Safety and efficacy of direct oral anticoagulants in children with infection-related cerebral venous thrombosis: a real-life multicenter retrospective study.

BACKGROUND

Cerebral venous thrombosis (CVT) in children is rare and may complicate head and neck infections, particularly mastoiditis. Optimal anticoagulation strategies in this setting remain uncertain.

METHODS

We conducted a multicenter retrospective study across four Italian pediatric referral centers, including consecutive children hospitalized for infections-related CVT and treated with Direct Oral Anticoagulants from July 2023 to December 2024.

RESULTS

Thirty-four children (median age 63 months; 67.6% males) met the inclusion criteria and were included in the study. Mastoiditis was the most frequently reported infection (85.3%). The most common site of CVT was the sigmoid sinus (91.1%), followed by the transverse sinus (67.6%). All patients initially received heparin, followed by rivaroxaban. Twenty patients (58.8%) required additional medical therapy for intracranial hypertension. Eight patients (23.5%) underwent therapeutic lumbar puncture, and four (11.8%) required ventriculoperitoneal shunt placement. At three months, 61.8% of patients achieved complete recanalization and 85.3% showed thrombus improvement. Female sex, younger age, internal jugular vein involvement, papilledema, and surgical treatment for intracranial hypertension were associated with lower recanalization rates. No major bleeding events occurred; minor bleeding (epistaxis) was observed in 8.8% of patients. At a median follow-up of 12 months, no recurrences or new thromboembolic events were observed.

CONCLUSION

Our findings suggest that rivaroxaban is safe and effective for the treatment of pediatric infections-related CVT and support an individualized duration of anticoagulation based on thrombotic burden and clinical complexity.