Comparing Efficacy and Safety of Different Anticoagulants in Cerebral Venous Thrombosis: A Systematic Review and Network Meta-Analysis

BackgroundCerebral venous thrombosis (CVT) is a rare but severe type of stroke, typically treated with vitamin K antagonists (VKAs). This study compares different direct oral anticoagulants (DOACs) with VKAs for the management of CVT.MethodsPubMed, Cochrane Central, and ScienceDirect were searched up to May 2025. A network meta-analysis using a frequentist approach was performed in RStudio version 4.3.3. P-scores were used to rank treatments. The evaluated outcomes included full recanalization, recurrent venous thromboembolism (VTE), major hemorrhage, intracranial hemorrhage (ICH), and mortality. The Cochrane Risk of Bias (RoB 2.0) tool and the Newcastle-Ottawa Scale (NOS) were employed to assess the quality of randomized controlled trials (RCTs) and observational studies.ResultsOur analysis included 16 studies involving 1403 patients. We found that various DOACs, including apixaban, dabigatran, and rivaroxaban, had rates of full recanalization, VTE recurrence, major hemorrhage, ICH, and mortality comparable to those of VKAs. VKAs showed the highest likelihood of full recanalization, with a P-score of 0.70, whereas apixaban had the lowest, with a P-score of 0.04. For reducing recurrent VTE rates, apixaban was the most effective (P-score = 0.83), and dabigatran the least (P-score = 0.04). Apixaban also led to the greatest reduction in ICH risk (P-score = 0.70), while rivaroxaban had the lowest likelihood (P-score = 0.29). Regarding major hemorrhage, apixaban had the highest probability of reduction (P-score = 0.81), with VKAs performing worst (P-score = 0.26). Lastly, apixaban ranked highest for reducing mortality (P-score = 0.78), whereas VKAs ranked lowest (P-score = 0.39).ConclusionDOACs showed no significant differences in rates of full recanalization, VTE recurrence, major hemorrhage, ICH, or mortality compared with VKAs. Apixaban had the highest probability of reducing VTE recurrence, mortality, and hemorrhagic events, whereas VKAs had the highest probability of achieving full recanalization.