This study aims to compare different direct oral anticoagulants (DOACs) with vitamin K antagonists (VKAs) for managing cerebral venous thrombosis (CVT) and rank them accordingly.

CVT is a rare but serious type of stroke, usually treated with VKAs. However, DOACs are emerging as a new approach to anticoagulation.

PubMed, Cochrane Central, and ScienceDirect were searched through May 2025. We conducted a network meta-analysis in RStudio version 4.3.3 using the “meta” and “netmeta” packages, applying a frequentist approach. P-scores ranked treatments, and risk ratios (RRs) were pooled for dichotomous outcomes to estimate network effects. The split node analysis assessed inconsistencies in direct and indirect evidence.

Our analysis included 16 studies, consisting of six randomized controlled trials and ten observational studies. We found that various DOACs, including apixaban, dabigatran, and rivaroxaban, had comparable rates of complete recanalization, CVT recurrence, major hemorrhage, intracranial hemorrhage (ICH), and mortality compared to VKAs. VKAs showed the best probability of increasing complete recanalization (P-score = 0.70), while apixaban showed the worst (P-score = 0.04). Apixaban had the best probability of reducing recurrent CVT (P-score = 0.83), while dabigatran had the worst (P-score = 0.04). Apixaban also had the highest probability of reducing the risk of ICH (P-score = 0.70), while rivaroxaban had the lowest (P-score = 0.29). Apixaban has the best probability of reducing the risk of major hemorrhage (P-score = 0.81), while VKAs have the worst (P-score = 0.26). Lastly, apixaban was ranked best in reducing mortality (P-score = 0.78), while VKAs were ranked worst (P-score = 0.39).

DOACs showed no significant change in rates of recanalization, CVT recurrence, hemorrhage, ICH, and mortality compared to VKAs. Apixaban has the best probability of reducing the risk of CVT recurrence, mortality, and hemorrhagic events, while VKAs have the highest probability of increasing complete recanalization.