Is it safe to treat cerebral venous thrombosis with oral rivaroxaban without heparin? A preliminary study from 20 patients.

Newer oral anticoagulants like rivaroxaban are increasingly becoming the mainstay of treatment in systemic thrombosis. However cerebral venous thrombosis (CVT) is conventionally treated with heparin followed by oral vitamin K antagonists. Currently very little information is available about the use of rivaroxaban in CVT. Rivaroxaban has been used only after the initial treatment with heparin in the available studies. All patients with CVT between January 2017 and June 2017 were initiated directly on oral rivaroxaban. Critically ill patients including those requiring surgical intervention were excluded. The modified Rankin scale was used to assess clinical severity and a scale of 0-1 was defined as excellent outcome. Recanalization was assessed at 3 months follow-up with MR angiography. Complications of the drug including bleeding episodes during treatment and at follow-up were noted. Twenty patients were initiated on rivaroxaban and followed up for a mean duration of 6 months. Eighty percent (16/20) were males and the mean age was 34.1 years. Associated cerebral hemorrhagic infarcts were seen in 11(55%).Outcome was excellent in 19(95%). Complete recanalization was noted in 12(60%) and partial recanalization in 8(40%). No complications emerged out of the drug use. In clinically stable CVT rivaroxaban is safe and effective and may be used without previous heparin therapy. This can shorten the duration of hospitalization thereby decreasing the costs of treatment.

Shankar Iyer R ，Tcr R ，Akhtar S ，Muthukalathi K ，Kumar P ，Muthukumar K ... -  《-》

Direct Oral Anticoagulants for the Treatment of Cerebral Venous Thrombosis.

Cerebral venous thrombosis (CVT) is an uncommon neurological condition usually treated with heparin followed by oral vitamin K antagonists (VKAs). In patients with venous thromboembolism (VTE), compared to VKAs, direct oral anticoagulants (DOACs) offer several advantages. However, there is little data concerning their use in managing CVT. This retrospective observational study pursued 2 objectives: (1) to investigate clinical characteristics of CVT patients treated with heparin + DOACs vs. heparin + standard treatment; (2) to compare clinical outcomes. Consecutive CVT patients recruited from January 2016 to March 2018 in 2 French university hospitals (Lyon, Saint-Etienne), and treated with DOACs or VKAs were identified. Radiological evolution, VTE, hemorrhagic events, and antithrombotic medication were recorded. Functional outcome was assessed by the modified Rankin scale score and venous recanalization was assessed by magnetic resonance imaging. Overall, 41 patients were included: 25 (61%) received VKAs and 16 (39%) DOACs. We identified no clinical or radiological features explaining the physicians' preference for a specific anticoagulation treatment, and age, initial clinical presentation, radiological severity, and individual risk factors thus unlikely guided the choice of anticoagulant. No DOAC patient exhibited clinical or radiological thrombosis aggravation, and the thrombosis completely vanished in 6 (40%). Two of the VKA-treated patients (28.6%) demonstrated complete venous recanalization, whereas 3 others experienced clinical or radiological aggravation versus baseline. There was no major bleeding leading to hospitalization in both groups. The collected data on DOAC efficacy and safety in CVT management appear encouraging, yet needs to be confirmed by larger prospective randomized clinical trials.

Lurkin A ，Derex L ，Fambrini A ，Bertoletti L ，Epinat M ，Mismetti P ，Dargaud Y ... -  《-》

Rivaroxaban for the treatment of cerebral venous thrombosis: a single-center experience.

The mainstay of cerebral venous thrombosis (CVT) treatment according to current guidelines is parenteral anticoagulation with unfractionated heparin or low-molecular-weight heparin followed by long-term oral anticoagulation with vitamin K antagonists. Direct oral anticoagulants (DOACs), including the factor Xa inhibitor rivaroxaban, are used occasionally off-label for CVT based on individual treatment plans. This publication sought to report our experience with rivaroxaban for the indication of CVT and to review the relevant literature data concerning this topic. We performed a single-center retrospective analysis including patients from our institution with the diagnosis of cerebral venous thrombosis treated with rivaroxaban. Among 12,500 stroke patients over an 11-year period, we identified 87 cases with a diagnosis of CVT (0.7%). As long-term anticoagulation, 80 of these patients were receiving vitamin K antagonists and seven were receiving DOACs, including six receiving rivaroxaban and one receiving apixaban. Of the six patients receiving rivaroxaban, at least 6 months of clinical follow-up data were available for five of them. Excellent clinical outcomes were obtained in four of these five cases (modified Rankin scale score: 0-1 points). No hemorrhagic events, recurrent thrombosis, or other relevant complications were recorded during the follow-up period. Despite our small study sample size, our positive results support that rivaroxaban may be a safe and effective treatment option for patients with CVT. Hopefully, ongoing randomized clinical trials will better clarify the role of rivaroxaban in the treatment of CVT so as to provide a more convenient and safer alternative to vitamin K antagonists in this context.

Bajko Z ，Maier S ，Motataianu A ，Filep RC ，Stoian A ，Andone S ，Balasa R ... -  《-》

Novel factor xa inhibitor for the treatment of cerebral venous and sinus thrombosis: first experience in 7 patients.

Thrombosis of cerebral veins and sinus (cerebral venous thrombosis) is a rare stroke pathogenesis. Pharmaceutical treatment is restricted to heparin and oral anticoagulation with vitamin K antagonists (VKAs). Between January 2012 and December 2013, we recorded data from our patients with cerebral venous thrombosis. The modified Rankin scale was used to assess clinical severity; excellent outcome was defined as modified Rankin scale 0 to 1. Recanalization was assessed on follow-up MR angiography. Patients were then divided into 2 treatment groups: phenprocoumon (VKA) and a novel factor Xa inhibitor. Clinical and radiological baseline data, outcome, recanalization status, and complications were retrospectively compared. Sixteen patients were included, and 7 were treated with rivaroxaban. Overall outcome was excellent in 93.8%, and all patients showed at least partial recanalization. No statistical significant differences were found between the groups, except the use of heparin before start of oral anticoagulation (P=0.03). One patient in the VKA and 2 patients in the factor Xa inhibitor group had minor bleeding (P=0.55) within the median (range) follow-up of 8 months (5-26). Factor Xa inhibitor showed a similar clinical benefit as VKA in the treatment of cerebral venous thrombosis. Further systematic prospective evaluation is warranted.

Geisbüsch C ，Richter D ，Herweh C ，Ringleb PA ，Nagel S ... -  《-》

Rivaroxaban for the treatment of cerebral venous thrombosis.

Esmaeili S ，Abolmaali M ，Aarabi S ，Motamed MR ，Chaibakhsh S ，Joghataei MT ，Mojtahed M ，Mirzaasgari Z ... -  《BMC Neurology》