Direct Oral Anticoagulants for the Treatment of Cerebral Venous Thrombosis

Abstract

Background: Cerebral venous thrombosis (CVT) is an uncommon neurological condition usually treated with heparin followed by oral vitamin K antagonists (VKAs). In patients with venous thromboembolism (VTE), compared to VKAs, direct oral anticoagulants (DOACs) offer several advantages. However, there is little data concerning their use in managing CVT. Aims: This retrospective observational study pursued 2 objectives: (1) to investigate clinical characteristics of CVT patients treated with heparin + DOACs vs. heparin + standard treatment; (2) to compare clinical outcomes. Methods: Consecutive CVT patients recruited from January 2016 to March 2018 in 2 French university hospitals (Lyon, Saint-Etienne), and treated with DOACs or VKAs were identified. Radiological evolution, VTE, hemorrhagic events, and antithrombotic medication were recorded. Functional outcome was assessed by the modified Rankin scale score and venous recanalization was assessed by magnetic resonance imaging. Results: Overall, 41 patients were included: 25 (61%) received VKAs and 16 (39%) DOACs. We identified no clinical or radiological features explaining the physicians’ preference for a specific anticoagulation treatment, and age, initial clinical presentation, radiological severity, and individual risk factors thus unlikely guided the choice of anticoagulant. No DOAC patient exhibited clinical or radiological thrombosis aggravation, and the thrombosis completely vanished in 6 (40%). Two of the VKA-treated patients (28.6%) demonstrated complete venous recanalization, whereas 3 others experienced clinical or radiological aggravation versus baseline. There was no major bleeding leading to hospitalization in both groups. Conclusion: The collected data on DOAC efficacy and safety in CVT management appear encouraging, yet needs to be confirmed by larger prospective randomized clinical trials.

Direct oral anticoagulants in treatment of cerebral venous thrombosis: a systematic review

“…Of 1843 titles, 33 studies met inclusion criteria (figure 1), representing 279 patients with CVT treated with a DOAC listed in table 1. We identified one RCT consisting of 60 patients treated with dabigatran and 60 patients treated with warfarin; 23 five observational cohorts of 101 patients treated with rivaroxaban (n=80), dabigatran (n=11) and apixaban (n=10) compared with warfarin (n=301) or LMWH (n=14); [24][25][26][27][28] six case series of patients treated with rivaroxaban (n=44), dabigatran (n=36) and apixaban (n=13); [29][30][31][32][33][34] and 21 case studies of rivaroxaban (n=8), dabigatran (n=8), apixaban (n=4) and edoxaban (n=5). The clinical characteristics and outcomes of the patients are listed in table 2.…”

Comparison of Novel Oral Anticoagulants and Vitamin K Antagonists in Patients With Cerebral Venous Sinus Thrombosis on Efficacy and Safety: A Systematic Review

“…At last, six studies (four retrospective studies, one prospective study, and one RCT) including 398 patients were included (13)(14)(15)(16)(17)(18). Further examination of relevant studies in the references of the included studies yielded no other studies.…”

“…The RCT was assessed by the Cochrane Risk of Bias tool, and the results are shown in Table 3. Among the observational studies, four out of five were good quality (13,14,16,18), and one study (17) was fair quality assessed by Newcastle-Ottawa quality scale, and the results are shown in Table 4.…”

“…Direct comparison between NOACs and another VKA, warfarin, was performed by four studies (14)(15)(16)18). Recanalization, hemorrhage events, and functional recovery were comparable (Figures 12-14).…”

“…Recurrence of VTEs or death was recorded as an outcome in every study; however, such events were reported in only two studies (16,18). The rates of recurrence and death events were both low (Figure 2).…”