Use of direct oral anticoagulants in cerebral venous thrombosis: a systematic review

ObjectivesCurrent guidelines do not recommend direct oral anticoagulants (DOACs) to treat cerebral venous thrombosis (CVT) despite their benefits over standard therapy. We performed a systematic review to summarise the published experience of DOAC therapy in CVT.Data sourcesMEDLINE, Embase and COCHRANE databases up to 18 November 2020.Eligibility criteriaAll published articles of patients with CVT treated with DOAC were included. Studies without follow-up information were excluded.Data extraction and synthesisTwo independent reviewers screened articles and extracted data. A risk of bias analysis was performed.Primary and secondary outcome measuresSafety data included mortality, intracranial haemorrhage (ICH) or other adverse events. Efficacy data included recurrent CVT, recanalisation rates and disability by modified Rankin Scales (mRS).Results33 studies met inclusion criteria. One randomised controlled trial, 5 observational cohorts and 27 case series or studies reported 279 patients treated with DOAC for CVT: 41% dabigatran, 47% rivaroxaban, 10% apixaban and 2% edoxaban, in addition to 315 patients treated with standard therapy. The observational cohorts showed a similar risk of death in DOAC and standard therapy arms (RR 2.12, 95% CI 0.29 to 15.59). New ICH was reported in 2 (0.7%) DOAC-treated patients and recurrent CVT occurred in 4 (1.5%). A favourable mRS between 0 and 2 was reported in 94% of DOAC-treated patients, more likely than standard therapy in observational cohorts (RR 1.13, 95% CI 1.02 to 1.25).ConclusionThe evidence for DOAC use in CVT is limited although suggests sufficient safety and efficacy despite variability in timing and dose of treatment. This systematic review highlights that further rigorous trials are needed to validate these findings and to determine optimal treatment regimens.

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Cerebral Venous Thrombosis Case Series at a Tertiary Care Hospital: Exploring Treatment Safety and Efficacy of Direct Oral Anticoagulants

Blood ◽

10.1182/blood-2019-128406 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3658-3658

Author(s):

Mohammed Abdullah Alsheef ◽

Mukhtar Alomar ◽

Abdul Rehman Z. Zaidi ◽

Ghaydaa Juma Kullab ◽

Mohammed AlHazzaa ◽

...

Keyword(s):

Venous Thrombosis ◽

Cerebral Venous Thrombosis ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Tertiary Care ◽

Case Series ◽

Case Report Form ◽

Care Hospital ◽

Safety And Efficacy ◽

Number Of Patients

Background: Cerebral venous thrombosis (CVT) is an uncommon cause of stroke that mainly affects young adults and children. Initial treatment with heparin followed by wafarin is the mainstay of treatment. Only insufficient experience is available for direct oral anticoagulants (DOACs). Aims: The study aims to demonstrate the efficacy and safety of DOACs such as (Rivaroxaban and Dabigatran) in patients with objectively confirmed CVT. Methods: Data of 46 cases of CVT collected using a standardized case report form. Inclusion criteria were patients diagnosed with CVT, confirmed by CT or MRI imaging. Results: The total number of patients was 46 (9 males and 37 females). The mean age of the patients was 35.2± 5 years. The most common clinical manifestations among our patients were headache followed by seizure. 52% of cases were unprovoked, while 48% were provoked by pregnancy and oral contraceptive pills. Superior sagittal sinus (55%) and transverse sinus (44.9%) were the most common sites. Involvement of more than three venous sinuses was 34.8%. Thrombophilic abnormality was detected in 21.7% of patients. Initiation of anticoagulation (AC) was mostly low molecular weight heparin (LMWH) (80%), followed by unfractionated heparin (UFH) (17.7%) and fondaparinex (2%). Maintenance AC with Rivaroxaban after heparin (LMWH/UFH) was in 63% of our patients, the rest were switched from Warfarin to Rivaroxaban (34.8%), and one was treated by Dabigatran (2%). CVT recurrence was observed in one patient. Major bleeding (according to ISTH criteria) was not reported in our case series. Conclusions: DOACs demonstrated good safety and efficacy profile and can potentially replace warfarin in CVT patients. Disclosures No relevant conflicts of interest to declare.

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Recurrent Cerebral Venous Thrombosis Treated with Direct Oral Anticoagulants in a Japanese Man with Hereditary Protein C Deficiency

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2020.105320 ◽

2021 ◽

Vol 30 (1) ◽

pp. 105320

Author(s):

Kazuyuki Saito ◽

Kazuyuki Ishii ◽

Konosuke Furuta ◽

Masaki Kobayashi ◽

Yoshiaki Wada ◽

...

Keyword(s):

Venous Thrombosis ◽

Cerebral Venous Thrombosis ◽

Protein C ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Protein C Deficiency

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Preliminary findings regarding the use of direct oral anticoagulants in cerebral venous thrombosis

Clinical Neurology and Neurosurgery ◽

10.1016/j.clineuro.2020.106204 ◽

2020 ◽

Vol 198 ◽

pp. 106204

Author(s):

Andrew Hsu ◽

Hetal Mistry ◽

Nupur Lala ◽

John L. Reagan

Keyword(s):

Venous Thrombosis ◽

Cerebral Venous Thrombosis ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants

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Direct Oral Anticoagulants for the Treatment of Cerebral Venous Thrombosis

Cerebrovascular Diseases ◽

10.1159/000502454 ◽

2019 ◽

Vol 48 (1-2) ◽

pp. 32-37 ◽

Cited By ~ 5

Author(s):

Antoine Lurkin ◽

Laurent Derex ◽

Alexandra Fambrini ◽

Laurent Bertoletti ◽

Magali Epinat ◽

...

Keyword(s):

Venous Thrombosis ◽

Cerebral Venous Thrombosis ◽

Randomized Clinical Trials ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Individual Risk ◽

University Hospitals ◽

Imaging Results ◽

Venous Recanalization

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.

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Cerebral Venous Thrombosis: Reviewing Pathophysiology, Diagnosis, and Treatment Strategies

Journal of Neuroanaesthesiology and Critical Care ◽

10.1055/s-0039-1692023 ◽

2019 ◽

Vol 06 (02) ◽

pp. 140-144 ◽

Cited By ~ 1

Author(s):

Yasmin A. O'Keefe ◽

Peter G. Kranz ◽

Keith E. Dombrowski ◽

Brad J. Kolls ◽

Michael L. James

Keyword(s):

Venous Thrombosis ◽

Cerebral Venous Thrombosis ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Treatment Strategies ◽

Venous Drainage ◽

Diagnosis And Treatment ◽

Cerebral Veins ◽

Heparin Infusion ◽

Newer Anticoagulants

AbstractThis review discusses cerebral venous thrombosis (CVT), including diagnosis and treatment strategies, a rare class of stroke that, if unrecognized or untreated, can have devastating effects. Thrombosis of one or many cerebral veins leads to propagation of thrombosis and impaired cerebral venous drainage. Diagnosis is made using a combination of history and imaging, particularly computed tomography (CT) venogram, which demonstrates thrombosis. Currently, acute treatment consists of heparin infusion with transition to long-term oral anticoagulation. Further research, especially on prevention, endovascular therapy, and the role of newer anticoagulants (direct oral anticoagulants [DOACs]) is necessary and ongoing.

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