An Observational Study to Evaluate the Effectiveness of Rivaroxaban in the Management of Cerebral Venous Sinus Thrombosis

Abstract

Background and objectives Cerebral venous sinus thrombosis (CVST) is a relatively rare and underdiagnosed type of stroke. Rivaroxaban is licensed for venous thromboembolism in patients opting for elective knee and hip replacement surgeries, preventing pulmonary embolism and precluding stroke and systemic embolism in sufferers of non-valvular atrial fibrillation. Beneficial outcomes depicting the efficacious role of rivaroxaban in treating CVST are under study. Materials and methods We performed a prospective observational study in patients diagnosed with CVST in the medicine or neurology unit of a tertiary care hospital in Karachi, Pakistan, between January 2019 and December 2019. The diagnosis of CVST was made by magnetic resonance venography (MRV) in all the cases. Follow-up visits were scheduled at three months and six months, and the occurrence of thrombotic events or bleeding complications was recorded. Follow-up was done by magnetic resonance imaging at three and six months to assess vessel recanalization. Excellent outcome was defined as a modified Rankin Scale (mRS) of 0 or 1. A total of 31 patients were meeting the inclusion criteria and were inducted into the study after informed consent. Results The mean age of the study population was 35.11 ± 8.96 years with 71% females and 29% males. The most prevalent etiology was the pregnancy/postpartum period (52%) followed by antiphospholipid syndrome (23%). The frequent clinical manifestations were headache (84%) followed by vomiting (38%), altered level of consciousness (35%), focal deficit/limb weakness (32%), aphasia (29%), blurring of vision (26%), and seizures (23%). Radiological studies showed that the vessels chiefly occluded in our study were superior sagittal sinus (29%), transverse sinus (23%), sigmoid sinus (16%), jugular vein (9%), and cortical veins (3%). Common features on magnetic resonance imaging (MRI) were cerebral edema (45%), hemorrhage (39%), infarct incidence (32%), and raised intracranial pressure (26%). Clinical outcomes showed 55% of patients had partial recanalization and 39% had complete recanalization after a period of six months of the administration of rivaroxaban. Ninety-three percent (93%) of sufferers recovered excellently according to mRS and only 3% developed recurrent CVST within a span of six months. The frequency of thrombotic events and bleeding complications were reported in 6% of patients, respectively, while mortality reported was also 6%. Conclusion Rivaroxaban has shown promising results in the management of our CVST patients, hence, it further warrants randomized controlled trials of rivaroxaban against conventional treatments to prove its significant role.

Safety and efficacy of Direct Oral Anticoagulants in cerebral venous thrombosis: A meta‐analysis

“…Twelve studies compared DOAC with standard anticoagulation (VKA), 7,8,11,13,15,16,[19][20][21][22][23][24] and five studies had no control group. 10,12,14,17,18 Warfarin was used as the standard anticoagulation for comparison in most of the studies. However, two European studies used phenprocoumon as the standard anticoagulation therapy 16,19 .…”

“…Rivaroxaban was the most commonly used DOAC, followed by dabigatran and apixaban. Twelve studies compared DOAC with standard anticoagulation (VKA), 7,8,11,13,15,16,19–24 and five studies had no control group 10,12,14,17,18 . Warfarin was used as the standard anticoagulation for comparison in most of the studies.…”

“…The included studies were published from 2014 to 2021, consisting of two randomized controlled trials, 7,8 four prospective studies, [10][11][12][13] and eleven retrospective studies [14][15][16][17][18][19][20][21][22][23][24] . Four studies were from the USA, 17,20,23,24 three from Pakistan, 10,11,18 two from Germany, 16,19 and one study was from Iran, 15 Poland, 12 Portugal, 22 France, 21 and Italy 14 respectively. There were three multicenter studies conducted at different countries.…”

Vaccine Induced Immune Thrombotic Thrombocytopenia Causing a Severe Form of Cerebral Venous Thrombosis With High Fatality Rate: A Case Series

“…Decompressive surgery may be considered for patients with parenchymal lesions, edema and impending herniation (9). According to recent publications, anticoagulation with DOACS (direct acting anti-coagulants) is comparable to warfarin in some cases of CVT, but not in the acute phase with parenchymal hematoma or in a setting of major neurosurgical intervention (10,11). Severe thrombocytopenia further increased the risk of increasing parenchymal hemorrhage in our patients and platelet transfusions were therefore indicated.…”

Diagnostic and treatment recommendations from the FACME ad-hoc expert working group on the management of cerebral venous sinus thrombosis associated with COVID-19 vaccination

“…The use of direct-acting anticoagulants may be considered in less severe forms. Rivaroxaban 78 , 79 , 80 , 81 , 82 , 83 , 84 and apixaban 84 , 85 are the drugs for which most evidence is available, although it is of low quality. 86 , 87 , 88 , 89 Recommendation of these drugs is also justified by the fact that they do not require the concomitant use of heparin at treatment onset.…”