Study of Rivaroxaban for Cerebral Venous Thrombosis: A Randomized Controlled Feasibility Trial Comparing Anticoagulation With Rivaroxaban to Standard-of-Care in Symptomatic Cerebral Venous Thrombosis

Cerebral vein thrombosis: management tactics with a focus on pregnancy, the use of hormone therapy and assisted reproductive technologies

Purpose: Cerebral vein thrombosis is a rare, life-threatening condition that has now become more commonly diagnosed due to advancements in imaging techniques. Our purpose is to improve understanding of pathogenesis, diagnosis and pregnancy and IVF management in patients with a history of cerebral thrombosis.

Materials and methods: We present an overview of the modern tactics of anticoagulant therapy for cerebral thrombosis with a focus on pregnancy, the use of hormone therapy, and assisted reproductive technologies.

Results: The most common risk factors for cerebral vein thrombosis are pregnancy, the postpartum period, and the use of oral contraceptives, which explains the high incidence of this pathology in women. The development of cerebral thrombosis is a vivid example of the interaction and synergetic effects of persistent factors that cause an increased risk of thrombotic complications, which include thrombophilia and acquired risk factors. Despite the possible risks, pregnancy after previously suffered cerebral thrombosis is not contraindicated provided adequate anticoagulant therapy.

Conclusions: The most common provoking factors for the development of cerebral thrombosis in women are pregnancy and the use of estrogen-containing drugs. The issue of thromboprophylaxis during pregnancy, when using ART methods and the possibility of using hormonal therapy after cerebral vein thrombosis requires further study.

Patient reported outcomes of cerebral venous thrombosis compared to ischemic stroke

PURPOSE

Although both cerebral venous thrombosis (CVT) and ischemic stroke involve cerebrovascular flow disruption, they differ in pathophysiology, clinical features, and outcomes. This study compared patient-reported outcomes (PROs) and their trajectories over time between CVT and ischemic stroke patients.

METHODS

This retrospective cohort study included patients hospitalized for CVT or ischemic stroke who completed at least one of the following PRO in cerebrovascular clinic between January 2019 and April 2024: Patient Health Questionnaire-9, PROMIS Global Health, Neuro-QoL cognitive function, and PROMIS scales for pain interference, physical function, social role satisfaction, fatigue, self-efficacy and sleep disturbance. CVT patients were matched (1:3) with ischemic stroke patients by propensity scores. PROs were compared over time using mixed-effects models.

RESULTS

Of 72 CVT and 2,533 ischemic stroke patients, 69 CVT and 196 ischemic stroke patients were included after matching (average age 47.5 ± 17.0 years, 62.6% female, median modified Rankin score 1). Brain tissue injury occurred in 30.6% of CVT patients. Both groups exhibited comparable PROs, but CVT patients reported worse pain interference, and worsening PROMIS global mental health and health-related quality of life over time compared to ischemic stroke patients.

CONCLUSIONS

Despite favorable functional outcomes and lower rates of brain injury, CVT patients had worse or comparable PROs in severity and patterns compared to the subset of ischemic stroke patients with similar baseline characteristics. Traditional clinical assessments may not fully capture the impact of CVT, and a holistic care approach addressing broader spectrum of outcomes, in addition to vascular pathology, could be beneficial.

Rivaroxaban Versus Warfarin for the Treatment of Cerebral Venous Thrombosis (RWCVT): A Randomized Controlled Trial in Resource-Limited Setting

Background: Cerebral venous thrombosis (CVT) is a rare but potentially debilitating form of stroke. Current management guidelines recommend a course of low molecular weight heparin (LMWH) followed by an oral vitamin K antagonist. However, there is an emerging body of evidence to support the use of direct oral anticoagulant (DOAC) medications. Here, we assess the efficacy of rivaroxaban compared to the standard of care in a resource-limited setting. Methods: The study was designed as a Phase III, prospective, parallel, open-label, randomized controlled trial conducted in three sites in Syria. Seventy-one participants met inclusion criteria and were randomized 1:1 to receive either rivaroxaban or warfarin following initial bridging with LMWH for 3.5-12 days. The primary outcome was functional improvement determined by the Barthel Index. Secondary outcomes were adverse events during follow-up, including CVT recurrence, thrombotic events, intracranial pressure (ICP) requiring shunt placement, extra and intracranial bleeding, neurological deficit, and all-cause mortality. Results: Barthel Index scores did not differ between the study cohorts at 1-, 2-, 3-, 4-, 5-, or 6-month follow-up. Secondary analysis yielded no difference in rates of adverse effects or return of CVT. Two patients in the warfarin group developed major extracranial bleeds (uterine bleeding); however, there were no other extracranial or intracranial bleeds or thrombotic events reported. Rates of all-cause mortality and all assessed adverse effects were similar between the groups. Conclusion: We offer a prospective, parallel randomized controlled trial that suggests rivaroxaban may have comparable safety and efficacy when compared to warfarin for the treatment of CVT. Importantly, we offer the first randomized control trial of oral anticoagulants for the treatment of CVT in a resource-limited setting, providing support for the evolving literature and suggesting the safety and efficacy of oral anticoagulants in the management of CVT. Trial Registration: ClinicalTrials.gov identifier: NCT04569279.

Cerebral Venous Thrombosis: Selected Persisting Areas of Uncertainty

ABSTRACT

Although a rare stroke type, recent large collaborative efforts have further improved the state of knowledge regarding management of cerebral venous thrombosis (CVT). However, several areas of uncertainty remain. In this review, we focus on existing evidence and priorities for future research in some select areas in the acute management and longer-term follow-up of CVT: the role of endovascular therapy, management of CVT associated with head and neck infection, management of CVT associated with head trauma, monitoring for papilledema and vision loss, and the role of prophylactic antiseizure medication.

Pathophysiology and Management of Cerebral Venous Thrombosis

Cerebral venous thrombosis (CVT) is a less common type of stroke that can occur across all age groups but predominantly affects children and young adults. Diagnosis is often challenging due to the nonspecific and variable clinical presentation. The disease course is heterogeneous, with CVT-related parenchymal lesions developing in approximately 50 to 60% of cases. Despite some advancements, significant gaps persist in understanding the pathophysiology of CVT, including the mechanisms underlying brain injury. Anticoagulation is the cornerstone of CVT treatment, but strategies targeting secondary mechanisms of parenchymal damage are still lacking. Here, the current state of the field is briefly reviewed, with the aim to introduce a wide audience (neuroscientists and clinicians alike) to the disease and inform clinical practice and future research.

Feasibility of telephone and computerized cognitive testing as a secondary outcome in an acute stroke clinical trial: A mixed methods sub-study of the AcT Trial

INTRODUCTION

Post-stroke cognitive impairment is associated with impaired quality of life. Remote testing provides a potential avenue to measure cognitive outcomes efficiently.

PATIENTS AND METHODS

Prospective cognitive outcomes were collected at 90-180 days using both telephone MoCA (T-MoCA; range 0-22; <17 impairment) and Creyos, a computerized cognitive battery. Key variables associated with completion were assessed using logistic regressions. Mixed methods brief structured interviews and exit survey were performed to explore barriers to completing computer testing.

RESULTS

Of 791 potentially eligible patients (mean age 70 ± 14 years), there was low feasibility of remote cognitive testing, with only 401 (51%) completing the T-MoCA, and 242 (31%) completing Creyos. Our regression models show that age (ORT-MoCA: 0.95 (95% Confidence Interval (CI): 0.94-0.97); ORCreyos: 0.95 (95% CI: 0.94-0.96)), functional impairment (mRS 2-5; ORT-MoCA: 0.55 (95% CI: 0.37-0.81); ORCreyos: 0.66 (95% CI: 0.44-0.98)), quality of life (EQ-VAS; ORT-MoCA: 1.02 (95% CI: 1.01-1.03); ORCreyos: OR:1.02 (95% CI: 1.01-1.03)) and length of hospital stay (ORT-MoCA: 0.98 (95% CI: 0.96-0.99); ORCreyos: 0.97 (95% CI: 0.94-0.99)) predicted both telephone and computer cognitive test completion; computer literacy predicted computer test completion (ORCreyos: 1.12 (95% CI: 1.04-1.21)). In interviews, a preference for accessibility of computerized testing was reported.

DISCUSSION

Remote cognitive testing has limited feasibility as a secondary outcome in large acute stroke trials. Patients who are older, with worse quality of life, or severe functional impairment post-stroke are less likely to complete remote cognitive outcomes.

CONCLUSION

Innovative approaches to post-stroke cognitive outcomes in acute stroke trials are needed.Data AccessData available upon request.

Direct Oral Anticoagulants for the Treatment of Unusual-Site Venous Thrombosis: An Update

Direct oral anticoagulants (DOACs) have emerged as the preferred oral anticoagulant therapy for patients with deep vein thrombosis of the lower extremities and pulmonary embolism. DOACs offer several advantages over vitamin K antagonists, including fixed dosage, fewer drug interactions, faster onset of action, and a lower risk of major bleeding, especially intracranial. Although evidence on the use of DOACs in unusual-site venous thrombosis (USVT) is limited, their use in such cases is becoming increasingly common. This narrative review examines the evidence derived from randomized controlled trials, and large observational studies focused on the use of the DOACs in USVT, including cerebral, splanchnic, upper extremity, ovarian, renal, and retinal vein thrombosis. In addition, it also provides practical advice for their use in these clinical settings according to the updated scientific literature.

Anticoagulant Therapy for Cerebral Venous Sinus Thrombosis: A Propensity Score Matching Study and Inverse Probability Weighting

BACKGROUND

New oral anticoagulants (NOACs) offer potential advantages for patients with cerebral venous sinus thrombosis (CVST). There is a lack of evidence to evaluate the efficacy and safety of NOACs in CVST. The purpose of this study was to compare the benefit and safety between NOACs and warfarin in patients with CVST.

METHODS

We performed a single-center prospective analysis including patients with CVST from the First Affiliated Hospital of Zhengzhou University between January 1, 2018, and December 31, 2021. The primary outcome was recurrent thrombotic events during the 6-month follow-up. Secondary outcomes included the modified Rankin scale (mRS) score, bleeding events, death, and cerebral venous recanalization during anticoagulant therapy. Propensity score matching (PSM) and inverse probability weighting (IPTW) were utilized to balance covariates between groups and mitigate selection bias in our study.

RESULTS

A total of 650 patients were identified. NOACs were used in 184 patients, and warfarin was used in 466 patients. Baseline characteristics were balanced between groups after IPTW or PSM. After 1:2 and 1:3 PSM, there were statistically significant differences between the two groups in death (2.2% vs. 8.0%, P = 0.014) and in mRS scores ≤ 2 (95. 1% vs. 88.7%, P = 0.020) in all patients. But there were no statistically significant differences between the two groups in recurrent CVST (odds ratio [OR] 0.543; 95% confidence interval [CI] 0.258-1.143; P = 0. 108), bleeding events (OR 0.823; 95% CI 0.074-9.143; P = 0.874), and partial/complete recanalization (OR 0.980; 95% CI 0.546-1.760; P = 0.946) in all patients. Similarly, there were no significant differences in patients who received anticoagulation therapy and in patients who received endovascular therapy plus anticoagulation therapy regarding any of the clinical outcomes. These results remained similar after IPTW analysis.

CONCLUSIONS

Our study demonstrates that the use of NOACs in CVST has similar efficacy and safety compared to warfarin treatment. NOACs treatment may improve the clinical prognosis in patients with CVST.

Effect of Immune Thrombocytopenic Purpura Medications on Depression Risk: An Analysis of NHANES Data

BACKGROUND

Immune thrombocytopenic purpura (ITP) in adults typically develops slowly and insidiously. The ITP medications might be linked to psychological disorders, but the connection is not well-understood.

OBJECTIVE

This study aimed to examine the association between ITP medication use and the risk of depression among participants in the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2018.

METHODS

Using data from 70 190 NHANES participants, we conducted a cross-sectional study, excluding individuals under 18 years, with hypertension, HIV, hepatitis C, and various comorbidities. A total of 17 299 individuals were included in the analysis of this study. We identified 2 populations within this study: those using ITP medications, including prednisone, dexamethasone, and rituximab and those not using ITP drugs. Depression status was assessed using the Patient Health Questionnaire-9 (PHQ-9), and the relationship between ITP medication use and depression was analyzed through multivariate logistic regression.

RESULTS

There was no significant association between ITP medication use and an increased risk of depression after adjusting for demographic and health-related variables. Notably, among the study participants, 1.8% of the non-depressed population were on ITP medication compared with 0.3% in the depressed population. The analysis revealed varying depression risks associated with different sociodemographic factors. For instance, the correlation between ITP medication and depression risk was influenced by a combination of age, race, income, and smoking status.

CONCLUSION AND RELEVANCE

The study suggests that ITP medication use does not independently increase the risk of depression. This finding is crucial for guiding clinical decisions and managing patient expectations regarding ITP treatment and its psychological impacts.

Direct oral anticoagulants versus vitamin K antagonists for cerebral venous thrombosis (DOAC-CVT): an international, prospective, observational cohort study

BACKGROUND

There is an unmet need for high-quality data from prospective studies on the safety and effectiveness of direct oral anticoagulants (DOACs) for the treatment of cerebral venous thrombosis (CVT). We aimed to compare the safety and effectiveness of DOACs versus vitamin K antagonists (VKAs) for the treatment of CVT in a setting that reflects daily clinical practice.

METHODS

DOAC-CVT was an international, prospective, observational cohort study done in 65 hospitals in 23 countries across five continents. Eligible patients were adults (aged ≥18 years) with radiologically confirmed CVT starting oral anticoagulant treatment with either DOACs or VKAs, as per local practice, within 30 days after diagnosis. Exclusion criteria were previous use of anticoagulants at the time of CVT diagnosis or an absolute contraindication to DOACs (eg, pregnancy and lactation, or severe renal or liver disease). Data were collected during routine clinical visits or telephone consultations at CVT diagnosis (baseline) and at 3 months, 6 months, and 12 months after CVT diagnosis. The primary endpoint was a composite of symptomatic venous thromboembolism and major bleeding events (International Society on Thrombosis and Haemostasis criteria) at 6 months. Main outcomes were adjusted for the confounders age, renal function, active cancer, CNS infections, concomitant antiplatelet use, country of inclusion's income status, Glasgow Coma Scale score, intracranial haemorrhage, antiphospholipid antibodies, previous major bleeding, and previous venous thromboembolism using inverse probability-of-treatment weighting. This study is registered at ClinicalTrials.gov (NCT04660747) and is ongoing.

FINDINGS

Between Jan 27, 2021, and Jan 15, 2024, 619 patients were included; 401 (65%) patients started DOAC treatment, and 218 (35%) patients started VKA treatment. 390 (63%) of 619 patients were female and 229 (37%) of 619 patients were male. Patients' median age was 41 years (IQR 28-51). 6-month follow-up data were available for 617 (>99%) of 619 patients. 12 (3%) of 401 patients in the DOAC group and seven (3%) of 218 patients in the VKA group had a primary outcome event (weighted odds ratio [OR] 0·99 [95% CI 0·37-3·38]). Three (1%) of 401 patients in the DOAC group died versus three (1%) of 218 patients in the VKA group (weighted OR 0·55 [95% CI 0·11-2·80]).

INTERPRETATION

The rate of recurrent thrombosis and major bleeding did not differ between patients with CVT treated with DOACs versus VKAs. This study adds to the increasing evidence that DOACs are a reasonable treatment option for CVT alongside VKAs.

FUNDING

Netherlands Thrombosis Foundation.

Practice-pattern variation in anticoagulation intensity in acute cerebral venous thrombosis: A two-center experience

BACKGROUND AND PURPOSE

Cerebral venous thrombosis (CVT) requires acute anticoagulation. Heparin is commonly used but specific recommendations on intensity and timing are lacking. We sought to characterize practice-pattern variation in the use of unfractionated heparin (UFH) for acute CVT treatment across multiple centers.

METHODS

This was a two-center retrospective study performed at Yale New Haven Hospital and Massachusetts General Hospital. Adult patients with CVT between 2013 and 2021 initially managed with parenteral anticoagulation and without endovascular therapy were included. The co-primary objectives were variation in UFH dosing and time to therapeutic anticoagulation by dosing intensity. Dosing intensity was defined as high intensity (≥12 units/kg/hr) or low intensity (<12 units/kg/hr), with or without initial boluses.

RESULTS

Seventy-two patients were included; 62 patients (86 %) received initial anticoagulation with UFH. The median initial UFH rate was 12 (IQR 11-14) units/kg/hr and 17 (27 %) patients received initial boluses (77 units/kg, IQR 40-80). Time to therapeutic anticoagulation was 11 (IQR 6-21) hours with high intensity UFH with a bolus (n = 13) and was 27 h (IQR 20-29) with low intensity UFH with a bolus (n = 4), while time to therapeutic anticoagulation was 30 (IQR 13-35) and 30 (IQR 23-39) hours with high (n = 21) and low intensity (n = 18) UFH without a bolus, respectively. Initial boluses reduced time to therapeutic anticoagulation overall (20 vs 30 h, p = 0.003).

CONCLUSIONS

Practice-pattern variation in UFH dosing leads to delays in time to therapeutic anticoagulation for CVT. Bolus dosing and high intensity UFH likely reduces the time to therapeutic anticoagulation.

Update on management of cerebral venous thrombosis

PURPOSE OF REVIEW

This review intends to systematize the diagnostic and treatment approach to cerebral venous thrombosis (CVT), highlighting key studies that have been recently published.

RECENT FINDINGS

In light of the recent pandemic, new risk factors for CVT have emerged. Contrast-enhanced MRI and susceptibility-weighted imaging have been shown to offer increased sensitivity for detecting cortical vein thrombosis.Dabigatran seems to be as effective and well tolerated as warfarin for long-term anticoagulation. Partial venous recanalization often occurs in patients treated with anticoagulation only, as early as 8 days after treatment onset. For patients with CVT and impending brain herniation, two-thirds of those who undergo decompressive craniectomy survive, with one-third being functionally independent 6 months after diagnosis.

SUMMARY

CVT is an unusual type of cerebrovascular disease that mostly affects women of fertile age. Risk factors should be identified and addressed. Diagnosis relies on confirmation of venous sinus and/or vein thrombosis, usually by CT venography or MRI. Anticoagulation is the cornerstone of treatment. Despite the lack of high-quality evidence, endovascular treatment is often considered in severe cases. Special populations require tailored approaches. About 80% achieve mRS 0-1, but residual symptoms often affect quality of life and the ability to return to work.

Cerebral Venous Thrombosis Presenting With Binocular Blindness and Bilateral Sensorineural Hearing Loss

Cerebral venous thrombosis (CVT) is caused by occlusion of dural sinuses and cerebral and cerebellar veins. It is a rare type of stroke usually presenting with headache, seizure, and focal motor deficit. We report a case of a 27-year-old Asian female with no significant medical history but a four-year history of unsupervised use of oral contraceptives, who presented with a sudden-onset headache followed by a generalized tonic-clonic seizure. Neurologic examination revealed papilledema with light perception in both eyes, right lateral rectus palsy, and bilateral sensorineural hearing loss. Imaging studies showed a subacute convexal subarachnoid hemorrhage over the right parietal lobe and thrombosis in the posterior superior sagittal sinus. She was given levetiracetam for seizure control and dabigatran for anticoagulation. Upon discharge, her hearing loss and lateral rectus palsy had resolved; however, bilateral blindness persisted. This case highlights the importance of recognizing rare manifestations of cerebral venous thrombosis, such as bilateral blindness and sensorineural hearing loss. These symptoms can be overlooked due to the more common presentations of headache, seizure, and focal motor deficits.

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.

Global trends and hot spots in cerebral venous sinus thrombosis research over the past 50 years: a bibliometric analysis

BACKGROUND

Cerebral venous sinus thrombosis (CVST) is an uncommon form of cerebrovascular disease. Although our understanding of CVST has improved significantly over the past decades, there has been no bibliometric analysis of CVST until now. We aimed to examine and visualize the hotspots and trends of the research related to CVST using a bibliometric analysis based on Citespace and provide new insights for scholars in their future researches in this area.

METHODS

The literature on CVST was collected from the Web of Science Core Collection database. Bibliometric analysis was performed using CiteSpace (6.2.R3) Advanced software.

RESULTS

A total of 2396 articles were included in the analysis. Publications regarding CVST have increased over time. U.S.A. contributed the most articles. Ferro JM had the highest number of published papers. Stroke was the journal with the most publications and the most commonly cited journal. Nine out of the top 10 cited journals belong to Q1. The risk factors for CVST, emerging and current treatment of CVST, and CVST related to COVID-19 and COVID-19 vaccines are the major potential research hot spots and trends.

CONCLUSIONS

CVST is a rapidly expanding research area and has received increasing attention by the researchers. Our study can provide researchers valuable information on the current status and trends in this area and guide for future studies.

Changes in the landscape of anticoagulation: a focus on direct oral anticoagulants

Over the last decade, the advent of direct oral anticoagulants (DOACs) has rapidly changed the landscape of anticoagulation. In the early 2010s, DOACs became widely available for stroke prevention in atrial fibrillation and the treatment of venous thromboembolism. About 10 years later, approximately two-thirds of patients requiring oral anticoagulant treatment were receiving a DOAC. The results of several post-marketing studies consistently confirmed the findings of phase 3 clinical trials, and research has focused on new areas of development, with heterogeneous results. A role for DOACs has emerged for patients with peripheral artery disease and other challenging conditions, such as cancer-associated thrombosis, unusual-site venous thromboembolism, and end-stage renal disease. Conversely, clinical trials showed that DOACs were not efficacious in patients with valvular atrial fibrillation, mechanical heart valves, embolic strokes of undetermined source, or antiphospholipid syndrome. In this Review, we discuss the impact of DOACs in clinical practice over the last decade, new areas under development, and practical issues in the management of these drugs.

Direct Oral Anticoagulants: Quick Primer on When to Use and When to Avoid

Direct oral anticoagulants (DOACs) have transformed the landscape of antithrombotic therapy in the past two decades. However, there is uncertainty about when they should or should not be used for treatment or prevention of thromboembolic events. DOACs have largely replaced warfarin for many patients with atrial fibrillation or venous thromboembolism who require anticoagulant therapy. In addition to noninferior efficacy, fewer drug-drug and food-drug interactions and improved convenience; DOACs have been shown to reduce the risk of intracranial hemorrhage. They have also received new indications compared with warfarin, such as cardiovascular risk reduction in patients with stable atherosclerotic diseases. However, there are some scenarios in which DOACs are associated with inferior efficacy or worse safety compared with standard treatment, such as warfarin. These include patients with mechanical heart valves, thrombotic antiphospholipid syndrome, and others. Although DOACs offer a streamlined and convenient option for the management of many patients with or at risk of thromboembolic events, their use should be avoided in certain high-risk scenarios. This minireview summarizes such conditions and those in which there is uncertainty for use of DOACs for particular diseases or particular patient subgroups.

Lead-In Parenteral Anticoagulation Prior to Direct Oral Anticoagulation for Cerebral Venous Thrombosis

BACKGROUND

Growing evidence suggests that direct oral anticoagulants (DOACs) may be suitable for cerebral venous thrombosis (CVT). The optimal strategy regarding lead-in parenteral anticoagulation (PA) prior to DOAC is unknown.

METHODS

In this post hoc analysis of the retrospective ACTION-CVT study, we compared patients treated with DOACs as part of routine care: those given "very early" DOAC (no PA), "early" (<5 days PA) and "delayed" (5-21 days PA). We compared baseline characteristics and outcomes between the very early/early and delayed groups. The primary outcome was a composite of day-30 CVT recurrence/extension, new peripheral venous thromboembolism, cerebral edema and intracranial hemorrhage.

RESULTS

Of 231 patients, 11.7% had very early DOAC, 64.5% early (median [IQR] 2 [1-2] days) and 23.8% delayed (5 [5-6] days). More patients had severe clinical/radiological presentations in the delayed group; more patients had isolated headaches in the very early/early group. Outcomes were better in the very early/early groups (90-day modified Rankin Scale of 0-2; 94.3% vs. 83.9%). Primary outcome events were rare and did not differ significantly between groups (2.4% vs. 2.1% delayed; adjusted HR 1.49 [95%CI 0.17-13.11]).

CONCLUSIONS

In this cohort of patients receiving DOAC for CVT as part of routine care, >75% had <5 days of PA. Those with very early/early initiation of DOAC had less severe clinical presentations. Low event rates and baseline differences between groups preclude conclusions about safety or effectiveness. Further prospective data will inform care.

Anticoagulation Status and Outcome in Cerebral Venous Thrombosis: A Single-Center Retrospective Study from South India

BACKGROUND AND OBJECTIVES

Early initiation and maintenance of anticoagulation appears to be the mainstay of treatment of cerebral venous thrombosis (CVT), but the evidence supporting the intensity and duration of anticoagulation is limited.

METHODS

We retrospectively collected data of patients admitted with CVT over a 5-year period, who had a minimum of 6 months of clinical follow-up and three or more prothrombin time international normalized ratio (INR) values spread over 6 months. Data collected included demographic, clinical, and radiologic parameters, anticoagulation status during the follow-up, complications, and clinical status at the last follow-up.

RESULTS

We identified 204 patients, and the mean age was 34.4 ± 11.1 years. The majority had a provoked etiology (194, 95.1%) for CVT. After initial anticoagulation with unfractionated heparin, all patients transitioned to acenocoumarol or warfarin and this was maintained for a mean duration of 16.02 ± 11.2 months. Time in therapeutic range of INR 2-3 was only 5.1 ± 11.8 percent days and time spent in an INR of 1-1.5 was 68.7 ± 31.8 percent days. The average INR over 6 months was 1.37 ± 0.33. Duration of follow-up was 18.9 ± 13.25 months, and a good outcome was noted in 183 (89.7%) patients. Complications were seen in 29 (14.2%) patients. Multivariate analysis showed only the CVT grading scale score to be an independent predictor of good outcome.

CONCLUSIONS

Maintenance of an intensive level of anticoagulation may not be required in patients with CVT and may be particularly true when a transient and treatable risk factor is the provoking etiology.

Cerebral Venous Sinus Thrombosis Triggered by Severe Dehydration

Cerebral venous sinus thrombosis (CVST) is the causative factor in a small proportion of strokes. It primarily affects individuals aged less than 55 years, with up to two-thirds of cases affecting females. It can be precipitated by a myriad of transient or permanent risk factors that result in a prothrombotic state. Diagnosis of CVST requires a high index of clinical suspicion as the presenting symptoms are often vague and include headaches, visual deficits, seizures, etc. Computed tomography or magnetic resonance venography are sensitive imaging diagnostic modalities. The majority of patients have a favorable prognosis. It is important to pursue thrombophilia work-up after the resolution of an acute episode as some cases are secondary to an underlying malignancy.

Efficacy and safety of direct oral anticoagulants versus warfarin in the treatment of cerebral venous sinus thrombosis

BACKGROUND

Given the evolving application and promising outcomes of direct oral anticoagulants (DOACs) in various thromboembolic conditions, we aimed to compare the efficacy and safety of DOACs with warfarin in the post-acute treatment of cerebral venous sinus thrombosis (CVST) using clinical and radiological parameters.

METHODS

A total of 140 CVST patients were enrolled, with 95 receiving warfarin and 45 receiving DOACs as post-acute treatment. Clinical and imaging parameters of the patients in follow-up visits were investigated, including the last modified Rankin Scale (mRS), venous thromboembolic events, CVST recurrence, mortality rate, recanalization status, and hemorrhagic events, to compare the efficacy and safety of treatment between the two groups.

RESULTS

At baseline, patients' assessments using two prognostic scores, ISCVT-RS and IN-REvASC, revealed that there was no statistically significant difference in the distribution of prognostic risk categories between the warfarin and DOACs groups. Following acute therapy, patients in the warfarin and DOACs groups were followed up for the median of 359 and 325 days, respectively. Analysis to compare the efficacy of warfarin and DOACs revealed no significant difference in last mRS scores, CVST recurrence rate, venous thromboembolic events, and recanalization status between the two groups. Additionally, there was no statistically significant difference in the risk of hemorrhagic events between warfarin and DOACs groups.

CONCLUSION

Our findings show that DOACs have comparable safety and efficacy in the post-acute treatment of CVST patients; however, large-scale randomized controlled trials are required to validate our findings.

Reducing the global burden of cerebral venous thrombosis: An international research agenda

BACKGROUND

Due to the rarity of cerebral venous thrombosis (CVT), performing high-quality scientific research in this field is challenging. Providing answers to unresolved research questions will improve prevention, diagnosis, and treatment, and ultimately translate to a better outcome of patients with CVT. We present an international research agenda, in which the most important research questions in the field of CVT are prioritized.

AIMS

This research agenda has three distinct goals: (1) to provide inspiration and focus to research on CVT for the coming years, (2) to reinforce international collaboration, and (3) to facilitate the acquisition of research funding.

SUMMARY OF REVIEW

This international research agenda is the result of a research summit organized by the International Cerebral Venous Thrombosis Consortium in Amsterdam, the Netherlands, in June 2023. The summit brought together 45 participants from 15 countries including clinical researchers from various disciplines, patients who previously suffered from CVT, and delegates from industry and non-profit funding organizations. The research agenda is categorized into six pre-specified themes: (1) epidemiology and clinical features, (2) life after CVT, (3) neuroimaging and diagnosis, (4) pathophysiology, (5) medical treatment, and (6) endovascular treatment. For each theme, we present two to four research questions, followed by a brief substantiation per question. The research questions were prioritized by the participants of the summit through consensus discussion.

CONCLUSIONS

This international research agenda provides an overview of the most burning research questions on CVT. Answering these questions will advance our understanding and management of CVT, which will ultimately lead to improved outcomes for CVT patients worldwide.

Efficacy and safety of Apixaban in the treatment of cerebral venous sinus thrombosis: a multi-center study

Background

Information regarding the safety and efficacy of specific direct oral anticoagulants (DOAC) in the treatment of cerebral sinus and venous thrombosis (CSVT) is scarce. Apixaban is one of the most frequently prescribed DOACs. Therefore, we aimed to compare the safety and efficacy of Apixaban with those of vitamin k antagonists (VKA) in patients with CSVT.

Methods

Prospective CSVT databases from seven academic medical centers were retrospectively analyzed. Patients treated with Apixaban were compared to those treated with VKA. Data on demographics, clinical presentations, risk factors, radiological and outcome parameters were studied.

Results

Overall, 403 patients were included in the analysis. Of them, 48 (12%) were treated with Apixaban, and 355 (88%) were treated with VKA. Rates of coagulopathies were significantly higher in the VKA-treated patients but no other differences between the groups were found in baseline characteristics and underlying etiology. No significant differences were found between groups in efficacy or safety parameters including the rates of recanalization, favorable outcomes, one-year mortality, seizures, intracranial hemorrhage or CSVT recurrences.

Conclusion

Our data suggests that Apixaban may be safe and effective for patients with CSVT. These results should be tested in prospective randomized clinical studies.

Diagnosis and Management of Cerebral Venous Thrombosis: A Scientific Statement From the American Heart Association

Cerebral venous thrombosis accounts for 0.5% to 3% of all strokes. The most vulnerable populations include young individuals, women of reproductive age, and patients with a prothrombotic state. The clinical presentation of cerebral venous thrombosis is diverse (eg, headaches, seizures), requiring a high level of clinical suspicion. Its diagnosis is based primarily on magnetic resonance imaging/magnetic resonance venography or computed tomography/computed tomographic venography. The clinical course of cerebral venous thrombosis may be difficult to predict. Death or dependence occurs in 10% to 15% of patients despite intensive medical treatment. This scientific statement provides an update of the 2011 American Heart Association scientific statement for the diagnosis and management of cerebral venous thrombosis. Our focus is on advances in the diagnosis and management decisions of patients with suspected cerebral venous thrombosis. We discuss evidence for the use of anticoagulation and endovascular therapies and considerations for craniectomy. We also provide an algorithm to optimize the management of patients with cerebral venous thrombosis and those with progressive neurological deterioration or thrombus propagation despite maximal medical therapy.

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.

Cerebral venous thrombosis: a practical review

The evolution of the Coronavirus Disease-2019 pandemic and its vaccination raised more attention to cerebral venous thrombosis (CVT). Although CVT is less prevalent than arterial stroke, it results in larger years of life lost. CVT is more common in women and young patients. Predisposing factors are categorized as transient factors such as pregnancy, puerperium, oral contraceptive pills, trauma, and dehydration; and permanent factors such as neoplastic, vasculitic, thrombophilic, hematologic conditions, infectious causes such as severe acute respiratory syndrome coronavirus-2 infection and HIV. The most common manifestations are headache, seizures, focal neurologic deficits, altered level of consciousness, and cranial nerve palsies. The most common syndromes are stroke-like, raised-intracranial-pressure (ICP), isolated-headache, and encephalopathy, which may have overlaps. Diagnosis is mostly based on computed tomography, magnetic resonance imaging, and their respective venous sequences, supported by blood results abnormalities such as D-dimer elevation. Treatment includes the prevention of propagation of current thrombus with anticoagulation (heparin, or low molecular weight heparinoids and then warfarin, or direct oral anticoagulants), decreasing ICP (even by decompressive craniotomy), and treatment of specific underlying diseases.

Efficacy and Safety of Direct Oral Anticoagulants in Cerebral Venous Thrombosis: Meta-Analysis of Randomized Clinical Trials

Current guidelines recommend the standard-of-care anticoagulation (vitamin K antagonists or low-molecular-weight heparin) in patients with cerebral venous thrombosis (CVT). Herein, we performed a meta-analysis of randomized clinical trials (RCTs) to assess the efficacy and safety of direct oral anticoagulants (DOACs) compared with the current standard of care in patients with CVT. We systematically searched the PubMed and Embase databases up to December 2023 to identify clinical trials on the effect of DOACs in patients with CVT. A Mantel-Haenszel fixed effects model was applied, and the effect measures were expressed as the absolute risk differences (RDs) and 95% confidence intervals (CIs). A total of 4 RCTs involving 270 participants were included. In the pooled analysis, DOACs and standard of care had low incidence rates of recurrent VTE and all-cause death, and similar rates of any recanalization (78.2% vs 83.2%; RD = -4%, 95%CI:-14% to 5%) and complete recanalization (60.9% vs 69.4%; RD = -7%, 95%CI:-24% to 10%). Compared with the standard of care, DOACs had non-significant reductions in the rates of major bleeding (1.2% vs 2.4%; RD = -1%, 95%CI: -6% to 3%), intracranial hemorrhage (1.9% vs 3.6%; RD = -2%, 95%CI:-7% to 3%), clinically relevant non-major bleeding (3.8% vs 7.4%; RD = -4%, 95%CI:-9% to 2%), and any bleeding (17.3% vs 21.4%; RD = -4%, 95%CI:-16% to 8%) in patients with CVT. DOACs and standard of care showed similar efficacy and safety profiles for the treatment of CVT. DOACs might be safe and a convenient alternative to vitamin K antagonists for thromboprophylaxis in patients with CVT.

Direct oral anticoagulants for the treatment of cerebral venous thrombosis - a protocol of an international phase IV study

Introduction

Current guidelines recommend that patients with cerebral venous thrombosis (CVT) should be treated with vitamin K antagonists (VKAs) for 3-12 months. Direct oral anticoagulants (DOACs), however, are increasingly used in clinical practice. An exploratory randomized controlled trial including 120 patients with CVT suggested that the efficacy and safety profile of dabigatran (a DOAC) is similar to VKAs for the treatment of CVT, but large-scale prospective studies from a real-world setting are lacking.

Methods

DOAC-CVT is an international, prospective, observational cohort study comparing DOACs to VKAs for the prevention of recurrent venous thrombotic events after acute CVT. Patients are eligible if they are 18 years or older, have a radiologically confirmed CVT, and have started oral anticoagulant treatment (DOAC or VKA) within 30 days of CVT diagnosis. Patients with an absolute contra-indication for DOACs, such as pregnancy or severe renal insufficiency, are excluded from the study. We aim to recruit at least 500 patients within a three-year recruitment period. The primary endpoint is a composite of recurrent venous thrombosis and major bleeding at 6 months of follow-up. We will calculate an adjusted odds ratio for the primary endpoint using propensity score inverse probability treatment weighting.

Discussion

DOAC-CVT will provide real-world data on the comparative efficacy and safety of DOACs versus VKAs for the treatment of CVT.

Clinical trial registration

ClinicalTrials.gov, NCT04660747.