Four-factor prothrombin complex concentrate for emergency ventriculostomy in a patient with left ventricular thrombus: a case report
Gabriel Leite de Castro Vieira, Rafael Coelho Tibúrcio
Abstract
The management of neurosurgical patients receiving anticoagulant and antiplatelet therapy presents a major clinical challenge. This case report describes the perioperative management of emergency anticoagulation reversal using four-factor prothrombin complex concentrate (4F-PCC) in a 53-year-old man with coronary artery disease, left ventricular thrombus, and recent ischemic stroke who required urgent ventriculostomy for cerebellar infarction complicated by obstructive hydrocephalus and intracranial hypertension. Anticoagulation reversal allowed timely neurosurgical intervention with satisfactory hemostasis and a favorable postoperative outcome, highlighting the potential role of four-factor prothrombin complex concentrate in selected high-risk emergency neurosurgical patients.
Keywords
References
1. Prior A, Fiaschi P, Iaccarino C, Stefini R, Battaglini D, Balestrino A, et al. How do you manage ANTICOagulant therapy in neurosurgery? The ANTICO survey of the Italian Society of Neurosurgery (SINCH). BMC Neurol. 2021;21(1):98. https://doi.org/10.1186/s12883-021-02126- 7. PMid:33658003.
2. Thompson A, Fleischmann KE, Smilowitz NR, de Las Fuentes L, Mukherjee D, Aggarwal NR, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery: a report of the American College of Cardiology/ American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2024;84(19):1869- 969. https://doi.org/10.1016/j.jacc.2024.06.013. PMid:39320289.
3. Baron TH, Kamath PS, McBane RD. Management of antithrombotic therapy in patients undergoing invasive procedures. N Engl J Med. 2013;368(22):2113-24. https:// doi.org/10.1056/NEJMra1206531. PMid:23718166.
4. Sherrod BA, Condie CK, Brock AA, Ledyard HK, Menacho ST, Mazur MD. Emergent reversal of direct oral anticoagulants permitting neurosurgical intervention for nonhemorrhagic pathology. World Neurosurg. 2020;135:38-41. https://doi. org/10.1016/j.wneu.2019.11.162. PMid:31809896.
5. Frontera JA, Bhatt P, Lalchan R, Yaghi S, Ahuja T, Papadopoulos J, et al. Cost comparison of andexanet versus prothrombin complex concentrates for direct factor Xa inhibitor reversal after hemorrhage. J Thromb Thrombolysis. 2020;49(1):121-31. https://doi.org/10.1007/ s11239-019-01973-z. PMid:31664662.
6. Douketis JD, Spyropoulos AC. Perioperative management of patients taking direct oral anticoagulants: a review. JAMA. 2024;332(10):825-34. https://doi.org/10.1001/ jama.2024.12708. PMid:39133476.
7. Pham H, Medford WG, Horst S, Levesque M, Ragoonanan D, Price C, et al. Andexanet alfa versus four-factor prothrombin complex concentrate for the reversal of apixaban- or rivaroxaban-associated intracranial hemorrhages. Am J Emerg Med. 2022;55:38-44. https:// doi.org/10.1016/j.ajem.2022.02.029. PMid:35272069.
8. Scerrati A, Scanferla G, Sgarbanti L, Mantovani G, Angelini C, Flacco ME, et al. Clinical outcomes and hemorrhagic or thromboembolic risks in decompressive craniectomy for patients taking antiplatelet or anticoagulant therapy. Neurosurg Rev. 2025;48(1):328. https://doi.org/10.1007/ s10143-025-03491-4. PMid:40140119.
9. Bradley CA, Ma C, Hollon MM. Perioperative point-of-care ultrasound for hemodynamic assessment: a narrative review. Semin Cardiothorac Vasc Anesth. 2023;27(3):208- 23. https://doi.org/10.1177/10892532231165088. PMid:36943777.
Submitted date:
05/19/2026
Accepted date:
08/29/2026
Facebook
LinkedIn
Mendeley
Reddit
Email