Specific reversal agents for direct oral anticoagulants in neurosurgical emergencies - a systematic review

Direct oral anticoagulants (DOACs) are widely used but pose significant challenges in emergency neurosurgical settings. Idarucizumab and andexanet alfa are approved reversal agents, yet their effectiveness and safety in neurosurgical emergencies remain unclear.

This systematic review evaluates the current evidence on DOAC reversal in patients undergoing emergency neurosurgical interventions.

We conducted a systematic review of case series of a minimum of 5 patients on DOACs receiving andexanet or idarucizumab for emergency neurosurgery (<24 hours after the last DOAC intake). The primary outcome was safety, defined by hemostatic efficacy. Secondary outcomes were thromboembolic events, mortality, and the functional clinical outcome.

Seven studies, comprising 148 patients, met the inclusion criteria. Andexanet was investigated in 4 studies, including 37 patients. Adequate intraoperative hemostasis was confirmed in 80% to 100% of patients. One study showed a thromboembolic event rate of 8.3% and an in-hospital mortality rate of 50% in 12 patients, while others showed lower rates. Idarucizumab was analyzed in 3 studies of 111 patients, of whom 97 were from a single large cohort. Satisfactory hemostasis was reported in 93.5% to 100% of patients. Thromboembolic event rates ranged from 0% to 4.1% and mortality rates were 0%, 3.1%, and 12.5%, respectively.

The use of DOAC reversal agents in emergency neurosurgery appears feasible and may support surgical hemostasis in selected patients. However, further research is warranted, particularly regarding the off-label use of andexanet, given the limited evidence and potential safety concerns.