New Oral Anticoagulants versus Warfarin for Cerebral Venous Thrombosis: A Multi-Center, Observational Study

Abstract

The incidence of cerebral venous thrombosis (CVT) is on the rise, partly due to an improvement in the diagnostic techniques. However, the therapeutic options have not changed much in the past three decades. Heparin followed by vitamin K antagonist (VKA), Warfarin is still the mainstay of treatment, although the limitations of VKA therapy including risk of major bleeding, need for constant monitoring, and drug and dietary interactions are all well recognized. New direct oral anticoagulants (NOACs), which are target specific for factor Xa (rivaroxaban, apixaban, edoxaban) or thrombin (dabigatran), were developed to overcome some of these limitations. These drugs have already shown to be safer then VKA for recurrent venous thromboembolism and embolism prevention in atrial fibrillation, with fewer intracranial and extracranial hemorrhages, fewer fatal hemorrhages and no increase in the risk of gastrointestinal hemorrhages. Based on this safety data, and the efficacy results from venous thromboembolism studies, there is a growing tendency for neurologists to consider them for treatment of CVT. A few case series have been published supporting the safety and efficacy of these drugs in CVT cases. More recently, the results of one randomized controlled trial (randomized controlled trial of the safety and efficacy of dabigatran etexilate vs. dose-adjusted warfarin in patients with cerebral venous thrombosis [RESPECT CVT]) were presented at World Stroke Congress in 2018. The trial randomized 120 patients to either dabigatran or warfarin and showed no recurrence of venous thrombotic events and a small number of major bleedings in both arms. Before the results of RESPECT CVT were made available, we conducted a multicenter prospective, observational study to evaluate the safety of NOACs compared to warfarin in patients with CVT. Data was collected from October 2016 to October 2018. Nine centers in four countries Pakistan, Saudi Arabia, Egypt, and the United Arab Emirates participated in the study. All nine centers are tertiary care hospitals with full time neurologists and availability of diagnostic modalities for the diagnosis of CVT. We included consecutive patients aged 18 years or more, who presented with clinical features of CVT, confirmed with venography (either computed tomography [CT] or magnetic resonance [MR]). Those with traumatic or septic CVT were excluded. Baseline characteristics including demographics, Glasgow Coma Scale, clinical features, imaging findings, and anticoagulant at discharge were recorded. Choice of oral anticoagulation was left New Oral Anticoagulants versus Warfarin for Cerebral Venous Thrombosis: A Multi-Center, Observational Study