• Brandon A Sherrod, Chad K Condie, Andrea A Brock, Holly Ledyard, Sarah T Menacho, and Marcus D Mazur.
• Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA.
• World Neurosurg. 2020 Mar 1; 135: 38-41.

BackgroundDirect oral anticoagulants (DOACs) are becoming the medication of choice for the management of venous thromboembolism and stroke prevention in atrial fibrillation because of simplified dosing, a more predictive pharmacokinetic profile, and better clinical outcomes when compared with traditional vitamin K antagonists. Recently, reversal agents for DOACs have been approved by the U.S. Food and Drug Administration for use in managing life-threatening or uncontrolled bleeding; however, for acute nonhemorrhagic conditions requiring surgical intervention, such as acute hydrocephalus requiring ventriculostomy, there is little evidence to help guide appropriate management for patients on DOACs.Case DescriptionWe report the use of andexanet alfa to counteract rivaroxaban treatment in a 28-year-old woman who developed herniation syndrome and acute hydrocephalus from a cerebellar tumor.ConclusionsWe describe how appropriate timing of administration of the DOAC reversal agent may permit urgent neurosurgical intervention.Copyright © 2019 Elsevier Inc. All rights reserved.

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