From the Guidelines
For patients with cranial venous sinus thrombosis, DOACs are preferred over warfarin due to their comparable efficacy, lower risk of bleeding, and greater convenience, as suggested by recent guidelines 1. When considering treatment options, it's essential to weigh the benefits and drawbacks of each. DOACs, such as rivaroxaban and apixaban, offer fixed dosing without routine monitoring, fewer drug interactions, and no dietary restrictions. In contrast, warfarin may be preferred in specific situations, such as severe renal impairment, pregnancy planning, or antiphospholipid syndrome. Some key points to consider when choosing between DOACs and warfarin include:
- The patient's ability to comply with medication regimens
- Presence of comorbidities, such as renal or hepatic insufficiency
- Access to medications and cost considerations
- Individual patient preferences, such as once- or twice-daily dosing According to the American Society of Hematology 2020 guidelines, DOACs are conditionally recommended over vitamin K antagonists (VKAs) for the treatment of venous thromboembolism, including cranial venous sinus thrombosis 1. Additionally, the Chest guideline update in 2021 suggests that DOACs have similar efficacy to VKAs in reducing the risk of VTE, with a lower risk of overall and intracranial bleeding 1. In terms of specific dosing, rivaroxaban (15-20 mg twice daily for 21 days, then 20 mg daily) or apixaban (10 mg twice daily for 7 days, then 5 mg twice daily) are commonly used options for DOACs. If warfarin is chosen, an INR target of 2-3 should be maintained with frequent monitoring. Ultimately, the decision between DOACs and warfarin should be based on individual patient factors and careful consideration of the potential benefits and risks.
From the Research
Comparison of DOACs and Warfarin in Cranial Venous Sinus Thrombosis
- The study 2 compared the efficacy and safety of new oral anticoagulants (NOACs) with warfarin in patients with cerebral venous sinus thrombosis (CVST) and found that NOACs have similar efficacy and safety compared to warfarin treatment.
- Another study 3 demonstrated that direct oral anticoagulants (DOACs) have similar efficacy and safety compared to vitamin K antagonists (VKAs) with better recanalization rate in CVT.
- The use of anticoagulants such as dose-adjusted intravenous heparin or body weight-adjusted subcutaneous low molecular weight heparin is recommended for patients with CVST without contraindications for anticoagulation 4, 5.
- Concomitant intracranial hemorrhage related to CVST is not a contraindication for heparin therapy 4, 5.
Treatment Outcomes
- The study 2 found that there were no statistically significant differences between the NOACs and warfarin groups in recurrent CVST, bleeding events, and partial/complete recanalization.
- The optimal duration of oral anticoagulant therapy after the acute phase is unclear, but it may be given for 3 months if CVST was secondary to a transient risk factor, for 6-12 months in patients with idiopathic CVST, and indefinitely in patients with recurrent episodes of CVST or severe thrombophilia 4, 5.
Endovascular Treatment
- A case study 6 described a medically-refractory case of CVST that was treated with endovascular treatment, including continuous infusion of tissue plasminogen activator (tPA), which led to complete radiographic and clinical resolution of CVST.
- The study 6 also found that whole blood coagulation testing using Rotational Thromboelastometry (ROTEM) from simultaneous samples taken intracranially and peripherally revealed differences in coagulopathy levels, suggesting that peripheral blood draws may not accurately capture local coagulopathy levels.