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

Abstract

Cerebral venous thrombosis (CVT) is caused by partial or complete occlusion of the major cerebral venous sinuses or the smaller feeding cortical veins which predispose to the risk of venous infarction and hemorrhage. Current guidelines recommend treating CVT with either low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) followed by an oral vitamin K antagonist (VKA) for 3-12 months. Direct oral anticoagulants (DOACs) have already established benefit over warfarin as a long-term treatment of symptomatic venous thromboembolic disorder like deep vein thrombosis (DVT), and pulmonary embolism (PE) given its equal efficacy and better safety profile. The benefit of DOACs over warfarin as a long-term anticoagulation for CVT has likewise been extensively studied, yet it has not been approved as first-line therapy in the current practice. We therefore performed a systematic review and meta-analysis of relevant studies to generate robust evidence regarding the safety and efficacy of DOACs in CVT. This meta-analysis demonstrates that the use of DOACs in CVT has similar efficacy and safety compared to VKAs with better recanalization rate.

Dabigatran in Cerebral Sinus Vein Thrombosis and Thrombophilia

“…The efficacy and safety of dabigatran etexilate compared to dose adjusted warfarin has been shown recently by Ferro et al in CSVT [26,27]. These findings were confirmed in systemic reviews also in other direct oral anticoagulants (DOCS) [28,29]. Therefore, many clinicians view DOACS and especially dabigatran etexilate as a viable alternative to vitamin K antagonists, in particular in young and active patients with CSVT.…”

Cerebral Venous Thrombosis

“…Recent systematic reviews and meta-analyses have generated robust evidence regarding the safety and efficacy of DOACs in CVT and showed similar efficacy and safety compared with VKAs with better recanalization rate. 36,38 Although the lack of recommendations in guidelines, physicians recognize the benefits of DOACs also in CVT and are increasingly using DOACs instead of VKA. 39 As only a few studies used DOACs directly and the majority use LMWH or UFH before starting DOACs, 38,39 it is still recommended to use heparin when initiating anticoagulation therapy in the acute phase.…”

“…36,38 Although the lack of recommendations in guidelines, physicians recognize the benefits of DOACs also in CVT and are increasingly using DOACs instead of VKA. 39 As only a few studies used DOACs directly and the majority use LMWH or UFH before starting DOACs, 38,39 it is still recommended to use heparin when initiating anticoagulation therapy in the acute phase. 36 In CVT, treatment of underlying conditions, such as infection and dehydration, is recommended.…”

“…This sign probably represents increased deoxyhemoglobin and engorgement of the deep veins and is associated with clinical presentation with focal signs, more extensive thrombosis, and ipsilateral parenchymal brain lesion. 38…”

“…This sign probably represents increased deoxyhemoglobin and engorgement of the deep veins and is associated with clinical presentation with focal signs, more extensive thrombosis, and ipsilateral parenchymal brain lesion. 38 Catheter angiography remains the most accurate method for diagnosis of CVT but is seldom required. 39 As catheter angiography is an invasive technique with a nonnegligible risk, a patient should only undergo this procedure when CTV or MRV are inconclusive, a dural arteriovenous fistula is suspected, or when an endovascular therapeutic intervention is planned.…”