ESOC 2025 | An overview of recent evidence and trial findings for the treatment of CVT

So there are a few studies that are relatively new in the last few years on cerebral venous thrombosis. One of these studies is ESCOA-CVT in which we couldn’t find the difference on establishing a long-term duration of anticoagulation, meaning 12 months compared with three to six months. So there was no difference in terms of recurrent events, in terms of bleeding events, and there were numerically higher rates of death and vascular death in patients with CVT, which suggests that there is no early benefit on prolonging anticoagulation. However, this of course has to be considered when discussing and making the individual patient decisions on the duration of anticoagulation. This information can be considered, but the decisions should be always tailored to the individual patient. Another recent study is the DECOMPRESS 2 study. This was a prospective study. It was published in Stroke last year. This is a prospective study on decompressive surgery on cerebral venous thrombosis, including 118 patients. And indeed, the conclusion is that this is a procedure that is associated with good functional outcomes, but still comparing the prospective data with the retrospective data, we could understand that the mortality rates are indeed higher than what was reported in the retrospective data. So there is some reporting bias, probably, on the retrospective analysis. And so one third of patients still die despite decompressive surgery. But still the conclusion is that we should perform decompressive surgery in patients with impending brain herniation. Although this was a study without a control group, we know that the outcome is very deadly in patients that are not submitted to surgery. And what we can see from the results is that either patients die, about one third, or very few patients, only 10%, is left with severe disability. So Rankin scale five, which means that we should offer this treatment to these patients because they tend to recover in the long term, even despite the fact that this was a cohort of very severely affected patients with large proportions of coma, midline shift and all signs of impending brain herniation. Still the outcomes, the functional outcomes in the long term are quite good and after six months one third of patients achieve functional independence so that is another important recent study in the last years. Another important study was DOAC-CVT it was published this year on Lancet Neurology. This is a study that was observational, that was assessing patients with oral anticoagulation after CVT, comparing vitamin K antagonists and DOACs. And indeed, the conclusion is that DOACs are safe and effective in terms of preventing recurrent events and bleeding events. And so this adds to the previous data on the use of DOACs in these patients. There was a randomized control trial and also some retrospective cohorts, the randomized control trial. The largest one is the RESPECT-CVT study, which was the first study assessing the bigger trend or VKA in patients with CVT. And the conclusion was the same, similar rates of bleeding, similar rates of thrombotic events, similar rates even of recanalization. And also some retrospective data that was also published recently from the US group, the Action CVT group. So we do have now quite a large set of evidence that can help us to decide on the use of DOACs and in general to manage anticoagulation in this patient, duration of anticoagulation and decision on the type of anticoagulant. We were also presenting at ESOC a sub-analysis of the DOAC-CVT study, assessing also recanalization rates in these patients. And actually, the rates of complete recanalization were a bit better on VKAs. But I think the most interesting is that we found, even after controlling for other predictors of outcome, an association between venous recanalization and functional outcome, which was something that was still lacking this more robust analysis on a large data set of prospective data. So I think these are the main new studies that have been published and presented in the last years. And indeed, this adds to the evidence that we have on the management of CVT patients, especially the acute treatment decisions and also the long-term decisions on management of anticoagulation for secondary prevention of thrombotic events.

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