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.