Misdiagnosis of rivaroxaban-associated multiple intracranial hemorrhages as intracranial metastatic tumor: a case report

Rivaroxaban, a direct oral anticoagulant (DOAC), has emerged as a first-line therapy for the prevention and treatment of thromboembolic diseases, such as stroke in atrial fibrillation, due to its consistent anticoagulant effect. Nevertheless, vigilance remains imperative concerning its potential adverse reactions, particularly rare imaging manifestations that may result in misdiagnosis. This report details an 88-year-old female patient with atrial fibrillation who experienced multiple intracranial hemorrhages approximately 20 days after commencing rivaroxaban therapy. Initial contrast-enhanced cranial magnetic resonance imaging revealed multiple intracranial nodules with ring enhancement and edema, leading to a misdiagnosis of "multiple intracranial metastatic tumors with hemorrhage." Following the discontinuation of rivaroxaban, no antitumor therapy was administered; only antihypertensive therapy and symptomatic management were provided. Dynamic follow-up revealed gradual lesion shrinkage, with partial resolution several months post-discontinuation. The case was ultimately diagnosed as rivaroxaban-associated multiple intracranial cerebral hemorrhages. This case highlights that rivaroxaban-associated intracranial hemorrhage may present as rare multiple nodular lesions. Their imaging characteristics can easily be confused with those of intracranial metastatic tumors. Clinical diagnosis requires comprehensive evaluation incorporating medication history, dynamic imaging follow-up, and lesion progression to avoid misdiagnosis and overtreatment. Additionally, for elderly patients with multiple comorbidities, the prescription of DOACs should include individualized evaluation to optimize dosage selection and monitoring strategies.