Journal Article

DKFZ-2026-01049

http://join2-wiki.gsi.de/foswiki/pub/Main/Artwork/join2_logo100x88.png Emergency reversal of Rivaroxaban with Andexanet alfa in a child with hemorrhagic brain metastasis from Wilms tumor.

Rafaelian, A. ; Won, S.-Y. ; Mueller, L. ; Armbrust, M.DKFZ* ; Weber, K.DKFZ* ; Haas, A. ; Reuter, D. A. ; Freiman, T. M. ; Gessler, F. ; Spang, C. ; Meyer-Bahlburg, A. ; Hingst, P. ; Classen, C. F. ; Dubinski, D. ; Cardesa-Salzmann, T. M.

2026
Springer Heidelberg

Abstract: Central nervous system (CNS) metastases from Wilms tumor (WT) are exceedingly rare. Intracerebral hemorrhage secondary to metastatic WT is even less common, and the management of such cases is further complicated when patients are receiving a direct oral anticoagulant (DOAC) like Rivaroxaban, for which pediatric reversal guidelines are lacking.We report on the case of a 5-year-old boy with relapsed stage IV Wilms tumor who presented with rapidly progressive neurological deterioration caused by brain metastases with extensive intraparenchymal and intraventricular hemorrhage while receiving Rivaroxaban due to prior thrombosis. An emergent craniotomy and tumor resection was safely performed after emergent reversal of anticoagulation with Rivaroxaban using Andexanet alfa, administered in this pediatric patient with off-label consent in the setting of a life-threatening intracranial hemorrhage requiring emergent neurosurgical intervention. No excessive intraoperative bleeding was noted. Treatment for relapsed WT according to the SIOP-UMBRELLA-Protocol was initiated. Three weeks after Andexanet alfa treatment, a thrombotic event in the left iliac veins occurred, requiring anticoagulation with unfractionated heparin.This case highlights the therapeutic challenges of managing intracranial hemorrhage in a pediatric patient requiring emergent neurosurgical debulking in the setting of Rivaroxaban anticoagulation. To our knowledge, this is the second case reporting on Rivaroxaban reversal through Andexanet alfa in children. Early multidisciplinary intervention, meticulous neurosurgical management and continuation of oncologic therapy can lead to favorable outcomes even in such complex presentations.

Keyword(s): Humans (MeSH) ; Male (MeSH) ; Child, Preschool (MeSH) ; Rivaroxaban: adverse effects (MeSH) ; Rivaroxaban: therapeutic use (MeSH) ; Brain Neoplasms: secondary (MeSH) ; Brain Neoplasms: complications (MeSH) ; Brain Neoplasms: drug therapy (MeSH) ; Brain Neoplasms: surgery (MeSH) ; Wilms Tumor: complications (MeSH) ; Wilms Tumor: drug therapy (MeSH) ; Wilms Tumor: secondary (MeSH) ; Recombinant Proteins: therapeutic use (MeSH) ; Factor Xa: therapeutic use (MeSH) ; Kidney Neoplasms: pathology (MeSH) ; Factor Xa Inhibitors: adverse effects (MeSH) ; Factor Xa Inhibitors: therapeutic use (MeSH) ; Intracranial Hemorrhages (MeSH) ; Andexanet alfa ; DOAC ; Intracranial hemorrhage ; Pediatric anticoagulation ; Rivaroxaban ; Rivaroxaban ; Recombinant Proteins ; Factor Xa ; Factor Xa Inhibitors ; PRT064445

Note: #DKTKZFB26#

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Contributing Institute(s):

1. DKTK Koordinierungsstelle Frankfurt (FM01)

Research Program(s):

1. 899 - ohne Topic (POF4-899) (POF4-899)

Appears in the scientific report 2026

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Database coverage:
; BIOSIS Previews ; Biological Abstracts ; Clarivate Analytics Master Journal List ; Current Contents - Clinical Medicine ; DEAL Springer ; DEAL Springer ; Ebsco Academic Search ; Essential Science Indicators ; IF < 5 ; JCR ; SCOPUS ; Science Citation Index Expanded ; Web of Science Core Collection

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