Thromboelastography may assess the effect of anticoagulation reversal in intracranial hemorrhage

A Zepeski; B A Faine; M Ghannam; H M Olalde; L Wendt; A Naidech; N M Mohr; E C Leira

doi:10.1016/j.jstrokecerebrovasdis.2025.108228

Thromboelastography may assess the effect of anticoagulation reversal in intracranial hemorrhage

J Stroke Cerebrovasc Dis. 2025 Jan 8:108228. doi: 10.1016/j.jstrokecerebrovasdis.2025.108228. Online ahead of print.

Authors

A Zepeski¹, B A Faine², M Ghannam³, H M Olalde³, L Wendt⁴, A Naidech⁵, N M Mohr⁶, E C Leira⁷

Affiliations

¹ Department of Emergency Medicine, University of Iowa College of Medicine; University of Iowa College of Pharmacy. Electronic address: anne-zepeski@uiowa.edu.
² Department of Emergency Medicine, University of Iowa College of Medicine; University of Iowa College of Pharmacy.
³ Department of Neurology, University of Iowa College of Medicine.
⁴ Institute for Clinical and Translational Sciences, University of Iowa.
⁵ Department of Neurology, Northwestern Medicine Feinberg School of Medicine.
⁶ Department of Emergency Medicine, University of Iowa College of Medicine; Department of Anesthesia, University of Iowa College of Medicine; Department of Epidemiology, University of Iowa College of Public Health.
⁷ Department of Neurology, University of Iowa College of Medicine; Department of Epidemiology, University of Iowa College of Public Health; Department of Neurosurgery, University of Iowa College of Medicine.

PMID: 39793720
DOI: 10.1016/j.jstrokecerebrovasdis.2025.108228

Abstract

Background: Intracranial hemorrhage (ICH) is a complication of oral anticoagulation and is associated with significant morbidity and mortality. Clinical need exists for biomarkers to measure anticoagulation in patients with factor Xa inhibitor-associated ICH to assess the hemostatic effect of reversal agents. This study explored the utility of thromboelastography (TEG) to assess anticoagulation in emergency department (ED) patients who received activated prothrombin complex concentrate (aPCC) reversal for factor Xa-inhibitor-associated ICH.

Methods: This was a prospective, single-center, cohort study in a convenient sample of adult patients presenting to the ED with acute factor Xa-associated ICH. Exclusion criteria included pregnancy, incarceration, polytrauma, hepatic failure, or other known coagulopathic conditions. TEG samples were collected prior to anticoagulation reversal, as well as at 30-minutes, 12-hours, and 24-hours post-reversal. Only patients who received aPCC reversal were included in the final analysis.

Results: Pre-reversal TEG was collected on 10 participants prior to aPCC administration. A significant decrease in TEG R-time was observed at 30 minutes post-aPCC reversal (Beta = -0.91, p = 0.035). R-time increased at 12- and 24-hours post-aPCC reversal to baseline levels. Significant changes were not observed in K-time, clot strength, maximum amplitude, or coagulation index.

Conclusions: TEG R-time decreases acutely after anticoagulation reversal with aPCC and rebounds at 12- and 24-hours post-reversal. TEG R-time may serve as a potential sensitive biomarker of the residual anticoagulation activity of factor Xa inhibitors in patients with ICH that undergo anticoagulation reversal with aPCCs.

Keywords: Anticoagulation reversal; anticoagulation; hematologic studies; intracranial hemorrhage.