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Background: High level evidence for direct oral anticoagulants (DOACs) in patients with cerebral venous thrombosis is lacking. We performed a systematic review and meta-analysis to assess the efficacy and safety of DOACs versus vitamin K antagonists in patients with cerebral venous thrombosis. Methods: This systematic review was registered in PROSPERO (CRD42021228800). We searched MEDLINE (via Ovid), EMBASE, CINAHL, and the Web of Science Core Collection between January 1, 2007 and Feb 22, 2022. Search terms included a combination of keywords and controlled vocabulary terms for cerebral venous thrombosis, vitamin K antagonists/warfarin, and DOACs. We included both randomized and nonrandomized studies that compared vitamin K antagonists and DOACs in 5 or more patients with cerebral venous thrombosis. Where studies were sufficiently similar, we performed meta-analyses for efficacy (recurrent venous thromboembolism and complete recanalization) and safety (major hemorrhage) outcomes, using relative risks (RRs). Results: Out of 10 665 records identified, we screened 254 as potentially eligible. Nineteen studies (16 observational studies [n=1735] and 3 randomized controlled trials [n=215]) met the inclusion criteria. All 3 randomized controlled trials had some concerns, and all 16 observational studies had at least moderate risk of bias. When compared with vitamin K antagonist treatment, DOAC had comparable risks of recurrent venous thromboembolism (relative risk [RR], 0.85 [95% CI, 0.52–1.37], I 2 =0%), major hemorrhage (RR, 0.70 [95% CI, 0.40–1.21], I 2 =0%), intracranial hemorrhage (RR, 0.58 [95% CI, 0.30–1.12]; I 2 =0%), death (RR, 1.14 [95% CI, 0.54–2.43], I 2 =1%), and complete venous recanalization (RR, 0.98 [95% CI, 0.87–1.11]; I 2 =0%). Conclusions: This systematic review and meta-analysis suggest that in patients with cerebral venous thrombosis, DOACs, and warfarin may have comparable efficacy and safety. Given the limitations of the studies included (low number of randomized controlled trials, modest total sample size, rare outcome events), our findings should be interpreted with caution pending confirmation by ongoing randomized controlled trials and large, prospective, observational studies.

Introduction: Direct oral anticoagulants (DOACs) have emerged as a potential anticoagulant therapy for patients with cerebral venous thrombosis (CVT). We conducted a systematic review and meta-analysis comparing DOACs versus vitamin K antagonists (VKAs) for treatment of CVT. Methods: We registered the review in PROSPERO (registration number CRD42021228800). We searched Medline, Embase, CINAHL, and the Web of Science Core Collection from January 1, 2007, to May 26, 2021. We included randomized controlled trials (RCTs) and non-randomized comparative studies (NRCSs) evaluating key outcomes for efficacy (recurrent venous thromboembolism [VTE] and complete recanalization) and safety (major hemorrhage). We assessed risk of bias using the Cochrane Risk of Bias Tool 2.0 (for RCTs) and the ROBINS-I tool (for NRCSs). Where studies were sufficiently similar, we performed meta-analyses using random-effects models. This review was funded by Brown Neurology. Results: Of 8213 identified records,10 studies (1 RCT and 9 NRCSs) with a total of 662 patients (33% DOAC and 67% VKAs) met the inclusion criteria. We will present our risk of bias assessment at the conference. DOACs and VKAs had comparable efficacy: recurrent VTE (risk ratio [RR] 1.00, 95% confidence interval [CI] 0.44-2.23; I 2 =0%; 10 studies) and complete recanalization (RR 1.00, 95% CI 0.77-1.28; I 2 =0%; 6 studies). DOAC and VKA also had comparable safety: major hemorrhage (RR 0.89, 95% CI 0.37-2.14; I 2 =0%; 9 studies). Conclusions: Studies comparing DOACs with VKAs in patients with CVT consist mostly of small, non-randomized, poorly controlled studies. While the two treatments appear comparable for major efficacy and safety outcomes, large, rigorously conducted studies, preferably randomized, are needed to overcome these limitations and permit development of clinical practice guidelines for the use of DOACs in patients with CVT.

Introduction: Antiplatelet agents are commonly used after endovascular repair of ruptured aneurysms in patients with subarachnoid hemorrhage (SAH). Recent evidence suggests post-treatment antiplatelets may reduce risk of delayed cerebral ischemia (DCI) and worse outcome. We sought to determine potential risks and benefits of antiplatelets in our patients’ population Methods: This is a retrospective cohort study of consecutive patients with aneurysmal SAH who were admitted to an academic referral center from 2016 to 2021. We used multivariable logistic regression analysis, propensity score matching and multiple linear regression to test the association of antiplatelets use and functional outcome (modified Rankin Scale at 3 months), DCI, any intracranial hemorrhagic complications including EVD tract hemorrhage and ICU length of stay (continuous variable). Results: Of the confirmed aneurysmal SAH patients (n=315), mean age was 57 years (SD 13.6) and majority of patients were female (62%) and white (70%). Thirty-nine percent of patients received antiplatelets (26% single agent; 13% dual agents) with no differences in demographics. Of the patients in the cohort, 85% received endovascular treatments (including 59% coil, 12% pipeline and stent assisted coil, 14 other endovascular treatments) and 15% underwent surgical clipping. Antiplatelets were used more in aneurysms originating from posterior circulation compared to anterior circulation (54% vs 35%, p=0.012). There was no difference in functional outcome (modified Rankin Scale at 3 months), DCI, or any intracranial hemorrhagic complications including EVD tract hemorrhage. ICU length of stay was longer in patients who received antiplatelets (3.32 additional days, 95% CI 0.4-6.3; p=0.02) and this association was independent of Hunt and Hess grades, modified Fisher scales, aneurysm treatment modality, age, comorbidities, and hospital complications. Conclusion: Use of antiplatelets may not reduce risk of DCI and worse outcome but can be associated with longer ICU length of stay. Further studies are required to identify appropriate candidates who may benefit from antiplatelets.