Warfarin versus factor Xa inhibitors in the long-term treatment of cerebral venous sinus thrombosis a single-center retrospective analysis

Comparing the effectiveness and safety of direct oral anticoagulants and warfarin in patients with cerebral venous thrombosis: A real-world study

BACKGROUND

Cerebral venous thrombosis (CVT), a rare stroke variant, poses treatment challenges, especially in young individuals. While guidelines recommend heparin followed by warfarin, warfarin has limitations. Direct oral anticoagulants (DOACs) offer a potential alternative, but evidence on their use in CVT management is limited. The TriNetX study aimed to provide real-world insights into DOAC efficacy and safety for CVT.

METHODS

We conducted a retrospective cohort study utilizing data from TriNetX to identify patients with CVT. Propensity score matching (PSM) was used to balance the covariates between patients receiving DOACs and those receiving warfarin. The primary outcome was recurrent CVT, with secondary outcomes including intracerebral hemorrhage and all-cause mortality.

RESULTS

Among 1,507 patients with CVT, PSM generated 551 matched individuals in both the study and control groups. The study group that received DOACs exhibited a lower risk of CVT recurrence (Hazard Ratio [HR], 0.77; 95 % Confidence Interval [CI], 0.628-0.97) and a higher 360-day event-free survival rate (p < 0.001). Subgroup analyses revealed significantly reduced recurrent CVT risk in the study group, particularly among females (HR, 0.67; 95 % CI, 0.50-0.89), individuals aged 41-64 years (HR, 0.52; 95 % CI, 0.35-0.75), and patients with normal weight (HR, 0.65; 95 % CI, 0.50-0.84). Moreover, recipients of DOACs had a lower risk of intracerebral hemorrhage (HR, 0.62; 95 % CI, 0.43-0.91) and comparable all-cause mortality (HR, 1.03; 95 % CI, 0.67-1.59).

CONCLUSIONS

This study underscores the potential of DOACs as a promising treatment for CVT, demonstrating reduced recurrence and intracerebral hemorrhage risks with comparable all-cause mortality.

Direct-Acting Oral Anticoagulants in the Management of Cerebral Venous Sinus Thrombosis-Where Do We Stand?

BACKGROUND

Cerebral venous sinus thrombosis (CVT) is a rare cause of stroke, constituting 0.5-3% of all strokes with an extremely varied spectrum of presentation, predisposing factors, neuroimaging findings, and eventual outcomes. A high index of suspicion is needed because timely diagnosis can significantly alter the natural course of the disease, reduce acute complications, and improve long-term outcomes. Due to its myriad causative factors, protean presentation, and association with several systemic diseases, CVT is encountered not only by neurologists but also by emergency care practitioners, internists, hematologists, obstetricians, and pediatricians.

DISCUSSION

Anticoagulation remains the mainstay of treatment for CVT. Heparin and warfarin previously had been the anticoagulation of choice. Recently there has been an increased interest in utilizing direct-acting oral anticoagulants in the treatment of CVT given comparable safety and efficacy with ease of utilization. However recent clinical guidelines given by multiple societies including the American Stroke guidelines and European guidelines do not include these agents so far in their treatment recommendations. Ongoing multicentric clinical trials are currently reviewing the role of these agents in both short-term as well as long-term. Our review of the literature supports the safety and reinforces the efficacy of DOAC in the treatment of CVT. Additionally, patient satisfaction has been shown to be better with the use of DOAC. In conclusion, DOAC continues to have a valid role in the management of CVT.

Cerebral Vein Thrombosis and Direct Oral Anticoagulants: A Review

Cerebral venous thrombosis (CVT) is a rare type of cerebrovascular event in which the thrombosis occurs in a vein of the cerebral venous system. The diagnosis could be challenging due to the great clinical variability, but the outcome is favourable in most cases, especially in the case of early diagnosis. Anticoagulant therapy is the core of CVT management and currently consists of heparin in the acute phase followed by vitamin K antagonists (VKAs) in the long term. The ideal duration of anticoagulant therapy is still unclear, and the same criteria for the treatment of extracerebral venous thromboembolism currently apply. In this paper, we reviewed the literature regarding the use of direct oral anticoagulants (DOACs) in CVT since in recent years a considerable number of studies have been published on the use of these drugs in this specific setting. DOACs have already been shown to be equally effective with VKAs in the treatment of venous thromboembolism. In addition to efficacy, DOACs appear to have the same safety profile, being, on the other hand, more manageable, as they do not require close monitoring with continuous personalised dose adjustments. In addition, a further advantage of DOACs over VKAs is the possibility of anticoagulant prophylaxis using a reduced dosage of the drug. In conclusion, although the use of DOACs appears from preliminary studies to be effective and safe in the treatment of CVT, additional studies are needed to include these drugs in the treatment of CVT.

Direct oral anticoagulants compared to warfarin in long-term management of cerebral venous thrombosis: A comprehensive meta-analysis

Objectives

We compared the safety and efficacy of direct oral anticoagulants (DOACs) with those of warfarin in the long-term (≥6 months) treatment of cerebral venous thrombosis (CVT).

Methods

We searched electronic databases up to November 2023 to compare the use of DOACs and warfarin in CVT management. Modified Rankin scores (mRS), new intracranial hemorrhage, all-cause mortality, recurrence and nonrecanalisation events were used to assess outcome. RevMan v5.4 software and the Cochran-Mantel-Haenszel method were utilized to analyse data.

Results

A total of 25 studies involving 2301 patients were identified as having treated CVT with either DOACs or warfarin. Good long-term mRS scores 0-2 (risk ratio [RR] = 1.01, 95% CI = 0.98-1.03; p = 0.61), new intracranial hemorrhage (RR = 1.00, 95% CI = 0.48-2.08; p = 0.99), all-cause mortality (RR = 1.00, 95% CI = 0.50-1.98; p = 0.99), nonrecanalisation (RR = 0.95, 95% CI = 0.77-1.18; p = 0.65) and recurrence venous thrombosis events (RR = 0.63, 95% CI = 0.33-1.22; p = 0.17) were similar between the two treatment arms. Subgroup analysis found recurrence of venous thrombosis was lower in the rivaroxaban group compared to warfarin (2.2% vs. 8.5%, RR = 0.33, 95% CI = 0.11-0.98; p = 0.05).

Conclusion

DOACs and warfarin provide comparable long-term safety and efficacy profiles. DOACs may be preferred over warfarin due to their ease of clinical management.