Original Research November 24, 2021

An Observational Study Comparing the Safety and Efficacy of Conventional Anticoagulation Versus New Oral Anticoagulants in the Management of Cerebral Venous Sinus Thrombosis

Rizwana Shahid, MBBS, FCPS; Azra Zafar, MBBS, FCPS; Saima Nazish, MBBS, FCPS; Foziah Alshamrani, MD, SBN; Noman Ishaque, MBBS, FCPS; Majed Alabdali, MD, FRCPC; Aishah Albakr, MD, FRCPC; Danah Al Jaafari, MD, FRCPC; Fahd A. Alkhamis, MD, UOD; Erum Shariff, MBBS, FCPS; Nehad Mahmoud Soltan, MD, MSc; Maher Saqqur, MD, MPH, FRCPC

Prim Care Companion CNS Disord 2021;23(6):21m02927

ABSTRACT

Objective: To compare the safety and efficacy of conventional anticoagulants with new oral anticoagulants (NOACs) for management of cerebral venous sinus thrombosis (CVST).

Methods: This was a retrospective, prospective cohort study of patients who presented with CVST to a tertiary stroke center in the Middle East from January 2012 to October 2019. Patients with a diagnosis of CVST were identified, and data were analyzed for demographic characteristics. Specific consideration was given to compare the efficacy and safety of different anticoagulation treatments.

Results: A total of 36 patients were included in the final analysis, with 15 (41%) men and 21 (59%) women and a male to female ratio of 1:1.4. Most of the patients (n = 22, 61%) were Saudi. Their ages ranged between 15 and 82 years (mean ± SD age of 34.22 ± 13.16 years). Headache was the most common feature, present in 22 (61%) of the patients, followed by unilateral weakness in 15 (41%) and cranial nerve palsies in 11 (30%). The most common etiology was prothrombotic state (both hereditary and acquired thrombophilia: n = 16, 45%). Other etiologies were postpartum state/oral contraceptive pill usage in 7 (19%), infections in 7 (19%), and trauma in 3 (8%). Most of the patients (n = 24, 67%) still received conventional anticoagulation (warfarin/low molecular weight heparin), but 9 (25%) of the patients consented to start NOACs. Efficacy (as measured by clinical improvement plus rate of recanalization of previously thrombosed venous sinuses) showed no statistically significant difference, although it proved to be better tolerated, as none of the patients stopped the treatment due to adverse events and risk of major bleeding was significantly low in the NOAC group. Nine patients in the warfarin group stopped medication, while none in the NOAC group did so (P = .034).

Conclusion: NOACs were found to be at least as good as conventional anticoagulation for the management of CVST. However, efficacy was almost similar, a finding that is consistent with most of the published case series and the few recently published prospective studies. Larger prospective and population-based studies are needed to clarify our preliminary results.

Continue Reading...

Did you know members enjoy unlimited free PDF downloads as part of their subscription? Subscribe today for instant access to this article and our entire library in your preferred format. Alternatively, you can purchase the PDF of this article individually.

Subscribe Now

Already a member? Login

Purchase PDF for $40

Members enjoy free PDF downloads on all articles. Join today

  1. Ribes MF. Des recherches faites sur la phlebite. In: Revue Medical Francais et Etrangere er Journal de clinique del′ Hotel Dieu et de la Charite de Paris. 1825;3:5–41.
  2. Luo Y, Tian X, Wang X. Diagnosis and treatment of cerebral venous thrombosis: a review. Front Aging Neurosci. 2018;10:2. PubMed CrossRef
  3. Leach JL, Strub WM, Gaskill-Shipley MF. Cerebral venous thrombus signal intensity and susceptibility effects on gradient recalled-echo MR imaging. AJNR Am J Neuroradiol. 2007;28(5):940–945. PubMed
  4. Röttger C, Trittmacher S, Gerriets T, et al. Reversible MR imaging abnormalities following cerebral venous thrombosis. AJNR Am J Neuroradiol. 2005;26(3):607–613. PubMed
  5. Manzione J, Newman GC, Shapiro A, et al. Diffusion- and perfusion-weighted MR imaging of dural sinus thrombosis. AJNR Am J Neuroradiol. 2000;21(1):68–73. PubMed
  6. Saposnik G, Barinagarrementeria F, Brown RD Jr, et al; American Heart Association Stroke Council and the Council on Epidemiology and Prevention. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(4):1158–1192. PubMed CrossRef
  7. Einhäupl KM, Villringer A, Meister W, et al. Heparin treatment in sinus venous thrombosis. Lancet. 1991;338(8767):597–600. PubMed CrossRef
  8. Stam J, Lensing AWA, Vermeulen M, et al. Heparin treatment for cerebral venous and sinus thrombosis. Lancet. 1991;338(8775):1154. PubMed CrossRef
  9. Ferro JM, Bousser MG, Canhão P, et al; European Stroke Organization. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis—endorsed by the European Academy of Neurology. Eur J Neurol. 2017;24(10):1203–1213. PubMed CrossRef
  10. Hon SF, Li HL, Cheng PW. Use of direct thrombin inhibitor for treatment of cerebral venous thrombosis. J Stroke Cerebrovasc Dis. 2012;21(8):915.e11–915.e15. PubMed CrossRef
  11. Geisbüsch C, Richter D, Herweh C, et al. Novel factor xa inhibitor for the treatment of cerebral venous and sinus thrombosis: first experience in 7 patients. Stroke. 2014;45(8):2469–2471. PubMed CrossRef
  12. Mendonça MD, Barbosa R, Cruz-e-Silva V, et al. Oral direct thrombin inhibitor as an alternative in the management of cerebral venous thrombosis: a series of 15 patients. Int J Stroke. 2015;10(7):1115–1118. PubMed CrossRef
  13. Rao SK, Ibrahim M, Hanni CM, et al. Apixaban for the treatment of cerebral venous thrombosis: a case series. J Neurol Sci. 2017;381:318–320. PubMed CrossRef
  14. Ferro JM, Coutinho JM, Dentali F, et al; RE-SPECT CVT Study Group. Safety and efficacy of dabigatran etexilate vs dose-adjusted warfarin in patients with cerebral venous thrombosis: a randomized clinical trial. JAMA Neurol. 2019;76(12):1457–1465. PubMed CrossRef
  15. Wasay M, Khan M, Rajput HM, et al. New oral anticoagulants versus warfarin for cerebral venous thrombosis: a multi-center, observational study. J Stroke. 2019;21(2):220–223. PubMed CrossRef
  16. Nagaraja D, Rao BSS, Taly AB, et al. Randomized controlled trial of heparin in puerperal cerebral venous/sinus thrombosis. NIMHANS J. 1995;13(2):111–115.
  17. Linkins LA, Choi PT, Douketis JD. Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis. Ann Intern Med. 2003;139(11):893–900. PubMed CrossRef
  18. Fang MC, Go AS, Chang Y, et al. Death and disability from warfarin-associated intracranial and extracranial hemorrhages. Am J Med. 2007;120(8):700–705. PubMed CrossRef
  19. Ferro JM, Dentali F, Coutinho JM, et al. Rationale, design, and protocol of a randomized controlled trial of the safety and efficacy of dabigatran etexilate versus dose-adjusted warfarin in patients with cerebral venous thrombosis. Int J Stroke. 2018;13(7):766–770. PubMed CrossRef
  20. Ferro JM, Canhão P, Stam J, et al; ISCVT Investigators. Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke. 2004;35(3):664–670. PubMed CrossRef
  21. Shahid R, Zafar A, Nazish S, et al. Etiologic and clinical features of cerebral venous sinus thrombosis in Saudi Arabia. J Neurosci Rural Pract. 2019;10(2):278–282. PubMed CrossRef
  22. Dentali F, Gianni M, Crowther MA, et al. Natural history of cerebral vein thrombosis: a systematic review. Blood. 2006;108(4):1129–1134. PubMed CrossRef
  23. Arauz A, Vargas-González JC, Arguelles-Morales N, et al. Time to recanalisation in patients with cerebral venous thrombosis under anticoagulation therapy. J Neurol Neurosurg Psychiatry. 2016;87(3):247–251. PubMed CrossRef