Background: Cerebral venous thrombosis (CVT) is an uncommon cause of stroke that primarily affects young adults and children. Anticoagulation is the standard therapy to prevent thrombus propagation and recurrent venous thromboembolism (VTE). Vitamin K antagonists (VKAs) have traditionally been used for long-term treatment. However, direct oral anticoagulants (DOACs) have been increasingly adopted due to predictable pharmacokinetics, fewer drug and food interactions, and no requirement for routine monitoring. Given the growing body of literature on DOACs and CVT, we performed an updated systematic review and meta-analysis evaluating the evidence comparing safety and efficacy of DOACs versus VKAs. Methods: We conducted a systematic review and meta-analysis registered in PROSPERO. We searched five databases: Embase, Scopus, MEDLINE, Web of Science, and CINAHL from 2007 to 2025. We included randomized controlled trials (RCTs) in humans of any age, and multicenter observational studies enrolling ≥25 patients per arm. Eligible studies directly compared outcomes with DOACs versus VKAs in patients with CVT. The primary endpoint was recurrent VTE. Secondary outcomes included complete recanalization, major extracranial bleeding, intracerebral hemorrhage (ICH), and favorable functional outcome (mRS 0–1). Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using random-effects modeling. Results: Out of 15,204 records identified, fourteen studies met the inclusion criteria (8 RCTs and 6 observational). Of 3,927 patients, 1,906 were treated with DOACs and 2,119 with VKAs. Recurrent VTE occurred in 169/1,906 (8.9%) patients on DOACs and 217/2,119 (10.2%) on VKAs. DOACs showed a nonsignificant trend toward fewer recurrent VTEs (RR 0.83; 95% CI 0.69–1.00; p=0.052; heterogenity=0), and significantly lower rates of ICH (RR 0.73; 95% CI 0.55–0.97, p=0.03, heterogenity=0) which . No significant differences were observed for complete recanalization(RR 1.04; 95% CI 0.91–1.18; p=0.56, heterogenity=0), extracranial bleeding(RR 0.68; 95% CI 0.40–1.16; p=0.16, heterogenity =0), or mRS 0-1(RR 1.02; 95% CI 0.94–1.12; p=0.62, heterogenity=0). Conclusions: DOACs appear safe and are associated with lower ICH risk and a trend toward fewer recurrent VTEs compared with VKAs, though benefits are mainly from observational data and not confirmed in RCTs.
Khan et al. (Thu,) studied this question.