Direct Oral Anticoagulants Versus Vitamin K Antagonists in Cerebral Venous Thrombosis: A Systematic Review and Meta-Analysis of 4,929 Patients.
Muhammad Hassan Waseem, Zain Ul Abideen, Areeba Shoaib, Nohela Rehman, Muhammad Osama, Barka Sajid, Muhammad Mukhlis, Sania Aimen, Muhammad Wajih Ansari, Rowaid Ahmad, Zara Fahim, Ameer Haider Cheema, Muhammad Bilal Zahid, Pawan Kumar Thada
Abstract
Open AccessBackgroundCerebral venous thrombosis (CVT), a rare cause of stroke, primarily occurs in young individuals. The established treatment regimen involves anticoagulation with low molecular weight heparin (LMWH) and vitamin K antagonists (VKA). Although direct oral anticoagulants (DOACs) have emerged as a promising alternative, their efficacy and safety remain unclear. This meta-analysis compared the efficacy and safety of DOACs versus VKA in managing CVT.MethodsElectronic databases, including PubMed, Cochrane Library, and ScienceDirect, were searched from inception until April 2025. Risk ratios (RR) with a 95% Confidence interval (CI) were pooled under the random effects model in the Review Manager 5.4.1. Quality assessment was done through the Cochrane risk of bias (RoB 2.0) tool and the Newcastle Ottawa Scale (NOS). Subgroup analyses based on study design and different types of DOACs were carried out.ResultsThirty-one studies, including five randomized controlled trials (RCTs) and 26 observational studies, were included in this meta-analysis. Our analysis showed a significant reduction in the risk of recurrent venous thromboembolism (VTE) in the DOACs arm compared to VKA (RR = 0.84; 95%CI: [0.71,0.99]; p = 0.04; I2 = 0%). Similarly, the DOACs showed significant superiority over VKA regarding the intracranial hemorrhage (ICH) (RR = 0.67; 95%CI: [0.50,0.89]; p = 0.007; I2 = 0%). Other endpoints, including major hemorrhage (RR = 0.70; 95%CI:[0.42,1.15]; p = 0.16; I2 = 0%), all-cause mortality (RR = 0.96; 95%CI:[0.68,1.35]; p = 0.81; I2 = 0%), and full recanalization (RR = 0.92; 95%CI:[0.82,1.03]; p = 0.16; I2 = 21%), are comparable between the two arms.ConclusionDOACs showed a significant reduction in the risk of recurrent VTE and ICH compared to VKA, whereas other endpoints are comparable. Further RCTs with a robust sample size are required to validate and confirm these findings.