Direct oral anticoagulant in cerebral venous sinus thrombosis: efficacy and safety evaluation

Background Venous thromboembolism (VTE) is a common and potentially fatal condition that most frequently presents as deep vein thrombosis and pulmonary embolism. Cerebral venous sinus thrombosis (CVST) is a rare form of atypical-site VTE, accounting for approximately 0.5% of all strokes and predominantly affecting younger populations. Risk factors include female sex, pregnancy, oral contraceptive use, thrombophilia, infections, trauma, and SARS-CoV-2 infection. Clinical presentation is highly variable, ranging from isolated headache to severe neurological deficits and death, making diagnosis and management challenging. Anticoagulation remains the cornerstone of therapy, with growing interest in the role of direct oral anticoagulants. Methods This systematic review and meta-analysis was conducted in accordance with the PRISMA 2020 guidelines. A comprehensive search of PubMed, ScienceDirect, Cochrane Library, and BASE was performed to identify randomized controlled trials and observational studies evaluating the use of direct oral anticoagulants in adult patients with confirmed cerebral venous sinus thrombosis. The investigated agents included rivaroxaban, apixaban, and other factor Xa inhibitors. Outcomes assessed included recurrence of thrombosis, recanalization, major bleeding, intracranial hemorrhage, and mortality. Results 12 studies published between 2019 and 2025, including a total of 2,422 patients, were included. Recurrence rates of CVST or venous thromboembolism were low across studies, ranging from 0% to approximately 10.5%, with no significant difference compared to conventional anticoagulation. Recanalization outcomes were favorable, with complete recanalization reported in approximately 36% to 68% of patients, and higher rates when partial recanalization was included. Major bleeding events were infrequent, ranging from 0% to 8.3%. Follow-up duration varied across studies, ranging from 3 months to up to 5 years. Conclusion The available evidence suggests that DOACs particularly rivaroxaban and apixaban are an effective and safe alternative to conventional anticoagulation for CVST. However, further large randomized controlled trials are required to define optimal treatment strategies.