Safety and Efficacy of Rivaroxaban Versus Warfarin in Cerebral Venous Thrombosis: A Comprehensive Meta-Analysis

<b>Background:</b> Long-term management of cerebral venous thrombosis (CVT) with rivaroxaban is still under evaluation. The primary objective was to compare the contemporary evidence of the safety and efficacy of rivaroxaban versus warfarin in the long-term (≥ 6 months) treatment of CVT. <b>Methods:</b> We searched electronic databases up to 30 April 2025 for randomised control trials (RCTs) and observational studies in CVT management. We utilised the Mantel-Haenszel (M-H) method with a fixed-effects model to calculate risk differences (RDs) between rivaroxaban and warfarin arms. The ROB 2.0 and ROBINS-I tools were used to observe the risk of bias among included studies. <b>Results:</b> A total of 12 studies were identified (4 RCTs and 8 observational cohorts), evaluating 1174 patients treated with rivaroxaban (n = 262) or warfarin (n = 912). The rate of recurrence of venous thrombosis was 4% lower among rivaroxaban- compared to warfarin-treated patients (1.5% vs. 4.0%; RD = -0.04; <i>p</i> = 0.04). However, non-recanalisation events were identical among rivaroxaban and warfarin arms (16.4% vs. 16.5%; RD = -0.01, <i>p</i> = 0.68). Additionally, long-term all-cause mortality (<i>p</i> = 0.39), clinically relevant bleeding events (<i>p</i> = 0.18), new intracranial haemorrhage (<i>p</i> = 0.79), and good clinical outcome (<i>p</i> = 0.92) events were similar between rivaroxaban and warfarin arms. While RCTs and observational cohorts have methodological concerns and potential bias, we validated our results by excluding studies with serious or critical risks of bias to ensure the robustness of our findings. <b>Conclusions:</b> Compared to warfarin, rivaroxaban offers lower recurrence rates with similar efficacy and safety profiles along with improved clinical convenience.