New Oral Anticoagulant Management in Patients Who Experienced a Hemorrhagic Stroke

A 73-year-old male presents to the emergency department with a severe headache, nausea, and left arm and leg weakness. While the patient receives neurological assessment, his level of consciousness decreases (Glasgow Coma Score 9). He has a medical history significant for hypertension, diabetes, hyperlipidemia, mild renal impairment, atrial fibrillation (AF), and previous cardioembolic stroke that occurred two years before. The outpatient medications include amlodipine 10 mg daily, insulin, rosuvastatin 10 mg daily, and rivaroxaban 20 mg daily, all of which he last took three hours ago.

A non-contrast brain computed tomography (CT) scan shows a subcortical hemorrhage in the right frontal lobe with associated vasogenic edema and mild midline shift, without signs of intraventricular extension. Neurosurgery is consulted and recommends prophylactic anticonvulsant therapy, intravenous mannitol, a repeat head CT in four hours, and neurosurgical intensive care unit admission.

Based on current evidence, after discontinuing rivaroxaban, which of the following is the most appropriate strategy to normalize coagulation in the acute phase of hemorrhagic stroke?

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