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Post-splenectomy prevention — USMLE Step 3 MCQ

Instant feedback + full explanation. One question, done properly.

HardSurgery (post-operative, follow-up)Post-splenectomy preventionUSMLE Step 3

A 78-year-old woman taking apixaban for atrial fibrillation develops headache and left hemiparesis 3 hours after her morning dose. CT shows a 35-mL right basal-ganglia hemorrhage with expansion on repeat imaging. Creatinine is normal, platelet count is normal, and no heparin was given. Which reversal strategy is most appropriate?

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Reveal the answer and explanation

Correct answer: A — Administer andexanet alfa for factor Xa inhibitor reversal and stop apixaban

The best answer is “Administer andexanet alfa for factor Xa inhibitor reversal and stop apixaban”. Recent apixaban exposure with expanding intracerebral hemorrhage requires immediate factor Xa inhibitor reversal. Andexanet alfa is a specific reversal agent; four-factor PCC is used when andexanet is unavailable. Vitamin K reverses warfarin, protamine reverses heparin, and platelets do not neutralize apixaban. Normal renal function does not make active life-threatening bleeding safe to observe.

Reference: 2022 AHA/ASA Guideline for Spontaneous Intracerebral Hemorrhage: https://www.ahajournals.org/doi/10.1161/STR.0000000000000407