Abstract Details

Title Efficacy and Safety of Direct Oral Anticoagulant Reversal Agents in Intracerebral Hemorrhage: A Systematic Review and Meta-analysis

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P7 - Poster Session 7 (8:00 AM-9:00 AM)

Poster/Presentation
Number 4-006

Objective To evaluate the efficacy and safety of direct oral anticoagulant (DOAC) reversal agents in patients with intracerebral hemorrhage (ICH).

Background Patients on DOACs who develop ICH often receive reversal therapy with agents like 4-factor prothrombin complex concentrate (4F-PCC), andexanet alfa (AA), or idarucizumab. However, data directly comparing the efficacy and safety of these agents remains limited.

Design/Methods A systematic search was conducted across PubMed, Embase, Web of Science, and others from inception through February 2025. Eligible studies enrolled adults on DOAC therapy who received a reversal agent for ICH and reported outcomes such as successful hemostatic reversal, all-cause mortality, or thromboembolic events. Meta-analysis was performed using R version 4.5.1.

Results

A total of 74 studies met inclusion criteria, encompassing 6,664 patients (2,678 receiving 4F-PCC; 3,401 AA; and 585 idarucizumab). The mean age across studies was 76 years (range, 65–85 years), and 56% were men. For 4F-PCC, anticoagulation reversal was 77% (95% CI, 73%–80%; I² = 53%), all-cause mortality 24% (95% CI, 20%–27%; I² = 62%), and thromboembolic events 5% (95% CI, 3%–8%; I² = 44%). For AA, reversal was 81% (95% CI, 77%–85%; I² = 63%), all-cause mortality 17% (95% CI, 13%–22%; I² = 76%), and thromboembolic events 10% (95% CI, 7%–13%; I² = 44%). For idarucizumab, reversal was 80% (95% CI, 33%–97%), all-cause mortality 18% (95% CI, 12%–26%), and thromboembolic events 5% (95% CI, 2%–15%). A direct comparison between 4F-PCC and AA showed no significant differences in anticoagulation reversal, mortality, or thromboembolic events.

Conclusions Among patients on DOAC who develop ICH, reversal with 4F-PCC, AA, or idarucizumab achieves high hemostatic success with low to moderate risk of all-cause mortality and thromboembolism. Head-to-head comparisons suggest similar reversal efficacy between AA and 4F-PCC. Findings support the effectiveness of available reversal strategies while underscoring the need for randomized trials to confirm comparative safety and longer-term outcomes.

Authors/Disclosures
Omar Abdelkader, MD (Westchester Medical Center) PRESENTER	Dr. Abdelkader has nothing to disclose.
Sai Krishna Vallamchetla, MBBS (Mayo Clinic, Florida)	Mr. Vallamchetla has nothing to disclose.
Karim Borei	Dr. Borei has nothing to disclose.
Amr Salem, MBBCH	Dr. Salem has nothing to disclose.
Vamsi reddy r. Lakkireddy, MBBS	Dr. Lakkireddy has nothing to disclose.
Anyna Shine, MBBS	Miss Shine has nothing to disclose.
Doaa Ramadan	Doaa Ramadan has nothing to disclose.
Ruaa Alsaeed, MBBS (Alfaisal University)	Dr. Alsaeed has nothing to disclose.
Sangharsha Thapa, MD	Dr. Thapa has nothing to disclose.
Sara Muhammad, MD (Westchester Medical Center)	Dr. Muhammad has nothing to disclose.
Tomoko Kitago, MD (Westchester Medical Center)	Dr. Kitago has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for MindMaze. The institution of Dr. Kitago has received research support from American Speech-Language Hearing Foundation. The institution of Dr. Kitago has received research support from National Institutes of Health.
Fawaz Al-Mufti, MD (Westchester Medical Center at New York Medical College)	Dr. Al-Mufti has received personal compensation in the range of $0-$499 for serving as a Consultant for Stryker. Dr. Al-Mufti has received personal compensation in the range of $0-$499 for serving as a Consultant for Cerenovus. Dr. Al-Mufti has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for Revalesio .

��ɫ��

��ɫ��