. This report highlights the potential of andexanet alfa for effective anticoagulation reversal in critical ICH cases while also addressing associated thrombotic risks. It underscores the need for a multidisciplinary approach and emphasizes the importance of further research to refine treatment strategies for anticoagulated patients with ICH.