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Netha A, Mazhar S, Azhar A, Moeez A, Choradia A, Mohtashim A, Anees U, Ejaz U, Tariq MU, Jawad S. Effectiveness of rivaroxaban in preventing cerebral venous thromboembolism: a systematic review and meta-analysis. Ann Med Surg (Lond) 2024; 86:2098-2104. [PMID: 38576935 PMCID: PMC10990339 DOI: 10.1097/ms9.0000000000001689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/27/2023] [Indexed: 04/06/2024] Open
Abstract
Background Cerebral venous thromboembolism (CVT) poses a significant risk of venous infarction and haemorrhage, which can lead to neurological deficits and, in severe cases, even death. The optimal treatment regimen for patients with CVT remains unclear. Methods MEDLINE, Embase, Google Scholar, Web of Science (WoS), and Cochrane Central databases were searched for randomized controlled trials (RCTs) and observational studies assessing the efficacy and safety of rivaroxaban in patients with CVT. All-site venous thromboembolism (VTE), risk of clinically relevant non-major bleeding, incidence of partial recanalization, complete recanalization and major haemorrhage were among outcomes of interest. Mantel-Haenszel weighted random-effects model was used to calculate relative risks (RRs) with 95% CIs. Results The analysis included 1 RCT and 3 observational studies containing 211 patients. Compared to vitamin K antagonists (VKAs), rivaroxaban did not significantly decrease the all-site VTE [RR 0.31 (95% CI 0.01, 8.43); P=0.49, I2=0%]. Compared with VKAs, patients on rivaroxaban did not show a significantly reduced risk of recurrent cerebral venous thrombosis. In terms of incidence of partial recanalization, there was no discernible difference between rivaroxaban and VKAs [RR 0.90 (95% CI 0.66, 1.22); P=0.49, I2=0%]. There was no discernible difference in incidence of complete recanalization [RR 0.98 (95% CI 0.32, 3.03); P=0.97, I2=28%] and incidence of major haemorrhage [RR 0.19 (95% CI 0.01, 4.54); P=0.30]. Conclusion Rivaroxaban was found to have similar efficacy to VKAs. Due to its lower risk of severe bleeding and no need for INR monitoring, rivaroxaban may be a preferable treatment option for CVT.
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Affiliation(s)
- Aadarsh Netha
- Department of Medicine, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Tamilnadu, India
| | - Saad Mazhar
- Department of Medicine, King Edward Medical University
| | - Aima Azhar
- Department of Medicine, Fatima Jinnah Medical University
| | - Abdul Moeez
- Department of Medicine, Services Institute of Medical Sciences
| | - Aakash Choradia
- Department of Medicine, Tribhuwan University, Kathmandu, Nepal
| | - Ali Mohtashim
- Department of Medicine, Allama Iqbal Medical College, Lahore
| | - Usama Anees
- Department of Medicine, Quaid-e-Azam Medical College, Bahawalpur
| | - Umer Ejaz
- Department of Medicine, Rawalpindi Medical College, Rawalpindi
| | | | - Sayed Jawad
- Department of Medicine, Kabul University of Medical Sciences, Kabul, Afghanistan
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Naik A, Smith E, Dharnipragada R, Catapano JS, Cramer SW, Johnson R, Khanam R, Hassaneen W, Lawton MT, Arnold PM. Endovascular and Medical Management of Cerebral Venous Thrombosis: A Systematic Review and Network Meta-Analysis. World Neurosurg 2022; 165:e197-e205. [PMID: 35688371 DOI: 10.1016/j.wneu.2022.05.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Management of cerebral venous thrombosis (CVT) involves minimizing expansion of the thrombus and promoting the recanalization of the venous sinus. While current guidelines include indications of endovascular management and anticoagulation with heparin and warfarin, the use of direct-acting oral anticoagulants (DOACs) has increased. In this study, we aim to conduct a network meta-analysis comparing these 3 therapeutic options: standard anticoagulation, DOACs, and endovascular treatments (EVTs). METHODS Seventeen of 2265 studies identified from 4 publication databases met inclusion criteria for this network meta-analysis. Outcomes analyzed included modified Rankin Scale score, complications, mortality, and 6-month recanalization rates using a frequentist network meta-analysis approach. For each outcome, the preferential order of each intervention was ranked hierarchically based on P-score calculations used for frequentist network meta-analyses. RESULTS Modified Rankin Scale outcomes were not significantly different based on the type of treatment modality (i.e., standard anticoagulation, DOACs, or EVT). Evaluation of complications demonstrated that patients treated with EVT were significantly more likely to experience a worse outcome than individuals treated with standard anticoagulation (odds ratio [OR] = 1.83, P = 0.04). Other comparisons did not demonstrate a significant difference in adverse events. For all-cause mortality outcomes, EVT demonstrated significantly greater odds of mortality than standard anticoagulation (OR = 1.89, P = 0.02). Mortality between DOACs and standard anticoagulation was not significantly different. When comparing 6-month recanalization rates, DOACs and EVT were significantly more effective than standard anticoagulation (OR = 1.93, OR = 2.2, P < 0.05). EVT followed by DOACs was preferred over standard anticoagulation for 6-month recanalization rates. CONCLUSIONS This network meta-analysis evaluates the outcomes in CVT treatment, comparing standard anticoagulation, DOACs, and EVT, with evidence that DOACs have similar outcomes to standard anticoagulation in the treatment of CVT. EVT resulted in an increased risk of overall mortality but improved 6-month recanalization rates.
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Affiliation(s)
- Anant Naik
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, Illinois
| | - Emily Smith
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, Illinois
| | - Rajiv Dharnipragada
- University of Minnesota Medical School, University of Minnesota Twin-Cities, Minneapolis, Minnesota
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Samuel W Cramer
- Department of Neurosurgery, University of Minnesota Twin-Cities, Minneapolis, Minnesota
| | - Ryan Johnson
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Rukhsaar Khanam
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, Illinois
| | - Wael Hassaneen
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, Illinois; Department of Neurosurgery, Carle Foundation Hospital, Urbana, Illinois
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Paul M Arnold
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, Illinois; Department of Neurosurgery, Carle Foundation Hospital, Urbana, Illinois.
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Nepal G, Kharel S, Bhagat R, Ka Shing Y, Ariel Coghlan M, Poudyal P, Ojha R, Sunder Shrestha G. Safety and efficacy of Direct Oral Anticoagulants in cerebral venous thrombosis: A meta-analysis. Acta Neurol Scand 2022; 145:10-23. [PMID: 34287841 DOI: 10.1111/ane.13506] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/25/2021] [Accepted: 07/11/2021] [Indexed: 12/14/2022]
Abstract
Cerebral venous thrombosis (CVT) is caused by partial or complete occlusion of the major cerebral venous sinuses or the smaller feeding cortical veins which predispose to the risk of venous infarction and hemorrhage. Current guidelines recommend treating CVT with either low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) followed by an oral vitamin K antagonist (VKA) for 3-12 months. Direct oral anticoagulants (DOACs) have already established benefit over warfarin as a long-term treatment of symptomatic venous thromboembolic disorder like deep vein thrombosis (DVT), and pulmonary embolism (PE) given its equal efficacy and better safety profile. The benefit of DOACs over warfarin as a long-term anticoagulation for CVT has likewise been extensively studied, yet it has not been approved as first-line therapy in the current practice. We therefore performed a systematic review and meta-analysis of relevant studies to generate robust evidence regarding the safety and efficacy of DOACs in CVT. This meta-analysis demonstrates that the use of DOACs in CVT has similar efficacy and safety compared to VKAs with better recanalization rate.
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Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine Maharajgunj Medical CampusTribhuvan University Institute of Medicine Maharajgunj, Kathmandu Nepal
| | - Sanjeev Kharel
- Department of Internal Medicine Maharajgunj Medical CampusTribhuvan University Institute of Medicine Maharajgunj, Kathmandu Nepal
| | - Riwaj Bhagat
- Department of Neurology University of Louisville School of Medicine Louisville KY USA
| | - Yow Ka Shing
- Department of Internal Medicine National University Hospital Singapore Singapore
| | - Megan Ariel Coghlan
- Department of Neurology University of Louisville School of Medicine Louisville KY USA
| | - Prasanta Poudyal
- Department of Otorhinolaryngology Tribhuvan University Teaching Hospital Maharajgunj Kathmandu Nepal
| | - Rajeev Ojha
- Department of Neurology Tribhuvan University Teaching Hospital Maharajgunj Kathmandu Nepal
| | - Gentle Sunder Shrestha
- Department of Anesthesiology Tribhuvan University Teaching Hospital Maharajgunj Kathmandu Nepal
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Patiño Arboleda M, Muñoz JF, Ocampo JM, Calzada MT, Cárdenas Prieto JM. Trombosis bilateral del seno cavernoso en un paciente con enfermedad periodontal y diabetes mellitus. descripción de un caso. DUAZARY 2021. [DOI: 10.21676/2389783x.4239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
La trombosis de los senos cavernosos (TSC) corresponde a una entidad vascular poco usual, asociada con alta morbimortalidad y secuelas neurológicas. La etiología más frecuente son los procesos infecciosos a nivel de cabeza y cuello, que sirven como puerta de entrada para diferentes microorganismos, generando una respuesta inflamatoria que desencadena el evento trombótico. La enfermedad periodontal caracterizada por inflamación gingival, pérdida de tejido conectivo circundante y eventual del diente está asociada con el desarrollo de enfermedades sistémicas secundarias a los patógenos periodontales y mediadores inflamatorios producidos en la cavidad oral. Estos pueden diseminarse y producir complicaciones por contigüidad como eventos trombóticos a nivel del sistema nervioso central. A continuación, se presenta el caso clínico de un paciente que desarrolló una TSC bilateral después de ser sometido a un procedimiento periodontal.
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Dubey AK, Kalita J, Chaudhary SK, Misra UK. Impact of anticoagulation status on recanalization and outcome of cerebral venous thrombosis. J Clin Neurosci 2021; 89:43-50. [PMID: 34119293 DOI: 10.1016/j.jocn.2021.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/23/2021] [Accepted: 04/17/2021] [Indexed: 11/26/2022]
Abstract
Effective anticoagulation status may determine the recanalization and outcome of cerebral venous thrombosis (CVT). We report impact of anticoagulation status on recanalization and outcome of CVT. This is a retrospective study on 126 patients with CVT diagnosed on magnetic resonance venography (MRV). Their clinical features and risk factors were noted. The data were retrieved from a prospectively maintained registry, and international normalized ratio (INR) was noted after discharge till 3 months. All the patients were on acenocoumarol. Based on INR value, patients were categorized as Group A (effective anticoagulation INR within the therapeutic range or above) and Group B (ineffective anticoagulation INR > 50% below the therapeutic range). A repeat MRV at 3 months was done for recanalization. Outcome at 3 months was evaluated using modified Rankin Scale (mRS), and categorized as good (mRS ≤ 2) and poor (mRS 2 or more) 101(80.2%) patients were in group A and 25(19.8%) in group B. Their demographic, risk factors, magnetic resonance imaging (MRI) and MRV findings were comparable. On repeat MRV, recanalization occurred in 22/24(91.7%); 15(88%) in group A and 7(100%) in group B. Recanalization was independent of coagulation status. Seven (5.6%) patients died and 107(84.9%) had good outcome; 85(84.2%) in group A and 22(88%) in group B. Kaplan Meier analysis also did not reveal survival or good outcome benefits between the groups. In CVT, outcome and recanalization at 3 months are not dependent on coagulation status. Further prospective studies are needed regarding duration of anticoagulant and its impact on recanalization and outcome.
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Affiliation(s)
- Ashish K Dubey
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow, Uttar Pradesh 226014, India
| | - Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow, Uttar Pradesh 226014, India.
| | - Sarvesh K Chaudhary
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow, Uttar Pradesh 226014, India
| | - Usha K Misra
- Apollo Medics Super-specialty Hospitals and Senior consultant neurologist, Vivekanand Polyclinic, and Institute of Medical science, Lucknow 226001, India
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Kow CS, Zaihan AF, Hasan SS. Anticoagulant approach in COVID-19 patients with cerebral venous thrombosis. J Stroke Cerebrovasc Dis 2020; 29:105222. [PMID: 32891494 PMCID: PMC7396886 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 07/29/2020] [Indexed: 11/03/2022] Open
Affiliation(s)
- Chia Siang Kow
- School of Postgraduate Studies, International Medical University, Kuala Lumpur, Malaysia.
| | | | - Syed Shahzad Hasan
- Department of Pharmacy, University of Huddersfield, Huddersfield, United Kingdom
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Avanali R, Gopalakrishnan MS, Devi BI, Bhat DI, Shukla DP, Shanbhag NC. Role of Decompressive Craniectomy in the Management of Cerebral Venous Sinus Thrombosis. Front Neurol 2019; 10:511. [PMID: 31156540 PMCID: PMC6529953 DOI: 10.3389/fneur.2019.00511] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 04/29/2019] [Indexed: 12/31/2022] Open
Abstract
Cerebral venous sinus thrombosis (CVST) is a relatively uncommon cause of stroke more often affecting women and younger individuals. Blockage of the venous outflow rapidly causes edema and space-occupying venous infarctions and it seems intuitive that decompressive craniectomy (DC) can effectively reduce intracranial pressure just like it works for malignant middle cerebral artery infarcts and traumatic brain injury. But because of the relative rarity of this type of stroke, strong evidence from randomized controlled trials that DC is a life-saving procedure is not available unlike in the latter two conditions. There is a possibility that other forms of interventions like endovascular recanalization, thrombectomy, thrombolysis, and anticoagulation, which cannot be used in established middle cerebral artery infarcts and TBI, can reverse the ongoing pathology of increasing edema in CVST. Such interventions, although presently unproven, could theoretically obviate the need for DC when used in early stages. However, in the absence of such evidence, we recommend that DC be considered early as a life-saving measure whenever there are large hemorrhagic infarcts, expanding edema, radiological, and clinical features of impending herniation. This review gives an overview of the etiology and risk factors of CVST in different patient populations and examines the effectiveness of DC and other forms of interventions.
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Affiliation(s)
- Raghunath Avanali
- Department of Neurosurgery, Government T. D. College, Allapuzha, India
| | - M S Gopalakrishnan
- Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - B Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India.,NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Dhananjaya I Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Dhaval P Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Nagesh C Shanbhag
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
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