• Michael Müther, Wolfram Schwindt, Rolf Michael Mesters, Jens Minnerup, Paul Stracke, Markus Holling, Heinz Wiendl, and Walter Stummer.
• Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Münster, Germany. michael.muether@ukmuenster.de.
• Neurocrit Care. 2022 Oct 1; 37 (2): 372-376.

BackgroundWith a growing number of patients on new oral anticoagulants, interest in reversal agents is rising. Andexanet alfa is used for reversal of factor Xa inhibitors in intracranial hemorrhage.MethodsWe provide a brief review on andexanet-alfa-associated heparin resistance and discuss potentially critical situations from different clinical perspectives.ResultsCase reports point out that andexanet alfa can cause unresponsiveness to heparin, leading to catastrophic events. As a result, regulatory bodies have issued warning notices to avoid heparinization parallel to the use of andexanet alfa.ConclusionsAlthough well known to hematologists, the phenomenon is underrecognized among stroke clinicians. However, patients with intracranial hemorrhage frequently undergo endovascular or surgical interventions that require periprocedural administration of heparin.© 2022. The Author(s).

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