Direct oral anticoagulants in treatment of cerebral venous thrombosis: systematic review

Objectives Current guidelines do not recommend direct oral anticoagulants
(DOAC) to treat cerebral venous thrombosis (CVT) despite their benefits
over standard therapy. We performed a systematic review to summarize the
published experience of DOAC therapy in CVT. Data sources MEDLINE, EMBASE,
and COCHRANE databases up to November 18, 2020. Eligibility criteria All
published articles of patients with CVT treated with DOAC were included.
Studies without follow-up information were excluded. Data extraction and
synthesis Two independent reviewers screened articles and extracted data.
A risk of bias analysis was performed. Primary and secondary outcome
measures Safety data included mortality, intracranial hemorrhage (ICH), or
other adverse events. Efficacy data included recurrent CVT, recanalization
rates, and disability by modified Rankin Scales (mRS). Results 33 studies
met inclusion criteria. One randomized 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 0.29-15.59). 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:
1.02-1.25). Conclusion The 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. PROSPERO ID: CRD42017078398