Direct Oral Anticoagulants Versus Vitamin K Antagonists in Cerebral Venous Thrombosis: A Systematic Review and Meta-Analysis

Abstract

BACKGROUND: High level evidence for direct oral anticoagulants (DOACs) in patients with cerebral venous thrombosis is lacking. We performed a systematic review and meta-analysis to assess the efficacy and safety of DOACs versus vitamin K antagonists in patients with cerebral venous thrombosis. METHODS: This systematic review was registered in PROSPERO (CRD42021228800). We searched MEDLINE (via Ovid), EMBASE, CINAHL, and the Web of Science Core Collection between January 1, 2007 and Feb 22, 2022. Search terms included a combination of keywords and controlled vocabulary terms for cerebral venous thrombosis, vitamin K antagonists/warfarin, and DOACs. We included both randomized and nonrandomized studies that compared vitamin K antagonists and DOACs in 5 or more patients with cerebral venous thrombosis. Where studies were sufficiently similar, we performed meta-analyses for efficacy (recurrent venous thromboembolism and complete recanalization) and safety (major hemorrhage) outcomes, using relative risks (RRs). RESULTS: Out of 10 665 records identified, we screened 254 as potentially eligible. Nineteen studies (16 observational studies [n=1735] and 3 randomized controlled trials [n=215]) met the inclusion criteria. All 3 randomized controlled trials had some concerns, and all 16 observational studies had at least moderate risk of bias. When compared with vitamin K antagonist treatment, DOAC had comparable risks of recurrent venous thromboembolism (relative risk [RR], 0.85 [95% CI, 0.52–1.37], I 2 =0%), major hemorrhage (RR, 0.70 [95% CI, 0.40–1.21], I 2 =0%), intracranial hemorrhage (RR, 0.58 [95% CI, 0.30–1.12]; I 2 =0%), death (RR, 1.14 [95% CI, 0.54–2.43], I 2 =1%), and complete venous recanalization (RR, 0.98 [95% CI, 0.87–1.11]; I 2 =0%). CONCLUSIONS: This systematic review and meta-analysis suggest that in patients with cerebral venous thrombosis, DOACs, and warfarin may have comparable efficacy and safety. Given the limitations of the studies included (low number of randomized controlled trials, modest total sample size, rare outcome events), our findings should be interpreted with caution pending confirmation by ongoing randomized controlled trials and large, prospective, observational studies.

Knowledge Attitudes and Practice about Stroke amongst Neurologists in India

“…Many (68.2%) used DOAC in treatment of CVT. 26 Dabigatran (42.9%) was the most commonly used followed by Apixaban (14.3%) and Rivaroxaban (11.6%). One-third used prophylactic anti-epileptics in treatment of CVT.…”

Diagnosis and Treatment of Cerebral Venous Thrombosis

“…It found that direct oral anticoagulant treatment was associated with a similar rate of recurrent venous thromboembolism (5.26 versus 5.87 per 100 patient years), a lower risk of major hemorrhage (2.44 versus 4.70 per 100 patient years), and similar rates of death and recanalization as with vitamin K antagonists. 94 In ACTION-CVT, two-thirds of patients on direct oral anticoagulants were treated with apixaban. Although ACTION-CVT and other retrospective treatment studies are prone to confounding by indication, no major safety issues have been found with the use of direct oral anticoagulants as opposed to vitamin K antagonists in clinical practice.…”

Obstetric and Gynecologic Disorders and the Nervous System

“…77 For longer-term treatment in stable patients, the tendency is toward the use of novel oral anticoagulants after the RE-SPECT CVT (A Clinical Trial Comparing Efficacy and Safety of Dabigatran Etexilate With Warfarin in Patients With Cerebral Venous and Dural Sinus Thrombosis) trial (randomized 1:1 dabigatran versus dose-adjusted warfarin) showed no significant differences in efficacy and safety, and the retrospective ACTION CVT (Direct Oral Anticoagulants Versus Warfarin in the Treatment of Cerebral Venous Thrombosis) showed that novel oral anticoagulants and warfarin had similar clinical and radiographic outcomes. 78,79 Considerations for anticoagulant choice during pregnancy and lactation, as well as the effects of anticoagulant choice on fertility, are included in TABLE 4-11. 80 For women with a history of CVT, prophylaxis with low-molecular-weight heparin during future pregnancies and postpartum periods is reasonable.…”