Efficacy and Safety of Direct Oral Anticoagulants vs Warfarin for Cerebral Venous Thrombosis: An Updated Systematic Review and Meta-analysis
Apoorva Vedula1, Sai Kumar Reddy Pasya2, Sai Krishna Vallamchetla3, Ashvath Pillai4, Aishwarya Jaikrishnan5, Bala Vignesh Kalyanasundaram6, Sarika Mutyala7, Mohammed Qussay Ali Al-Sabbagh2, Gary Gronseth2
1Osmania Medical College, Hyderabad, India, 2Neurology, University of Kansas Medical Center, Kansas City, USA, 3Neurology, Mayo Clinic, Florida, USA, 4SSPM Medical college and Lifetime Hospital, Malvan, India, 5Saveetha Medical College and Hospital, Chennai, India, 6Neurology, Mayo Clinic, Arizona, USA, 7Gandhi Medical College, Hyderabad, India
Objective:
To compare the safety and efficacy of direct oral anticoagulants (DOACs) versus warfarin for the treatment of Cerebral Venous Thrombosis (CVT).
Background:
CVT is a rare but highly morbid cause of stroke. While DOACs have emerged as potential alternatives to warfarin, their comparative safety and efficacy in treating CVT require further investigation.
Design/Methods:
We systematically searched PubMed, Embase, and Cochrane databases from inception till May 2025 for randomized controlled trials (RCTs) comparing DOACs with warfarin for CVT. Efficacy outcomes were functional independence (mRS 0-2) and recanalization. Safety outcomes included mortality, recurrent venous thromboembolism, and bleeding. Data was pooled using a random-effects model to calculate relative risks (RRs) with 95% CIs, and heterogeneity was assessed with the I2 statistic.
Results:
The analysis included six RCTs with a total of 428 patients. For efficacy outcomes, there were no statistically significant differences between DOACs and warfarin in achieving any degree of recanalization (RR 0.99, 95% CI 0.92–1.07, I2=8%), complete recanalization (RR 1.08, 95% CI 0.80–1.44, I2=0%), or functional independence (RR 1.00, 95% CI 0.98–1.02, I2=0%). Regarding safety, DOACs were associated with a non-significant trend toward fewer major bleeding events (RR 0.60, 95% CI 0.12–3.00, I2=0%) and intracranial hemorrhages (RR 0.78, 95%CI 0.08–7.71, I2=32%). Rates of all-cause mortality (RR 1.84, 95%CI 0.17–19.36) and recurrent venous thromboembolism (RR 2.78, 95%CI 0.86–8.95, I2=0%) were low and comparable between the groups.
Conclusions:
DOACs are equally effective as warfarin in the management of CVT with the potential additional advantage of lowering the risk of bleeding. Due to the few studies and small sample size, further larger studies are required to make definitive clinical recommendations. The results contribute to the justification of the use of DOACs as a valid alternative to warfarin, especially with their fixed dosing and lack of requirement for regular monitoring.
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