This meta-analysis aims to compare the effectiveness and safety of direct oral anticoagulants (DOACs) with those of vitamin K antagonists (VKAs) in treating cerebral venous thrombosis (CVT).

CVT is a rare cause of stroke, mainly affecting young people. The standard treatment plan includes anticoagulation with low molecular weight heparin (LMWH) and then VKAs. While DOACs show promise, their effectiveness and safety are still uncertain.

Electronic databases, including PubMed, Cochrane Library, and ScienceDirect, were searched from the inception to April 2025. We pooled risk ratios (RRs) with 95% confidence intervals (CIs) using a random-effects model in Review Manager 5.4.1. To assess quality, we used the Cochrane risk of bias (RoB 2.0) tool and the Newcastle-Ottawa Scale (NOS). We also conducted subgroup analyses based on study design and different types of DOACs.

Thirty-one studies, comprising 5 randomized controlled trials (RCTs) and 26 observational studies, were included in this meta-analysis. Our analysis revealed a significant decrease in the risk of recurrent venous thromboembolism (VTE) in the DOACs group compared to VKA (RR= 0.84; 95%CI: [0.71,0.99]; p=0.04; I²=0%). Likewise, DOACs showed a significant advantage over VKA in terms of intracranial hemorrhage (ICH) (RR= 0.67; 95%CI: [0.50,0.89]; p=0.007; I²=0%). Other outcomes, including major hemorrhage (RR= 0.70; 95%CI:[0.42,1.15]; p=0.16; I²=0%), all-cause mortality (RR= 0.96; 95%CI:[0.68,1.35]; p= 0.81; I²=0%), and full recanalization (RR= 0.92; 95%CI:[0.82,1.03]; p= 0.16; I²=21%), were comparable between the two groups.

DOACs showed a significant reduction in the risk of recurrent VTE and ICH compared to VKAs, whereas major hemorrhage, all-cause mortality, and full recanalization were comparable.