To compare patients discharged on warfarin versus direct oral anticoagulants (DOACs) for cerebral venous sinus thrombosis (CVST).

CVST is a rare etiology of stroke with limited large-scale evidence to guide management decisions. Warfarin remains the mainstay of therapy given paucity of data for DOACs.

We retrospectively identified CVST patients in a prospectively collected stroke registry between January 2012- June 2019 at our center. Patient demographics, clinical, radiographic and prescription data was collected. Patients without post-hospitalization follow up were excluded. Chi Square and Fischer exact tests were used to compare baseline characteristics, risk factors and outcomes across the two treatment groups with an alpha of 0.05. 

Forty-one cases of CVST were identified. Baseline demographics, presenting symptoms, and CVST etiology did not differ between the two groups. Thirteen (32.5%) cases were discharged on DOACs. Apixaban was the most commonly used DOAC (n=9), followed by rivaroxaban (n=3) and dabigatran (n=1). Patients with an unfavorable discharge mRS (3-6) were more likely to be discharged on a DOAC than warfarin (61 vs. 25%, p=0.04). On follow up within a year, 77% of the DOAC group and 75% of cases treated with warfarin had a favorable mRS (0-2). Clot resolution was achieved in 35% of patients on warfarin and 38% of patients on DOACs (p=0.7). No CVST recurrence was reported with DOAC use. There was 1 case of recurrent CVST, one DVT/PTE and one ischemic stroke on warfarin.  Additional radiographic and clinical outcome comparisons to be presented.

In our sample, we found increasing use of DOACs for post-hospitalization anticoagulation in CVST.  Interestingly, although DOAC patients had higher discharge mRS, long term mRS did not differ, nor did rates of clot resolution or subsequent thrombotic events.  Given the relative ease of DOAC use over warfarin, ongoing research is needed to establish safety and efficacy in larger samples.