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Momin SMB, Davies DJ, O’Halloran PJ, Belli A, Veenith T, Chelvarajah R. Management of Traumatic Cerebral Venous Sinus Thrombosis: A United Kingdom and Ireland Survey on Practice Variation. Neurotrauma Rep 2024; 5:540-551. [PMID: 39081662 PMCID: PMC11285999 DOI: 10.1089/neur.2023.0118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024] Open
Abstract
Traumatic cerebral venous sinus thrombosis (tCVST) is an increasingly recognized sequela of traumatic brain injury (TBI), with skull fractures and extradural hematomas overlying venous sinuses recognized as risk factors. Although it may be treated with anticoagulation, the decision to treat tCVST is nuanced by the risk of new or worsening hemorrhage. Presently, there are no guidelines on the investigation and management of tCVST. Therefore, we conducted a UK- and Ireland-wide practice variation survey. A 17-question survey was sent via Google Forms to neurosurgeons and intensive care doctors of at least ST3 (registrar) level and above in the UK and Ireland and distributed by the Society of British Neurological Surgeons and investigators of the Sugar or Salt trial between May 9, 2023, and September 15, 2023. Data were extracted from the survey for both qualitative and quantitative analyses. There were 41 respondents to the survey, 18 (43.9%) of whom were consultant neurosurgeons. Fifty-four percent of the respondents performed a computed tomography intracranial venogram to investigate for tCVST where there was a skull fracture overlying or adjacent to a venous sinus, whereas 43.9% performed these at the time of TBI diagnosis. Around three-fourth of the respondents anticoagulate for tCVST, largely within 3 days post-TBI. A range of hemorrhagic and thrombotic complications have been observed following decisions to treat and withhold treatment of tCVST, respectively. Around two-third of the respondents conducted follow-up imaging in confirmed tCVST. None of the respondents had an established departmental protocol for the management of tCVST. This UK- and Ireland-wide survey on the management of tCVST revealed a variation in its diagnosis, treatment, and follow-up with no departmental protocol established. The optimal diagnostic pathway, management protocol, and follow-up of patients with tCVST remain unknown and should be the subject of future studies.
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Affiliation(s)
- Sheikh M. B. Momin
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - David J. Davies
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Trauma Sciences Research, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Philip J. O’Halloran
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK
- Department of Physiology & Medical Physics, Royal College of Surgeons of Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Antonio Belli
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Trauma Sciences Research, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Tonny Veenith
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Department of Intensive Care Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - Ramesh Chelvarajah
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Human Brain Health, College of Life Sciences, University of Birmingham, Birmingham, UK
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Tan KS, Pandian JD, Liu L, Toyoda K, Leung TWH, Uchiyama S, Kuroda S, Suwanwela NC, Aaron S, Chang HM, Venketasubramanian N. Stroke in Asia. Cerebrovasc Dis Extra 2024; 14:58-75. [PMID: 38657577 PMCID: PMC11250668 DOI: 10.1159/000538928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 04/08/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND There is a significant burden of stroke in Asia. Asia has the largest population in the world in 2023, estimated at 4.7 billion. Approximately 9.5-10.6 million strokes will be anticipated annually in the backdrop of a diverse group of well-developed and less developed countries with large disparities in stroke care resources. In addition, Asian countries are in varying phases of epidemiological transition. SUMMARY In this review, we examined recent epidemiological features of ischaemic stroke and intracerebral haemorrhage in Asia with recent developments in hyperacute stroke reperfusion therapy and technical improvements in intracerebral haemorrhage. The article also discussed the spectrum of cerebrovascular diseases in Asia, which include intracranial atherosclerosis, intracerebral haemorrhage, infective aetiologies of stroke, moyamoya disease, vascular dissection, radiation vasculopathy, and cerebral venous thrombosis. KEY MESSAGES The review of selected literature and recent updates calls for attention to the different requirements for resources within Asia and highlights the breadth of cerebrovascular diseases still requiring further research and more effective therapies.
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Affiliation(s)
- Kay Sin Tan
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | | - Thomas Wai Hon Leung
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - Shinichiro Uchiyama
- Centre for Brain and Cerebral Vessels, Sanno Medical Centre, International University of Health and Welfare, Tokyo, Japan
| | - Sathoshi Kuroda
- Department of Neurosurgery, Toyama University, Toyama, Japan
| | - Nijasri C. Suwanwela
- Chulalongkorn Stroke Centre, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sanjith Aaron
- Department of Medicine, Christian Medical College, Vellore, India
| | - Hui Meng Chang
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore, Singapore
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Ekomwereren O, Sunkara V, Grezenko H, Hamid YH, Faran N, Abubakar M. Orbital Onset: The Intricate Journey From Ear Abscess to Cavernous Sinus Thrombosis in a Diabetic Male. Cureus 2023; 15:e48922. [PMID: 38106764 PMCID: PMC10725519 DOI: 10.7759/cureus.48922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 12/19/2023] Open
Abstract
Cavernous sinus thrombosis (CST) is a rare, yet severe condition often linked to infections in the nasal and facial areas. We present a case of a 43-year-old male farmer with diabetes who initially showed ear abscess symptoms that progressed to vision loss and CST-like symptoms. Self-treatment and an unidentified medication regimen may have worsened his condition. Advanced diagnostic evaluations, particularly magnetic resonance imaging with magnetic resonance venography, confirmed CST, likely originating from the ear infection spreading to the eyes, causing bilateral orbital cellulitis. Treatment with antibiotics, anticoagulants, and supportive therapy stabilized the patient's condition. This case emphasizes the importance of early detection and intervention in CST, especially in atypical presentations, and the need for comprehensive diagnostic and therapeutic approaches.
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Affiliation(s)
- Osatohanmwen Ekomwereren
- Trauma and Orthopaedics, Royal Shrewsbury Hospital, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, GBR
| | | | - Han Grezenko
- Medicine and Surgery, Guangxi Medical University, Nanning, CHN
- Translational Neuroscience, Barrow Neurological Institute, Phoenix, USA
| | - Yusra H Hamid
- Community Medicine, University of Khartoum Faculty of Medicine, Khartoum, SDN
| | - Nuzhat Faran
- Internal Medicine, Fatima Memorial Hospital, Lahore, PAK
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Schirmer CM, Bulsara KR, Al-Mufti F, Haranhalli N, Thibault L, Hetts SW. Antiplatelets and antithrombotics in neurointerventional procedures: Guideline update. J Neurointerv Surg 2023; 15:1155-1162. [PMID: 37188504 DOI: 10.1136/jnis-2022-019844] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/22/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Antiplatelet and antithrombotic medication management before, during, and after neurointerventional procedures has significant practice variation. This document updates and builds upon the 2014 Society of NeuroInterventional Surgery (SNIS) Guideline 'Platelet function inhibitor and platelet function testing in neurointerventional procedures', providing updates based on the treatment of specific pathologies and for patients with specific comorbidities. METHODS We performed a structured literature review of studies that have become available since the 2014 SNIS Guideline. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS The management of antiplatelet and antithrombotic agents before, during, and after endovascular neurointerventional procedures continues to evolve. The following recommendations were agreed on. (1) It is reasonable to resume anticoagulation after a neurointerventional procedure or major bleeding episode as soon as the thrombotic risk exceeds the bleeding risk in an individual patient (Class I, Level C-EO). (2) Platelet testing can be useful to guide local practice, and specific approaches to using the numbers demonstrate marked local variability (Class IIa, Level B-NR). (3) For patients without comorbidities undergoing brain aneurysm treatment, there are no additional considerations for medication choice beyond the thrombotic risks of the catheterization procedure and aneurysm treatment devices (Class IIa, Level B-NR). (4) For patients undergoing neurointerventional brain aneurysm treatment who have had cardiac stents placed within the last 6-12 months, dual antiplatelet therapy (DAPT) is recommended (Class I, Level B-NR). (5) For patients being evaluated for neurointeventional brain aneurysm treatment who had venous thrombosis more than 3 months prior, discontinuation of oral anticoagulation (OAC) or vitamin K antagonists should be considered as weighed against the risk of delaying aneurysm treatment. For venous thrombosis less than 3 months in the past, delay of the neurointerventional procedure should be considered. If this is not possible, see atrial fibrillation recommendations (Class IIb, Level C-LD). (6) For patients with atrial fibrillation receiving OAC and in need of a neurointerventional procedure, the duration of TAT (triple antiplatelet/anticoagulation therapy=OAC plus DAPT) should be kept as short as possible or avoided in favor of OAC plus single antiplatelet therapy (SAPT) based on the individual's ischemic and bleeding risk profile (Class IIa, Level B-NR). (7) For patients with unruptured brain arteriovenous malformations there is no indication to change antiplatelet or anticoagulant management instituted for management of another disease (Class IIb, Level C-LD). (8) Patients with symptomatic intracranial atherosclerotic disease (ICAD) should continue DAPT following neurointerventional treatment for secondary stroke prevention (Class IIa, Level B-NR). (9) Following neurointerventional treatment for ICAD, DAPT should be continued for at least 3 months. In the absence of new stroke or transient ischemic attack symptoms, reversion to SAPT can be considered based on an individual patient's risk of hemorrhage versus ischemia (Class IIb, Level C-LD). (10) Patients undergoing carotid artery stenting (CAS) should receive DAPT before and for at least 3 months following their procedure (Class IIa, Level B-R). (11) In patients undergoing CAS during emergent large vessel occlusion ischemic stroke treatment, it may be reasonable to administer a loading dose of intravenous or oral glycoprotein IIb/IIIa or P2Y12 inhibitor followed by maintenance intravenous infusion or oral dosing to prevent stent thrombosis whether or not the patient has received thrombolytic therapy (Class IIb, C-LD). (12) For patients with cerebral venous sinus thrombosis, anticoagulation with heparin is front-line therapy; endovascular therapy may be considered particularly in cases of clinical deterioration despite medical therapy (Class IIa, Level B-R). CONCLUSIONS Although the quality of evidence is lower than for coronary interventions due to a lower number of patients and procedures, neurointerventional antiplatelet and antithrombotic management shares several themes. Prospective and randomized studies are needed to strengthen the data supporting these recommendations.
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Affiliation(s)
| | - Ketan R Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
| | - Fawaz Al-Mufti
- Neurology, Neurosurgery, and Radiology, Westchester Medical Center, Valhalla, New York, USA
| | - Neil Haranhalli
- Neurosurgery and Radiology, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | - Lucie Thibault
- Scientific Committee, World Federation of Interventional and Therapeutic Neuroradiology, Paris, France
| | - Steven W Hetts
- Radiology, Biomedical Imaging, and Neurological Surgery, UCSF, San Francisco, California, USA
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Liberman AL. Diagnosis and Treatment of Cerebral Venous Thrombosis. Continuum (Minneap Minn) 2023; 29:519-539. [PMID: 37039408 DOI: 10.1212/con.0000000000001211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Cerebral venous thrombosis (CVT), thrombosis of the dural sinus, cerebral veins, or both, is a rare cerebrovascular disease. Although mortality rates after CVT have declined over time, this condition can result in devastating neurologic outcomes. This article reviews the latest literature regarding CVT epidemiology, details new factors associated with the development of CVT, and describes advances in CVT treatment. It also contains a discussion of future directions in the field, including novel diagnostic imaging modalities, and potential strategies to reduce the risks associated with CVT. LATEST DEVELOPMENTS The incidence of CVT may be as high as 2 per 100,000 adults per year. It remains a difficult condition to diagnose given its variable clinical manifestations and the necessity of neuroimaging for confirmation. The COVID-19 pandemic has revealed a novel CVT trigger, vaccine-induced immune thrombotic thrombocytopenia (VITT), as well as an association between COVID-19 infection and CVT. Although VITT is a very rare event, timely diagnosis and treatment of CVT due to VITT likely improves patient outcomes. Direct oral anticoagulants are currently being used to treat CVT and emerging data suggest that these agents are as safe and effective as vitamin K antagonists. The role of endovascular therapy to treat CVT, despite a recent clinical trial, remains unproven. ESSENTIAL POINTS The incidence of CVT has increased, outcomes have improved, and the use of direct oral anticoagulants to treat CVT represents an important advance in the clinical care of these patients. Rates of CVT as a complication of COVID-19 vaccines using adenoviral vectors are very low (<5 per million vaccine doses administered), with the benefits of COVID-19 vaccination far outweighing the risks.
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Agyemang K, Gómez Rodríguez R, Rocha Marussi VH, Marte Arias SA, Feliciano Vilcahuaman Paitań A, Campos Filho JM, Chaddad-Neto F. Case report: Delayed outflow obstruction of a DVA: A rare complication of brainstem cavernoma surgery. Front Neurol 2023; 14:1073366. [PMID: 36998781 PMCID: PMC10044343 DOI: 10.3389/fneur.2023.1073366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 02/03/2023] [Indexed: 03/16/2023] Open
Abstract
IntroductionDevelopmental venous anomalies (DVAs) are considered variants of normal transmedullary veins. Their association with cavernous malformations is reported to increase the risk of hemorrhage. Expert consensus recommends meticulous planning with MR imaging, use of anatomical “safe zones”, intraoperative monitoring of long tracts and cranial nerve nuclei, and preservation of the DVA as key to avoiding complications in brainstem cavernoma microsurgery. Symptomatic outflow restriction of DVA is rare, with the few reported cases in the literature restricted to DVAs in the supratentorial compartment.CaseWe present a case report of the resection of a pontine cavernoma complicated by delayed outflow obstruction of the associated DVA. A female patient in her 20's presented with progressive left-sided hemisensory disturbance and mild hemiparesis. MRI revealed two pontine cavernomas associated with interconnected DVA and hematoma. The symptomatic cavernoma was resected via the infrafacial corridor. Despite the preservation of the DVA, the patient developed delayed deterioration secondary to venous hemorrhagic infarction. We discuss the imaging and surgical anatomy pertinent to brainstem cavernoma surgery, as well as the literature exploring the management of symptomatic infratentorial DVA occlusion.ConclusionDelayed symptomatic pontine venous congestive edema is extremely rare following cavernoma surgery. DVA outflow restriction from a post-operative cavity, intraoperative manipulation, and intrinsic hypercoagulability from COVID-10 infection are potential pathophysiological factors. Improved knowledge of DVAs, brainstem venous anatomy, and “safe entry zones” will further elucidate the etiology of and the efficacious treatment for this complication.
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Affiliation(s)
- Kevin Agyemang
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
- Department of Neurosurgery, Beneficência Portuguesa Hospital, São Paulo, Brazil
- School of Medicine, University of Glasgow, Glasgow, United Kingdom
| | | | | | | | | | | | - Feres Chaddad-Neto
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
- Department of Neurosurgery, Beneficência Portuguesa Hospital, São Paulo, Brazil
- *Correspondence: Feres Chaddad-Neto
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Pelletier J, Koyfman A, Long B. High risk and low prevalence diseases: Orbital cellulitis. Am J Emerg Med 2023; 68:1-9. [PMID: 36893591 DOI: 10.1016/j.ajem.2023.02.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/18/2023] [Accepted: 02/20/2023] [Indexed: 02/27/2023] Open
Abstract
INTRODUCTION Orbital cellulitis is an uncommon but serious condition that carries with it a potential for significant morbidity. OBJECTIVE This review highlights the pearls and pitfalls of orbital cellulitis, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Orbital cellulitis refers to infection of the globe and surrounding soft tissues posterior to the orbital septum. Orbital cellulitis is typically caused by local spread from sinusitis but can also be caused by local trauma or dental infection. It is more common in pediatric patients compared to adults. Emergency clinicians should first assess for and manage other critical, sight-threatening complications such as orbital compartment syndrome (OCS). Following this assessment, a focused eye examination is necessary. Though orbital cellulitis is primarily a clinical diagnosis, computed tomography (CT) of the brain and orbits with and without contrast is critical for evaluation of complications such as abscess or intracranial extension. Magnetic resonance imaging (MRI) of the brain and orbits with and without contrast should be performed in cases of suspected orbital cellulitis in which CT is non-diagnostic. While point-of-care ultrasound (POCUS) may be useful in differentiating preseptal from orbital cellulitis, it cannot exclude intracranial extension of infection. Management includes early administration of broad-spectrum antibiotics and ophthalmology consultation. The use of steroids is controversial. In cases of intracranial extension of infection (e.g., cavernous sinus thrombosis, abscess, or meningitis), neurosurgery should be consulted. CONCLUSION An understanding of orbital cellulitis can assist emergency clinicians in diagnosing and managing this sight-threatening infectious process.
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Affiliation(s)
- Jessica Pelletier
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Branco T, Marques C, Santos VC, Lopes JM. Gradenigo's Syndrome With Septic Lateral Sinus Thrombosis. Cureus 2023; 15:e34797. [PMID: 36915831 PMCID: PMC10007907 DOI: 10.7759/cureus.34797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 02/11/2023] Open
Abstract
Gradenigo's syndrome (GS) is a rare but life-threatening complication of acute otitis media (AOM). It is classically defined as a clinical triad of acute otitis media, ipsilateral sixth (abducens) nerve palsy, and pain in the distribution of the first and second branches of the trigeminal nerve. Another rare but serious complication of AOM is venous sinus thrombosis, which is often associated with GS. The diagnosis of these conditions requires clinical suspicion, sound interpretation of signs and symptoms, and the use of the correct imaging techniques. Here, we present the case of an 81-year-old man with a previous history of recurrent otitis media, who presented with GS and septic lateral sinus thrombosis. The clinical presentation, physiopathology, and management of these conditions are discussed.
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Affiliation(s)
- Tiago Branco
- Serviço de Medicina 2, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, PRT
| | | | - Vera C Santos
- Serviço de Medicina Intensiva, Hospital Prof. Doutor Fernando Fonseca, Amadora, PRT
| | - João M Lopes
- Serviço de Medicina 2, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, PRT
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Frol S, Šabovič M, Oblak JP. Apixaban for the Treatment of Cerebral Venous Sinus Thrombosis: A Single-Centre Experience and Systematic Review of the Literature. CNS Drugs 2023; 37:133-141. [PMID: 36646983 DOI: 10.1007/s40263-022-00981-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND OBJECTIVE Cerebral venous thrombosis (CVT) is a rare disease, and data regarding direct oral anticoagulant therapy are insufficient. Apixaban could have a safer profile than other direct oral anticoagulants. We present our case series of patients with CVT treated with apixaban and a systematic review of published real-world cases. METHODS We described our series of patients with CVT treated with apixaban and searched PubMed for similar published cases with reported complete outcome data: recanalisation rate, recurrent CVT, modified Rankin score, intracranial haemorrhage, other bleedings and mortality. RESULTS Four male patients (average age 43.5 years) with idiopathic CVT, who presented with a headache and/or seizure without neurological deficits/symptoms or cerebral infarcts/haemorrhage were treated with apixaban 5 mg twice daily for an average 28 months (18-46 months) and followed for on average 2.8 years. In two patients, a partial/complete recanalisation was achieved, there was no recurrent CVT, all patients achieved a modified Rankin score of 0, none experienced an intracranial haemorrhage, other bleedings or died. One patient, in whom anti-phospholipid syndrome was later diagnosed, had a recurrence of CVT after stopping apixaban. Our systematic review identified only 15 eligible patients (average age 39 years, 60% female). Partial/complete recanalisation was achieved in 74% of cases, there was no recurrent CVT, 95% achieved a modified Rankin score of ≤ 2, none experienced an intracranial haemorrhage, other bleedings or died. CONCLUSIONS Our cases and the review of similar published cases, albeit obtained on a smaller scale, suggest that apixaban may be a safe and effective therapy for CVT. This assumption should be tested in a large randomised study.
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Affiliation(s)
- Senta Frol
- Department of Vascular Neurology, University Clinical Centre Ljubljana, Ljubljana, Slovenia.
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
| | - Mišo Šabovič
- Department of Vascular Disorders, University Clinical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Janja Pretnar Oblak
- Department of Vascular Neurology, University Clinical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Stan A, Ilut S, Dragos HM, Bota C, Hanghicel PN, Cristian A, Vlad I, Mocanu D, Strilciuc S, Panaitescu PS, Stan H, Muresanu DF. The Burden of Cerebral Venous Thrombosis in a Romanian Population across a 5-Year Period. Life (Basel) 2022; 12:life12111825. [PMID: 36362980 PMCID: PMC9693190 DOI: 10.3390/life12111825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 10/28/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022] Open
Abstract
Health policies in transitioning health systems are rarely informed by the social burden and the incidence shifts in disease epidemiology. Cerebral venous thrombosis (CVT) is a type of stroke more often affecting younger adults and women, with higher incidences being reported in recent studies. A retrospective, hospital-based population study was conducted at Cluj-Napoca Emergency County Hospital across a 5-year period between 2017 and 2021. The overall incidence and the rates in distinctive gender and age groups were assessed. Length of hospital stay (LHS), modified Rankin score (mRS) and mortality at discharge and at 3 months were calculated. Fifty-three patients were included. The median age was 45 years, and 64.2% were women. In our population of 3,043,998 person-years, 53 CVT cases resulted in an incidence of 1.74 per 100,000 (95% CI 1.30–2.27). CVT incidence was higher in women (2.13 per 100,000, 95% CI 1.47–2.07). There was a statistically significant difference in LHS between patients with different intracranial complications (Kruskal–Wallis, p = 0.008). The discharge mRS correlated with increasing age (rs = 0.334, p = 0.015), transient risk factors (Fisher’s exact test, p = 0.023) and intracranial complications (Fisher’s exact test, p = 0.022). In addition, the mRS at 3 months was statistically associated with increasing age (rs = 0.372, p = 0.006) and transient risk factors (Fisher’s exact test, p = 0.012). In-hospital mortality was 5.7%, and mortality at follow up was 7.5%, with higher rates in women (5.9% and 8.8%, respectively). Our findings may provide insight regarding the epidemiological features of certain patient groups more prone to developing CVT and its complications, informing local and central stakeholders’ efforts to improve standards of care.
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Affiliation(s)
- Adina Stan
- Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
- Neurology Department, Emergency County Hospital Cluj-Napoca, 400347 Cluj-Napoca, Romania
| | - Silvina Ilut
- Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
- Neurology Department, Emergency County Hospital Cluj-Napoca, 400347 Cluj-Napoca, Romania
| | - Hanna Maria Dragos
- Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
- Neurology Department, Emergency County Hospital Cluj-Napoca, 400347 Cluj-Napoca, Romania
- Correspondence: ; Tel.: +40-773991273
| | - Claudia Bota
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
- Neurology Department, Emergency County Hospital Cluj-Napoca, 400347 Cluj-Napoca, Romania
| | - Patricia Nicoleta Hanghicel
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
- Neurology Department, Emergency County Hospital Cluj-Napoca, 400347 Cluj-Napoca, Romania
| | - Alexander Cristian
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
- Neurology Department, Emergency County Hospital Cluj-Napoca, 400347 Cluj-Napoca, Romania
| | - Irina Vlad
- Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
| | - Diana Mocanu
- Neurology Department, Emergency County Hospital Cluj-Napoca, 400347 Cluj-Napoca, Romania
| | - Stefan Strilciuc
- Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
| | - Paul Stefan Panaitescu
- Department of Microbiology, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
| | - Horatiu Stan
- Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
| | - Dafin F. Muresanu
- Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
- Neurology Department, Emergency County Hospital Cluj-Napoca, 400347 Cluj-Napoca, Romania
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Zhou Y, Jiang H, Wei H, Liu L, Zhou C, Ji X. Venous stroke–a stroke subtype that should not be ignored. Front Neurol 2022; 13:1019671. [PMID: 36277910 PMCID: PMC9582250 DOI: 10.3389/fneur.2022.1019671] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 09/22/2022] [Indexed: 11/13/2022] Open
Abstract
Based on the etiology, stroke can be classified into ischemic or hemorrhagic subtypes, which ranks second among the leading causes of death. Stroke is caused not only by arterial thrombosis but also by cerebral venous thrombosis. Arterial stroke is currently the main subtype of stroke, and research on this type has gradually improved. Venous thrombosis, the particular type, accounts for 0.5–1% of all strokes. Due to the lack of a full understanding of venous thrombosis, as well as its diverse clinical manifestations and neuroimaging features, there are often delays in admission for it, and it is easy to misdiagnose. The purpose of this study was to review the pathophysiology mechanisms and clinical features of arterial and venous thrombosis and to provide guidance for further research on the pathophysiological mechanism, clinical diagnosis, and treatment of venous thrombosis. This review summarizes the pathophysiological mechanisms, etiology, epidemiology, symptomatology, diagnosis, and treatment heterogeneity of venous thrombosis and compares it with arterial stroke. The aim is to provide a reference for a comprehensive understanding of venous thrombosis and a scientific understanding of various pathophysiological mechanisms and clinical features related to venous thrombosis, which will contribute to understanding the pathogenesis of intravenous stroke and provide insight into diagnosis, treatment, and prevention.
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Affiliation(s)
- Yifan Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Huimin Jiang
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Huimin Wei
- School of Engineering Medicine, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beihang University, Beijing, China
| | - Lu Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chen Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- Chen Zhou
| | - Xunming Ji
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- *Correspondence: Xunming Ji
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Woock M, Martinez-Majander N, Seiffge DJ, Selvik HA, Nordanstig A, Redfors P, Lindgren E, Sanchez van Kammen M, Rentzos A, Coutinho JM, Doyle K, Naess H, Putaala J, Jood K, Tatlisumak T. Cancer and stroke: commonly encountered by clinicians, but little evidence to guide clinical approach. Ther Adv Neurol Disord 2022; 15:17562864221106362. [PMID: 35785404 PMCID: PMC9243376 DOI: 10.1177/17562864221106362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/24/2022] [Indexed: 12/03/2022] Open
Abstract
The association between stroke and cancer is well-established. Because of an aging population and longer survival rates, the frequency of synchronous stroke and cancer will become even more common. Different pathophysiologic mechanisms have been proposed how cancer or cancer treatment directly or via coagulation disturbances can mediate stroke. Increased serum levels of D-dimer, fibrin degradation products, and CRP are more often seen in stroke with concomitant cancer, and the clot retrieved during thrombectomy has a more fibrin- and platelet-rich constitution compared with that of atherosclerotic etiology. Multiple infarctions are more common in patients with active cancer compared with those without a cancer diagnosis. New MRI techniques may help in detecting typical patterns seen in the presence of a concomitant cancer. In ischemic stroke patients, a newly published cancer probability score can help clinicians in their decision-making when to suspect an underlying malignancy in a stroke patient and to start cancer-screening studies. Treating stroke patients with synchronous cancer can be a delicate matter. Limited evidence suggests that administration of intravenous thrombolysis appears safe in non-axial intracranial and non-metastatic cancer patients. Endovascular thrombectomy is probably rather safe in these patients, but probably futile in most patients placed on palliative care due to their advanced disease. In this topical review, we discuss the epidemiology, pathophysiology, and prognosis of ischemic and hemorrhagic strokes as well as cerebral venous thrombosis and concomitant cancer. We further summarize the current evidence on acute management and secondary preventive therapy.
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Affiliation(s)
- Malin Woock
- Department of Neurology, Sahlgrenska University Hospital, Blå stråket 7, 413 46 Gothenburg, Sweden
| | | | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Annika Nordanstig
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Petra Redfors
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Lindgren
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mayte Sanchez van Kammen
- Department of Neurology, Amsterdam University Medical Center (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Alexandros Rentzos
- Department of Radiology, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Center (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Karen Doyle
- Department of Physiology, Centre for Research in Medical Devices (CÚRAM), National University of Ireland, Galway, Galway, Ireland
| | - Halvor Naess
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Katarina Jood
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Turgut Tatlisumak
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Moraes AADA, Conforto AB. Cerebral venous thrombosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:53-59. [PMID: 35976298 PMCID: PMC9491445 DOI: 10.1590/0004-282x-anp-2022-s108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/29/2022] [Indexed: 05/15/2023]
Abstract
Cerebral venous sinus thrombosis (CVT) consists of partial or complete occlusion of a sinus or a cerebral vein. CVT represents 0.5-1% of all strokes and is more frequent in young women. This review discusses particular aspects of CVT diagnosis and management: decompressive craniectomy (DC), anticoagulation with direct oral anticoagulants (DOACs), CVT after coronavirus-disease 19 (COVID-19) and Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT).
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Affiliation(s)
| | - Adriana Bastos Conforto
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brazil
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14
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Kalita J, Sachan A, Dubey AK, Jain N, Kumar S. A clinico-radiological study of deep cerebral venous thrombosis. Neuroradiology 2022; 64:1951-1960. [DOI: 10.1007/s00234-022-02938-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 03/25/2022] [Indexed: 11/25/2022]
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15
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Ng EMC, Othman O, Chan LY, Bahari NA. Cavernous Sinus Thrombosis and Blindness Complicating Dental Infection. Cureus 2022; 14:e21318. [PMID: 35186577 PMCID: PMC8848634 DOI: 10.7759/cureus.21318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2022] [Indexed: 12/04/2022] Open
Abstract
A 32-year-old gentleman with underlying hypertension presented with left eye ptosis and diplopia for two weeks. He also complained of the left eye progressive blurring of vision. One week of left-sided toothache, headache, and fever preceded these symptoms. He visited a dental clinic for the toothache and was prescribed oral metronidazole before scheduling tooth extraction. However, the disease progressed with ocular symptoms. On examination, his visual acuity was 20/20 on the right and perception to light on the left. The left eye pupil was sluggish, and relative afferent pupillary reflex was positive. There was partial ptosis, mild proptosis, and ophthalmoplegia involving cranial nerve III, IV, and VI over the left. Hypoesthesia over the left V1 region was also present. Bilateral anterior and posterior segments were unremarkable. Blood investigations revealed an elevated total white cell count and C- reactive protein. Hence, an urgent computed tomography of the brain was requested and demonstrated left cavernous sinus thrombosis with diffuse thickening and enhancement extended anteriorly to the left orbital apex. He was admitted for intravenous ceftriaxone and subcutaneous enoxaparin. He was hemodynamically stable and allowed home with new direct anti-coagulants. He sustained the permanent sequelae of a left blind eye and residual cranial nerve palsies despite the treatment.
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Abstract
BACKGROUND Stroke is the third leading cause of early death worldwide. Most ischaemic strokes are caused by a blood clot blocking an artery in the brain. Patient outcomes might be improved if they are offered anticoagulants that reduce their risk of developing new blood clots and do not increase the risk of bleeding. This is an update of a Cochrane Review first published in 1995, with updates in 2004, 2008, and 2015. OBJECTIVES To assess the effectiveness and safety of early anticoagulation (within the first 14 days of onset) for people with acute presumed or confirmed ischaemic stroke. Our hypotheses were that, compared with a policy of avoiding their use, early anticoagulation would be associated with: • reduced risk of death or dependence in activities of daily living a few months after stroke onset; • reduced risk of early recurrent ischaemic stroke; • increased risk of symptomatic intracranial and extracranial haemorrhage; and • reduced risk of deep vein thrombosis and pulmonary embolism. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (August 2021); the Cochrane Database of Systematic Reviews (CDSR); the Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 7), in the Cochrane Library (searched 5 August 2021); MEDLINE (2014 to 5 August 2021); and Embase (2014 to 5 August 2021). In addition, we searched ongoing trials registries and reference lists of relevant papers. For previous versions of this review, we searched the register of the Antithrombotic Trialists' (ATT) Collaboration, consulted MedStrategy (1995), and contacted relevant drug companies. SELECTION CRITERIA Randomised trials comparing early anticoagulant therapy (started within two weeks of stroke onset) with control in people with acute presumed or confirmed ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion, assessed trial quality, and extracted data. We assessed the overall certainty of the evidence for each outcome using RoB1 and GRADE methods. MAIN RESULTS We included 28 trials involving 24,025 participants. Quality of the trials varied considerably. We considered some studies to be at unclear or high risk of selection, performance, detection, attrition, or reporting bias. Anticoagulants tested were standard unfractionated heparin, low-molecular-weight heparins, heparinoids, oral anticoagulants, and thrombin inhibitors. Over 90% of the evidence is related to effects of anticoagulant therapy initiated within the first 48 hours of onset. No evidence suggests that early anticoagulation reduced the odds of death or dependence at the end of follow-up (odds ratio (OR) 0.98, 95% confidence interval (CI) 0.92 to 1.03; 12 RCTs, 22,428 participants; high-certainty evidence). Similarly, we found no evidence suggesting that anticoagulant therapy started within the first 14 days of stroke onset reduced the odds of death from all causes (OR 0.99, 95% CI 0.90 to 1.09; 22 RCTs, 22,602 participants; low-certainty evidence) during the treatment period. Although early anticoagulant therapy was associated with fewer recurrent ischaemic strokes (OR 0.75, 95% CI 0.65 to 0.88; 12 RCTs, 21,665 participants; moderate-certainty evidence), it was also associated with an increase in symptomatic intracranial haemorrhage (OR 2.47; 95% CI 1.90 to 3.21; 20 RCTs, 23,221 participants; moderate-certainty evidence). Similarly, early anticoagulation reduced the frequency of symptomatic pulmonary emboli (OR 0.60, 95% CI 0.44 to 0.81; 14 RCTs, 22,544 participants; high-certainty evidence), but this benefit was offset by an increase in extracranial haemorrhage (OR 2.99, 95% CI 2.24 to 3.99; 18 RCTs, 22,255 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS Since the last version of this review, four new relevant studies have been published, and conclusions remain consistent. People who have early anticoagulant therapy after acute ischaemic stroke do not demonstrate any net short- or long-term benefit. Treatment with anticoagulants reduced recurrent stroke, deep vein thrombosis, and pulmonary embolism but increased bleeding risk. Data do not support the routine use of any of the currently available anticoagulants for acute ischaemic stroke.
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Affiliation(s)
- Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Menglu Ouyang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Jie Yang
- Department of Neurology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Lili Song
- The George Institute China at Peking University Health Science Center, Beijing, China
| | - Min Yang
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- The George Institute China at Peking University Health Science Center, Beijing, China
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Just the facts: how to assess for cerebral venous thrombosis. CAN J EMERG MED 2021; 23:744-745. [PMID: 34427894 PMCID: PMC8383727 DOI: 10.1007/s43678-021-00194-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/05/2021] [Indexed: 11/08/2022]
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Jianu DC, Jianu SN, Dan TF, Iacob N, Munteanu G, Motoc AGM, Băloi A, Hodorogea D, Axelerad AD, Pleș H, Petrica L, Gogu AE. Diagnosis and Management of Mixed Transcortical Aphasia Due to Multiple Predisposing Factors, including Postpartum and Severe Inherited Thrombophilia, Affecting Multiple Cerebral Venous and Dural Sinus Thrombosis: Case Report and Literature Review. Diagnostics (Basel) 2021; 11:1425. [PMID: 34441359 PMCID: PMC8394489 DOI: 10.3390/diagnostics11081425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/04/2021] [Accepted: 08/04/2021] [Indexed: 11/24/2022] Open
Abstract
Cerebral venous and dural sinus thrombosis (CVT) is an uncommon disease in the general population, although it is a significant stroke type throughout pregnancy and the puerperium. Studies describing this subtype of CVT are limited. Most pregnancy-associated CVT happen in late pregnancy, or more commonly in the first postpartum weeks, being associated with venous thrombosis outside the nervous system. Case presentation: The current study describes a case of multiple CVT in a 38-year-old woman with multiple risk factors (including severe inherited thrombophilia and being in the puerperium period), presenting mixed transcortical aphasia (a rare type of aphasia) associated with right moderate hemiparesis and intracranial hypertension. The clinical diagnosis of CVT was confirmed by laboratory data and neuroimaging data from head computed tomography, magnetic resonance imaging, and magnetic resonance venography. She was successfully treated with low-molecular-weight heparin (anticoagulation) and osmotic diuretics (mannitol) for increased intracranial pressure and cerebral edema. At discharge, after 15 days of evolution, she presented a partial recovery, with anomic plus aphasia and mild right hemiparesis. Clinical and imaging follow-up was performed at 6 months after discharge; our patient presented normal language and mild right central facial paresis, with chronic left thalamic, caudate nucleus, and internal capsule infarcts and a partial recanalization of the dural sinuses.
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Affiliation(s)
- Dragoș Cătălin Jianu
- Department of Neurology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (D.C.J.); (A.E.G.)
- Centre for Cognitive Research in Neuropsychiatric Pathology (NeuroPsy-Cog), “Victor Babeș” University of Medicine and Pharmacy, 300736 Timișoara, Romania; (H.P.); (L.P.)
- First Department of Neurology, “Pius Brînzeu” Emergency County Hospital, 300736 Timișoara, Romania;
| | - Silviana Nina Jianu
- Department of Ophthalmology, “Dr. Victor Popescu” Military Emergency Hospital, 300080 Timișoara, Romania;
| | - Traian Flavius Dan
- Department of Neurology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (D.C.J.); (A.E.G.)
- Centre for Cognitive Research in Neuropsychiatric Pathology (NeuroPsy-Cog), “Victor Babeș” University of Medicine and Pharmacy, 300736 Timișoara, Romania; (H.P.); (L.P.)
- First Department of Neurology, “Pius Brînzeu” Emergency County Hospital, 300736 Timișoara, Romania;
| | - Nicoleta Iacob
- Neuromed Diagnostic Imaging Centre, Department of Multidetector Computed Tomography and Magnetic Resonance Imaging, 300218 Timișoara, Romania;
| | - Georgiana Munteanu
- Department of Neurology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (D.C.J.); (A.E.G.)
- Centre for Cognitive Research in Neuropsychiatric Pathology (NeuroPsy-Cog), “Victor Babeș” University of Medicine and Pharmacy, 300736 Timișoara, Romania; (H.P.); (L.P.)
- First Department of Neurology, “Pius Brînzeu” Emergency County Hospital, 300736 Timișoara, Romania;
| | - Andrei Gheorghe Marius Motoc
- Centre for Cognitive Research in Neuropsychiatric Pathology (NeuroPsy-Cog), “Victor Babeș” University of Medicine and Pharmacy, 300736 Timișoara, Romania; (H.P.); (L.P.)
- Department of Anatomy and Embryology, “Victor Babeş” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Adelina Băloi
- Department of Anaesthesia and Intensive Care, “Pius Brînzeu” Emergency County Hospital, 300736 Timișoara, Romania;
| | - Daniela Hodorogea
- First Department of Neurology, “Pius Brînzeu” Emergency County Hospital, 300736 Timișoara, Romania;
| | - Any Docu Axelerad
- Department of Neurology, General Medicine Faculty, Ovidius University, 900470 Constanța, Romania;
| | - Horia Pleș
- Centre for Cognitive Research in Neuropsychiatric Pathology (NeuroPsy-Cog), “Victor Babeș” University of Medicine and Pharmacy, 300736 Timișoara, Romania; (H.P.); (L.P.)
- Department of Neurosurgery, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Ligia Petrica
- Centre for Cognitive Research in Neuropsychiatric Pathology (NeuroPsy-Cog), “Victor Babeș” University of Medicine and Pharmacy, 300736 Timișoara, Romania; (H.P.); (L.P.)
- Department of Internal Medicine II, Division of Nephrology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Anca Elena Gogu
- Department of Neurology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (D.C.J.); (A.E.G.)
- Centre for Cognitive Research in Neuropsychiatric Pathology (NeuroPsy-Cog), “Victor Babeș” University of Medicine and Pharmacy, 300736 Timișoara, Romania; (H.P.); (L.P.)
- First Department of Neurology, “Pius Brînzeu” Emergency County Hospital, 300736 Timișoara, Romania;
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Patiño Arboleda M, Muñoz JF, Ocampo JM, Calzada MT, Cárdenas Prieto JM. Trombosis bilateral del seno cavernoso en un paciente con enfermedad periodontal y diabetes mellitus. descripción de un caso. DUAZARY 2021. [DOI: 10.21676/2389783x.4239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
La trombosis de los senos cavernosos (TSC) corresponde a una entidad vascular poco usual, asociada con alta morbimortalidad y secuelas neurológicas. La etiología más frecuente son los procesos infecciosos a nivel de cabeza y cuello, que sirven como puerta de entrada para diferentes microorganismos, generando una respuesta inflamatoria que desencadena el evento trombótico. La enfermedad periodontal caracterizada por inflamación gingival, pérdida de tejido conectivo circundante y eventual del diente está asociada con el desarrollo de enfermedades sistémicas secundarias a los patógenos periodontales y mediadores inflamatorios producidos en la cavidad oral. Estos pueden diseminarse y producir complicaciones por contigüidad como eventos trombóticos a nivel del sistema nervioso central. A continuación, se presenta el caso clínico de un paciente que desarrolló una TSC bilateral después de ser sometido a un procedimiento periodontal.
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Digge P, Prakashini K, Bharath KV. Plain CT vs MR venography in acute cerebral venous sinus thrombosis: Triumphant dark horse. Indian J Radiol Imaging 2021; 28:280-284. [PMID: 30319203 PMCID: PMC6176664 DOI: 10.4103/ijri.ijri_328_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context Most patients with cerebral venous sinus thrombosis (CVST) present with nonspecific signs and symptoms and are likely to undergo nonenhanced head computed tomography (NCT) at presentation, which may show a normal report in up to two-thirds of patients. However, in case of acute thrombosis, sensitivity of diagnosing CVST is high as sinuses are hyperdense. Though magnetic resonance imaging (MRI) is considered the imaging modality of choice for diagnosing CVST, it is not universally available in an acute setting. Aims To evaluate whether increased attenuation in cerebral venous sinuses in acute condition can be used to diagnose acute CVST and to determine its diagnostic value. Materials and Methods The study involves two independent groups. One group of patients with sinus thrombosis were confirmed by MR venography (group A). The other group included patients without sinus thrombosis (group B). The HU (CT attenuation), hemoglobin (HGB), hematocrit (HCT), and H: H (HU: HCT) ratio of both groups were compared. Thirty-six patients (59 thrombotic sinuses) were studied in group A and 40 in group B. Statistical Analysis Average HU and H: H ratio were compared using two-tailed t-test, and linear regression analysis was used to assess correlation between HCT and HU. Results Average HU (73.7 vs 48.6) and H: H ratio values were higher in group A patients compared to group B (P < 0.05). Linear regression analysis showed positive correlation between HGB and HCT with HU among both the groups (P < 0.05). Conclusions Our study demonstrates that acute CVST can be diagnosed using HU values in NCT.
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Affiliation(s)
- Poornima Digge
- Department of Radio-Diagnosis, Pramukhswami Medical College, Karamsad, Gujarat, India
| | - Koteshwar Prakashini
- Department of Radio-Diagnosis, Kasturba Medical College (KMC), Manipal, Karnataka, India
| | - K V Bharath
- Department of Anaesthesia and Critical Care, Kasturba Medical College (KMC), Manipal, Karnataka, India
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KAVAK S, BATMAZ İ, ŞENOCAK A, HALİSÇELİK M, GÜL Y, ŞANLI C, BULU G, ÇİM B, ÇELİK KAVAK E. Cerebral Vein Sinus Thrombosis in Obstetrics and Gynecology Practice. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2021. [DOI: 10.17517/ksutfd.934151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Amaç. Serebral Ven Sinüs Trombozu (SVST) çok çeşitli ve nonspesifik semptomlarla kendini gösteren ve farklı etiyolojilere bağlı olarak ortaya çıkan klinik bir durumdur. Tanısı kolayca konulamayan nadir bir hastalıktır. SVST gelişen olgularda, jinekolojik ve obstetrik nedenlerin araştırılmasını amaçladık.
Gereç ve Yöntemler. Fırat Üniversitesi Tıp Fakültesi Hastanesi’ne Kasım 2010 ile Kasım 2020 tarihleri arasında nörolojik şikayetlerle başvuran, yapılan değerlendirmede SVST tanısı konulan olgular ile obstetrik/jinekolojik nedenlerle SVST gelişen kadınlar, retrospektif olarak incelendi. Kadınların başvuru şikâyetleri, nöroradyolojik bulguları ve uygulanan tedaviler kayıtlardan tespit edildi. Verilerin değerlendirmesinde tanımlayıcı istatistik kullanıldı.
Bulgular. Çalışmanın yapıldığı dönemde 166 olguya SVST tanısı konuldu. Olguların 105’i kadın (% 63,2) ve 61’i erkek (% 36,8) idi. 15 olguda (% 9) obstetrik ve jinekolojik nedenlere sekonder SVST geliştiği tespit edildi. En sık semptom baş ağrısı (%80) ve en sık bulgu papil ödemi (%20) ile birlikte hemiparezi (%13,3) ve hemipleji (%6,7) olarak tespit edildi. Çalışmaya dâhil edilen altı olgu (%40) puerperal dönemde idi. Bunlardan iki olgu (%13,3) vaginal yolla, dört olgu (%26,7) ise sezaryenle doğum yapmıştı. Olgulardan beş tanesi (%33,3) gebe idi. Gebelerin tamamı gebeliğin 3. trimesterinde bulunuyordu. Bir olguda (%6,7) mastoidit geliştiği ve 4 ay öncesinde vaginal yolla doğum yaptığı tespit edildi. Bir olgunun puerperal dönemde olduğu ve eşlik eden sinüzit enfeksiyonu bulunduğu (%6,7), ayrıca aile öyküsünde postpartum derin trombozu varlığı tespit edildi. İki olgunun (% 13,3) kombine oral kontraseptif (OKS) kullandığı, bunlardan birinde MTHFR homozigot mutasyon varlığı ve homosistein yüksekliği tespit edildi. Olguların tamamı değerlendirildiğinde 7 olguda (%46,7) kalıtsal trombofili tanısı mevcuttu.
Sonuç. SVST olgularında gebelik, puerperal dönem ve OKS kullanımı başta olmak üzere, obstetrik ve jinekolojik nedenler %10’a yakın yer tutar ve değerlendirme sırasında göz önünde bulundurulmalıdır.
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Affiliation(s)
| | | | | | | | - Yeliz GÜL
- UNIVERSITY OF HEALTH SCIENCES, ELAZIĞ HEALTH RESEARCH CENTER
| | - Cengiz ŞANLI
- UNIVERSITY OF HEALTH SCIENCES, ELAZIĞ HEALTH RESEARCH CENTER
| | - Gülay BULU
- UNIVERSITY OF HEALTH SCIENCES, ELAZIĞ HEALTH RESEARCH CENTER
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Abuserewa ST, Duff R. Transverse Sinus Thrombosis Secondary to Internal Jugular Vein Abnormalities. Cureus 2021; 13:e15747. [PMID: 34285853 PMCID: PMC8286797 DOI: 10.7759/cureus.15747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2021] [Indexed: 12/03/2022] Open
Abstract
Cerebral sinus venous thrombosis (CSVT) is a rare disorder that presents with highly variable neurological manifestations ranging from headache, confusion, seizures, coma to stroke-like symptoms. It predominantly affects young adults and children, with female predilection. We are presenting a case of 59-year-old female with left-sided transverse and sigmoid sinus thrombosis most likely secondary to dehydration on top of chronically diminutive left transverse sinus and internal jugular vein.
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Affiliation(s)
| | - Richard Duff
- Pulmonary and Critical Care Medicine, Grand Strand Medical Center, Myrtle Beach, USA
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Nessle CN, Rivas-Rodriguez F, Weyand AC. Catastrophic cerebral sinovenous thrombosis with haemorrhagic conversion in a new diagnosis of paediatric acute myelogenous leukaemia. BMJ Case Rep 2021; 14:14/6/e242873. [PMID: 34099452 DOI: 10.1136/bcr-2021-242873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- C Nathan Nessle
- Pediatric Hematology Oncology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Francisco Rivas-Rodriguez
- Radiology, Division of Neuroradiology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Angela C Weyand
- Pediatric Hematology Oncology, University of Michigan Hospital, Ann Arbor, Michigan, USA
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Safety and efficacy of rivaroxaban in pediatric cerebral venous thrombosis (EINSTEIN-Jr CVT). Blood Adv 2021; 4:6250-6258. [PMID: 33351120 DOI: 10.1182/bloodadvances.2020003244] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/20/2020] [Indexed: 11/20/2022] Open
Abstract
Anticoagulant treatment of pediatric cerebral venous thrombosis has not been evaluated in randomized trials. We evaluated the safety and efficacy of rivaroxaban and standard anticoagulants in the predefined subgroup of children with cerebral venous thrombosis (CVT) who participated in the EINSTEIN-Jr trial. Children with CVT were randomized (2:1), after initial heparinization, to treatment with rivaroxaban or standard anticoagulants (continued on heparin or switched to vitamin K antagonist). The main treatment period was 3 months. The primary efficacy outcome, symptomatic recurrent venous thromboembolism (VTE), and principal safety outcome, major or clinically relevant nonmajor bleeding,were centrally evaluated by blinded investigators. Sinus recanalization on repeat brain imaging was a secondary outcome. Statistical analyses were exploratory. In total, 114 children with confirmed CVT were randomized. All children completed the follow-up. None of the 73 rivaroxaban recipients and 1 (2.4%; CVT) of the 41 standard anticoagulant recipients had symptomatic, recurrent VTE after 3 months (absolute difference, 2.4%; 95% confidence interval [CI], -2.6% to 13.5%). Clinically relevant bleeding occurred in 5 (6.8%; all nonmajor and noncerebral) rivaroxaban recipients and in 1 (2.5%; major [subdural] bleeding) standard anticoagulant recipient (absolute difference, 4.4%; 95% CI, -6.7% to 13.4%). Complete or partial sinus recanalization occurred in 18 (25%) and 39 (53%) rivaroxaban recipients and in 6 (15%) and 24 (59%) standard anticoagulant recipients, respectively. In summary, in this substudy of a randomized trial with a limited sample size, children with CVT treated with rivaroxaban or standard anticoagulation had a low risk of recurrent VTE and clinically relevant bleeding. This trial was registered at clinicaltrials.gov as #NCT02234843.
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Dubey AK, Kalita J, Chaudhary SK, Misra UK. Impact of anticoagulation status on recanalization and outcome of cerebral venous thrombosis. J Clin Neurosci 2021; 89:43-50. [PMID: 34119293 DOI: 10.1016/j.jocn.2021.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/23/2021] [Accepted: 04/17/2021] [Indexed: 11/26/2022]
Abstract
Effective anticoagulation status may determine the recanalization and outcome of cerebral venous thrombosis (CVT). We report impact of anticoagulation status on recanalization and outcome of CVT. This is a retrospective study on 126 patients with CVT diagnosed on magnetic resonance venography (MRV). Their clinical features and risk factors were noted. The data were retrieved from a prospectively maintained registry, and international normalized ratio (INR) was noted after discharge till 3 months. All the patients were on acenocoumarol. Based on INR value, patients were categorized as Group A (effective anticoagulation INR within the therapeutic range or above) and Group B (ineffective anticoagulation INR > 50% below the therapeutic range). A repeat MRV at 3 months was done for recanalization. Outcome at 3 months was evaluated using modified Rankin Scale (mRS), and categorized as good (mRS ≤ 2) and poor (mRS 2 or more) 101(80.2%) patients were in group A and 25(19.8%) in group B. Their demographic, risk factors, magnetic resonance imaging (MRI) and MRV findings were comparable. On repeat MRV, recanalization occurred in 22/24(91.7%); 15(88%) in group A and 7(100%) in group B. Recanalization was independent of coagulation status. Seven (5.6%) patients died and 107(84.9%) had good outcome; 85(84.2%) in group A and 22(88%) in group B. Kaplan Meier analysis also did not reveal survival or good outcome benefits between the groups. In CVT, outcome and recanalization at 3 months are not dependent on coagulation status. Further prospective studies are needed regarding duration of anticoagulant and its impact on recanalization and outcome.
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Affiliation(s)
- Ashish K Dubey
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow, Uttar Pradesh 226014, India
| | - Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow, Uttar Pradesh 226014, India.
| | - Sarvesh K Chaudhary
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow, Uttar Pradesh 226014, India
| | - Usha K Misra
- Apollo Medics Super-specialty Hospitals and Senior consultant neurologist, Vivekanand Polyclinic, and Institute of Medical science, Lucknow 226001, India
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Rakhra A, Kiefer LE, Busireddy KR, Sankaraneni R. Cerebral Venous Sinus Thrombosis in an Immunocompetent HIV Patient. Cureus 2021; 13:e13694. [PMID: 33833915 PMCID: PMC8019322 DOI: 10.7759/cureus.13694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 11/05/2022] Open
Abstract
Cerebral venous sinus thrombosis (CVST) is an uncommon manifestation in patients with the human immunodeficiency virus (HIV) due to the virus's prothrombotic state. Our case involves a 41-year-old Hispanic male with a past medical history of HIV on bictegravir/emtricitabine/tenofovir/alafenamide (Biktarvy), hyperlipidemia, post-traumatic stress disorder, hypogonadism with the cessation of testosterone injections one month prior, and generalized anxiety disorder who presented with retro-orbital headache, intermittent bilateral blurry vision, and flashing lights in the lower lateral left eye for one week. Vitals signs and laboratory studies were within normal limits aside from new iron deficiency anemia. Neurological exam was unremarkable. Computed tomography (CT) of the head showed evidence of a subacute cerebral infarct with hemorrhagic transformation in the right superior parietal lobe. Magnetic resonance imaging (MRI) of the brain with contrast revealed a small thrombosed cortical vein with surrounding hemorrhage and edema in the same location, in addition to a partial thrombosis of the adjacent superior sagittal sinus, which was confirmed by magnetic resonance venogram (MRV). Although cerebral angiography was performed, no intervention was attempted for the partially occluded sagittal sinus. HIV viral load was undetectable with a robust cluster of differentiation (CD) 4 count on therapy. The patient was treated with strict blood pressure control, a statin, and a heparin drip. He remained stable and was discharged on enoxaparin injections with bridging to warfarin. In summary, appropriate lab testing, imaging, and high clinical suspicion are required for proper diagnosis and treatment of venous thromboembolism (VTE) or CVST in an HIV-positive patient.
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Affiliation(s)
- Amandeep Rakhra
- Internal Medicine, Creighton University School of Medicine, Omaha, USA
| | - Luke E Kiefer
- Neurology, Creighton University School of Medicine, Omaha, USA
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Bose G, Graveline J, Yogendrakumar V, Shorr R, Fergusson DA, Le Gal G, Coutinho J, Mendonça M, Viana-Baptista M, Nagel S, Dowlatshahi D. Direct oral anticoagulants in treatment of cerebral venous thrombosis: a systematic review. BMJ Open 2021; 11:e040212. [PMID: 33593766 PMCID: PMC7888326 DOI: 10.1136/bmjopen-2020-040212] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Current guidelines do not recommend direct oral anticoagulants (DOACs) to treat cerebral venous thrombosis (CVT) despite their benefits over standard therapy. We performed a systematic review to summarise the published experience of DOAC therapy in CVT. DATA SOURCES MEDLINE, Embase and COCHRANE databases up to 18 November 2020. ELIGIBILITY CRITERIA All published articles of patients with CVT treated with DOAC were included. Studies without follow-up information were excluded. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened articles and extracted data. A risk of bias analysis was performed. PRIMARY AND SECONDARY OUTCOME MEASURES Safety data included mortality, intracranial haemorrhage (ICH) or other adverse events. Efficacy data included recurrent CVT, recanalisation rates and disability by modified Rankin Scales (mRS). RESULTS 33 studies met inclusion criteria. One randomised controlled trial, 5 observational cohorts and 27 case series or studies reported 279 patients treated with DOAC for CVT: 41% dabigatran, 47% rivaroxaban, 10% apixaban and 2% edoxaban, in addition to 315 patients treated with standard therapy. The observational cohorts showed a similar risk of death in DOAC and standard therapy arms (RR 2.12, 95% CI 0.29 to 15.59). New ICH was reported in 2 (0.7%) DOAC-treated patients and recurrent CVT occurred in 4 (1.5%). A favourable mRS between 0 and 2 was reported in 94% of DOAC-treated patients, more likely than standard therapy in observational cohorts (RR 1.13, 95% CI 1.02 to 1.25). CONCLUSION The evidence for DOAC use in CVT is limited although suggests sufficient safety and efficacy despite variability in timing and dose of treatment. This systematic review highlights that further rigorous trials are needed to validate these findings and to determine optimal treatment regimens.
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Affiliation(s)
- Gauruv Bose
- Department of Medicine, University of Ottawa and The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Justin Graveline
- Department of Medicine, University of Ottawa and The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Vignan Yogendrakumar
- Department of Medicine, University of Ottawa and The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Risa Shorr
- Department of Medicine, University of Ottawa and The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Department of Medicine, University of Ottawa and The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Gregoire Le Gal
- Department of Medicine, University of Ottawa and The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jonathan Coutinho
- Department of Neurology, University Medical Center, Amsterdam, The Netherlands
| | - Marcelo Mendonça
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, NOVA Medical School, NMS, Universidade Nova de Lisboa, Champalimaud Research, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Miguel Viana-Baptista
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, NOVA Medical School, NMS, Universidade Nova de Lisboa, Champalimaud Research, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Simon Nagel
- Department of Neurology, University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa and The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Wong AK, Wong RH. Successful treatment of superior sagittal sinus thrombosis after translabyrinthine resection of metastatic neuroendocrine tumor: A case report and review of literature. Surg Neurol Int 2020; 11:410. [PMID: 33365173 PMCID: PMC7749965 DOI: 10.25259/sni_656_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/07/2020] [Indexed: 11/09/2022] Open
Abstract
Background: Postoperative cerebral venous sinus thrombosis (pCVST) after resection of cerebellopontine angle and posterior fossa tumor resections occur almost exclusively in the lateral venous sinuses and are generally asymptomatic. Thrombus extension and involvement of the superior sagittal sinus (SSS) – a serious and potentially devastating complication – are rarely described and, as such, successful treatment for which is still poorly understood. We report a case of pCVST involving the SSS after translabyrinthine approach for resection of a metastatic neuroendocrine tumor (NET), and the first that was successfully treated with anticoagulation therapy. Case Description: A 40-year-old man presented with headaches, diminished right-sided hearing, and ataxia was found to have a large right-sided cerebellopontine angle (CPA) lesion with extra-axial and possible intraparenchymal invasion. A retrosigmoid craniotomy for debulking and diagnosis was undertaken. Postoperative imaging revealed patent venous sinuses. Pathology confirmed NET. Further imaging revealed a likely pancreatic primary lesion. The patient then underwent subsequent translabyrinthine approach for definitive surgical resection. Postoperative imaging again revealed patent venous sinuses. The patient subsequently developed headaches on postoperative day 10 and was found to have pCVST involving the ipsilateral internal jugular to the SSS. The patient was started on therapeutic heparin with significant improvement in pCVST and symptoms. Conclusion: Extensive pCVST involving the SSS after CPA and posterior fossa tumor resections is extremely rare. Initial management with anticoagulation can yield promising results and should be initiated early in the clinical course unless otherwise contraindicated.
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Affiliation(s)
- Andrew K Wong
- Department of Neurosurgery, Rush University Medical Center, Chicago, United States
| | - Ricky H Wong
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, United States
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29
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Deliran SS, Brouwer MC, Coutinho JM, van de Beek D. Bacterial meningitis complicated by cerebral venous thrombosis. Eur Stroke J 2020; 5:394-401. [PMID: 33598558 PMCID: PMC7856580 DOI: 10.1177/2396987320971112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/09/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Community-acquired bacterial meningitis may be complicated by cerebral venous thrombosis (CVT), but this has not systematically been studied. Methods We evaluated clinical characteristics and outcome of CVT in adults with community-acquired bacterial meningitis in a prospective nationwide cohort study of bacterial meningitis (2006–2018) in the Netherlands. Results CVT occurred in 26 of 2220 episodes with bacterial meningitis (1%). The diagnosis of CVT was made on the day of presentation in 15 patients (58%) and during hospital stay in 11 patients after a median of 6 days (IQR 2–7). Sinusitis or otitis was present in 16 of 24 patients (67%). Patients with CVT presented more often in a coma than those without CVT (53 vs. 18%; P = 0.001) and the clinical course was more often complicated by focal neurologic deficits (58 vs. 22%; P < 0.001). Twelve patients of 26 (46%) had parenchymal lesions on neuroimaging, of whom two (8%) were specific for CVT. The transverse sinus was most frequently thrombosed (18 of 26; 69%). Streptococcus pneumoniae was the most common causative pathogen, occurring in 17 of 26 patients (65%). Eleven patients (44%) received anticoagulant therapy with heparin and none of them developed intracerebral hemorrhage during admission. Unfavorable outcome, as defined as a score on the Glasgow Outcome Scale <5, occurred in 14 of 26 patients (54%) and 4 patients (15%) died. Discussion and conclusion CVT is a rare complication of bacterial meningitis and mainly occurs in patients with coma, ear, nose and throat infections, and focal neurologic deficits.
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Affiliation(s)
- Shahrzad S Deliran
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Matthijs C Brouwer
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Diederik van de Beek
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
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Spontaneous Epidural Hematomas due to Cerebral Venous Thrombosis in a Patient with Immune Thrombocytopenic Purpura. J Stroke Cerebrovasc Dis 2020; 29:105244. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105244] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/06/2020] [Accepted: 08/08/2020] [Indexed: 11/17/2022] Open
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31
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Kaufmann MR, Camilon PR, Levi JR, Devaiah AK. Predicting Anticoagulation Need for Otogenic Intracranial Sinus Thrombosis: A Machine Learning Approach. J Neurol Surg B Skull Base 2020; 82:233-243. [PMID: 33777638 DOI: 10.1055/s-0040-1713105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/15/2020] [Indexed: 10/23/2022] Open
Abstract
Objective The role of anticoagulation (AC) in the management of otogenic cerebral venous sinus thrombosis (OCVST) remains controversial. Our study aims to better define when AC is used in OCVST. Methods MEDLINE, EMBASE, and The Cochrane Library were searched from inception to February 14, 2019 for English and English-translated articles. References cited in publications meeting search criteria were searched. Titles and abstracts were screened and identified in the literature search, assessing baseline risk of bias on extracted data with the methodological index for nonrandomized studies (MINORS) scale. Random effects meta-regression followed by random forest machine learning analysis across 16 moderator variables between AC and nonanticoagulated (NAC) cohorts was conducted. Results A total of 92% of treated patients were free of neurologic symptoms at the last follow-up (mean 29.64 months). Four percent of AC and 14% of NAC patients remained symptomatic (mean 18.72 and 47.10 months). 3.5% of AC patients experienced postoperative wound hematomas. AC and NAC recanalization rates were 81% (34/42) and 63% (five-eights), respectively. OCVST was correlated with cholesteatoma and intracranial abscess. Among the analyzed covariates, intracranial abscess was most predictive of AC and cholesteatoma was most predictive of NAC. Comorbid intracranial abscess and cholesteatoma were predictive of AC. Conclusion The present study is the first to utilize machine learning algorithms in approaching OCVST. Our findings support the therapeutic use of AC in the management of OCVST when complicated by thrombophilia, intracranial abscess, and cholesteatoma. Patients with intracranial abscess and cholesteatoma may benefit from AC and surgery. Patients with cholesteatoma can be managed with NAC and surgery.
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Affiliation(s)
- Matthew R Kaufmann
- Boston University School of Medicine, Boston, Massachusetts, United States
| | - Philip Ryan Camilon
- Boston University School of Medicine, Boston, Massachusetts, United States.,Department of Otolaryngology, Boston University, Boston, Massachusetts, United States
| | - Jessica R Levi
- Boston University School of Medicine, Boston, Massachusetts, United States.,Department of Otolaryngology, Boston University, Boston, Massachusetts, United States
| | - Anand K Devaiah
- Boston University School of Medicine, Boston, Massachusetts, United States.,Department of Otolaryngology, Boston University, Boston, Massachusetts, United States.,Department of Neurological Surgery and Ophthalmology, Boston, Massachusetts, United States.,Institute for Health System Innovation and Policy, Boston University, Boston, Massachusetts, United States
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32
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Idiculla PS, Gurala D, Palanisamy M, Vijayakumar R, Dhandapani S, Nagarajan E. Cerebral Venous Thrombosis: A Comprehensive Review. Eur Neurol 2020; 83:369-379. [PMID: 32877892 DOI: 10.1159/000509802] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 06/27/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cerebral sinus venous thrombosis (CSVT) is a relatively rare, potentially fatal neurological condition that can be frequently overlooked due to the vague nature of its clinical and radiological presentation. A literature search on PubMed using the keyword "Cerebral sinus venous thrombosis" was performed. We searched for the epidemiology, risk factors, pathophysiology, clinical features, diagnosis, and treatment of CSVT. All full-text articles in the last 10 years, in adults (>18 years), and the English language were included. We aim to give a comprehensive review of CSVT, with a primary focus on the management of the disease. SUMMARY The literature search revealed 404 articles that met our criteria. CSVT is a relatively rare condition that accounts for approximately 1% of all forms of stroke. They can be subdivided into acute, subacute, and chronic forms based on the time of onset of clinical symptoms. It is a multifactorial disease, and the major forms of clinical presentation include isolated intracranial hypertension syndrome, focal neurological deficits, and cavernous sinus syndrome. MRI with magnetic resonance venogram (MRV) is considered the gold standard for diagnosis. Anticoagulation with heparin or low-molecular-weight heparin is the mainstay of treatment. Endovascular management is indicated for those cases with severe symptoms or worsening of symptoms despite anticoagulation therapy. Favorable outcomes have been reported in patients who receive early diagnosis and treatment. CONCLUSION CSVT is a potentially fatal neurological condition that is often under-diagnosed due to its nonspecific presentation. Timely diagnosis and treatment can reduce morbidity and mortality, remarkably improving the outcome in affected individuals.
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Affiliation(s)
| | - Dhineshreddy Gurala
- Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
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33
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Gradenigo's Syndrome with Carotid Septic Stenosis. Case Rep Otolaryngol 2020; 2020:9439184. [PMID: 32148988 PMCID: PMC7053453 DOI: 10.1155/2020/9439184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 02/04/2020] [Indexed: 11/17/2022] Open
Abstract
Gradenigo's syndrome was firstly described in 1907 by Giusseppe Gradenigo and is defined as the clinical triad of suppurative otitis media, ipsilateral abducens nerve palsy, and pain in the distribution of the first and the second branches of the trigeminal nerve. Since the advent of antibiotics, the incidence of this potentially life-threatening complication has diminished, but occasional cases still occur. We herein report a pediatric case of otitis media associated with Gradenigo's syndrome complicated by ipsilateral septic cavernous sinus thrombosis and infectious arteritis of the internal carotid artery.
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34
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Riva N, Ageno W. Cerebral and Splanchnic Vein Thrombosis: Advances, Challenges, and Unanswered Questions. J Clin Med 2020; 9:E743. [PMID: 32164214 PMCID: PMC7141239 DOI: 10.3390/jcm9030743] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 03/03/2020] [Accepted: 03/08/2020] [Indexed: 02/07/2023] Open
Abstract
Cerebral vein thrombosis (CVT) and splanchnic vein thrombosis (SVT) are two manifestations of venous thromboembolism (VTE) at unusual sites. They have an incidence at least 25-50 times lower than usual site VTE, but represent true clinical challenges. Recent evidence on the epidemiology, risk factors, prognosis, and treatment of CVT and SVT has been published in the last two decades, thus contributing to a better understanding of these diseases. The improvement in imaging techniques and a higher degree of clinical suspicion may have led to the observed increased frequency, whereas a better knowledge of provoking mechanisms could have contributed to reducing the proportion of events classified as unprovoked or idiopathic (13%-21% of CVT, 15%-27% of SVT). Few small randomized clinical trials and a number of observational studies, although hampered by heterogeneous therapeutic approaches, shed light on the safety and effectiveness of anticoagulant therapy in these populations. However, there are still some grey areas that warrant future research. In this narrative review, we discuss recent advances and therapeutic challenges in CVT and SVT.
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Affiliation(s)
- Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida MSD2080, Malta;
- Department of Anatomy, Faculty of Medicine and Surgery, University of Malta, Msida MSD2080, Malta
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
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35
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Zuurbier SM, Hickman CR, Tolias CS, Rinkel LA, Leyrer R, Flemming KD, Bervini D, Lanzino G, Wityk RJ, Schneble HM, Sure U, Al-Shahi Salman R. Long-term antithrombotic therapy and risk of intracranial haemorrhage from cerebral cavernous malformations: a population-based cohort study, systematic review, and meta-analysis. Lancet Neurol 2019; 18:935-941. [PMID: 31401075 PMCID: PMC6744367 DOI: 10.1016/s1474-4422(19)30231-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 05/28/2019] [Accepted: 05/28/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Antithrombotic (anticoagulant or antiplatelet) therapy is withheld from some patients with cerebral cavernous malformations, because of uncertainty around the safety of these drugs in such patients. We aimed to establish whether antithrombotic therapy is associated with an increased risk of intracranial haemorrhage in adults with cerebral cavernous malformations. METHODS In this population-based, cohort study, we used data from the Scottish Audit of Intracranial Vascular Malformations, which prospectively identified individuals aged 16 years and older living in Scotland who were first diagnosed with a cerebral cavernous malformation during 1999-2003 or 2006-10. We compared the association between use of antithrombotic therapy after first presentation and the occurrence of intracranial haemorrhage or persistent or progressive focal neurological deficit due to the cerebral cavernous malformations during up to 15 years of prospective follow-up with multivariable Cox proportional hazards regression assessed in all individuals identified in the database. We also did a systematic review and meta-analysis, in which we searched Ovid MEDLINE and Embase from database inception to Feb 1, 2019, to identify comparative studies to calculate the intracranial haemorrhage incidence rate ratio according to antithrombotic therapy use. We then generated a pooled estimate using the inverse variance method and a random effects model. FINDINGS We assessed 300 of 306 individuals with a cerebral cavernous malformation who were eligible for study. 61 used antithrombotic therapy (ten [16%] of 61 used anticoagulation) for a mean duration of 7·4 years (SD 5·4) during follow-up. Antithrombotic therapy use was associated with a lower risk of subsequent intracranial haemorrhage or focal neurological deficit (one [2%] of 61 vs 29 [12%] of 239, adjusted hazard ratio [HR] 0·12, 95% CI 0·02-0·88; p=0·037). In a meta-analysis of six cohort studies including 1342 patients, antithrombotic therapy use was associated with a lower risk of intracranial haemorrhage (eight [3%] of 253 vs 152 [14%] of 1089; incidence rate ratio 0·25, 95% CI 0·13-0·51; p<0·0001; I2=0%). INTERPRETATION Antithrombotic therapy use is associated with a lower risk of intracranial haemorrhage or focal neurological deficit from cerebral cavernous malformations than avoidance of antithrombotic therapy. These findings provide reassurance about safety for clinical practice and require further investigation in a randomised controlled trial. FUNDING UK Medical Research Council, Chief Scientist Office of the Scottish Government, The Stroke Association, Cavernoma Alliance UK, and the Remmert Adriaan Laan Foundation.
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Affiliation(s)
- Susanna M Zuurbier
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Charlotte R Hickman
- Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Christos S Tolias
- Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Leon A Rinkel
- University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Rebecca Leyrer
- Department of Neurosurgery, University of Duisburg-Essen, Essen, Germany
| | | | - David Bervini
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | | | - Robert J Wityk
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Ulrich Sure
- Department of Neurosurgery, University of Duisburg-Essen, Essen, Germany
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.
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Felling RJ, Hassanein SMA, Armstrong J, Aversa L, Billinghurst L, Goldenberg NA, Lee JE, Maxwell EC, Noetzel MJ, Lo W. Treatment and outcome of childhood cerebral sinovenous thrombosis. Neurol Clin Pract 2019; 10:232-244. [PMID: 32642325 DOI: 10.1212/cpj.0000000000000720] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/26/2019] [Indexed: 11/15/2022]
Abstract
Objective To test our hypothesis that anticoagulation is associated with better neurologic outcomes in childhood cerebral sinovenous thrombosis (CSVT), we analyzed treatment and outcomes in a population of 410 children from the International Pediatric Stroke Study (IPSS). Methods We included patients enrolled in the IPSS registry with a diagnosis of CSVT at age >28 days with radiologic confirmation, in isolation or with concomitant arterial ischemic stroke. The primary outcome was the neurologic status at discharge. We defined unfavorable outcome as severe neurologic impairment or death at discharge. The Pediatric Stroke Outcome Measure was used for long-term outcome in those with follow-up. Predictors of anticoagulation use and outcome were analyzed by logistic regression. Results Most children (95%) had identifiable risk factors, and 82% received anticoagulation. Shift analysis demonstrated better outcomes at discharge in children who were anticoagulated, and this persisted with longer-term outcomes. In multivariable analysis, anticoagulation was significantly associated with favorable outcomes (adjusted odds ratio [aOR] unfavorable 0.32, p = 0.007) whereas infarct was associated with unfavorable outcome (aOR unfavorable 6.71, p < 0.001). The trauma/intracranial surgery was associated with a lower odds of anticoagulation use (aOR 0.14, p < 0.001). Conclusions Within the IPSS registry, children with risk factors of trauma or intracranial surgery were less likely to receive anticoagulation for CSVT. Anticoagulation was associated with a lower odds of severe neurologic impairment or death at hospital discharge, but this finding is limited and needs further confirmation in randomized, controlled, prospective studies.
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Affiliation(s)
- Ryan J Felling
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Sahar M A Hassanein
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Jennifer Armstrong
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Luis Aversa
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Lori Billinghurst
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Neil A Goldenberg
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Jo Ellen Lee
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Emily C Maxwell
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Michael J Noetzel
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Warren Lo
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
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Al-Sulaiman A. Clinical Aspects, Diagnosis and Management of Cerebral Vein and Dural Sinus Thrombosis: A Literature Review. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2019; 7:137-145. [PMID: 31543733 PMCID: PMC6734737 DOI: 10.4103/sjmms.sjmms_22_19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/10/2019] [Accepted: 07/16/2019] [Indexed: 12/29/2022]
Abstract
Cerebral vein and dural sinus thrombosis (CVST) is an uncommon cause of stroke, but its delayed diagnosis carries significant morbidity and mortality. Several studies have reported higher incidence of CVST than that previously reported. The clinical presentation of CVST varies and can be atypical. Advancement in neuroimaging modalities has made it possible to make an early diagnosis and initiate management with a wide range of therapeutic options, including direct oral anticoagulants and endovascular treatment. This narrative review summarizes the epidemiology, clinical aspects, diagnosis and management of CVST.
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Affiliation(s)
- Abdulla Al-Sulaiman
- Department of Neurology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Akhavan R, Abbasi B, Kheirollahi M, Ghamari Khameneh A, Hashemi J, Khoei S, Darban Hosseini Amirkhiz G. Factors affecting dural sinus density in non-contrast computed tomography of brain. Sci Rep 2019; 9:12016. [PMID: 31427710 PMCID: PMC6700311 DOI: 10.1038/s41598-019-48545-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/07/2019] [Indexed: 01/31/2023] Open
Abstract
The possibility of changing the intracranial vasculature computed tomography (CT) attenuation under the influence of variable factors is a long-held unestablished belief. The purpose of this study is to evaluate factors affecting dural sinus density in non-contrast computed tomography of the brain. Patients presented with acute neurologic symptoms to the emergency department were candidates to be enrolled in this study. A region of interest (ROI) measuring 1-2-mm2 recorder (base on sinus size) used to measure the attenuation of each sinus in Hounsfield Unit (HU) and then mean density calculated. CBC, BUN and Cr were extracted from patients' records. Chi-square test, correlation analyze, independent sample unpaired student t-test and one-way ANOVA test and Multivariate logistic regression were used. Positive significant correlation (0.48) was found between the hematocrit level (HCT) and average attenuation in the four sinus segments (P value < 0.0001) and between the HCT and basilar artery attenuation (P value < 0.0001). There was no significant correlation between the age and average attenuation. There was a significant and negative correlation between the BUN/Cr and average attenuation. Using a multivariate analysis on a large sample volume, we conclude that Hgb and HCT are the only factors that have a significant correlation with average sinus attenuation. This correlation is relatively stronger for Hgb in comparison to HCT.
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Affiliation(s)
- Reza Akhavan
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bita Abbasi
- Department of Radiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Moein Kheirollahi
- Department of Radiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Afshar Ghamari Khameneh
- Department of Radiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Jahanbakhsh Hashemi
- Department of Radiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Samin Khoei
- Department of Radiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Del Brutto VJ, Chaturvedi S, Diener HC, Romano JG, Sacco RL. Antithrombotic Therapy to Prevent Recurrent Strokes in Ischemic Cerebrovascular Disease: JACC Scientific Expert Panel. J Am Coll Cardiol 2019; 74:786-803. [PMID: 31395130 PMCID: PMC7291776 DOI: 10.1016/j.jacc.2019.06.039] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/11/2019] [Accepted: 06/24/2019] [Indexed: 01/02/2023]
Abstract
Stroke survivors carry a high risk of recurrence. Antithrombotic medications are paramount for secondary prevention and thus crucial to reduce the overall stroke burden. Appropriate antithrombotic agent selection should be based on the best understanding of the physiopathological mechanism that led to the initial ischemic injury. Antiplatelet therapy is preferred for lesions characterized by atherosclerosis and endothelial injury, whereas anticoagulant agents are favored for cardiogenic embolism and highly thrombophilic conditions. Large randomized controlled trials have provided new data to support recommendations for the evidence-based use of antiplatelet agents and anticoagulant agents after stroke. In this review, the authors cover recent trials that have altered clinical practice, cite systematic reviews and meta-analyses, review evidence-based recommendations based on older landmark trials, and indicate where there are still evidence-gaps and new trials being conducted.
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Affiliation(s)
- Victor J Del Brutto
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida.
| | | | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Jose G Romano
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida
| | - Ralph L Sacco
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida.
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Kasischke KA, Peguero EN, Sriaroon C, Moreo N, Ren Z, Mokin MV, Rose DZ. Immediate Transfer for Clot Extraction in a Young Woman With Leukemia and Asparaginase-Associated Acute Cerebral Vein Thrombosis. Neurohospitalist 2019; 10:58-63. [PMID: 31839868 DOI: 10.1177/1941874419852196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
We present the case of an 18-year-old woman with B-cell acute lymphoblastic leukemia (ALL) who developed hemorrhagic stroke and epilepsia partialis continua due to acute cerebral vein thrombosis (CVT). The patient had 10 risk factors for CVT (including use of asparaginase chemotherapy for the ALL) and also unfortunately had 4 biomarkers for poor prognosis for outcome post-CVT diagnosis. Immediate transfer to a Comprehensive Stroke Center allowed for hyperacute neurointerventional clot extraction with rapid restoration of the patency of the superior sagittal sinus. This resulted in an unexpectedly favorable neurological outcome and simultaneously allowed for early resumption of chemotherapy for ALL after only a 5-day hiatus. Our case highlights the importance of immediate transfer of highest risk patients with multiple biomarkers for poor prognosis to a Comprehensive Stroke Center with endovascular and neurosurgical capabilities and the possibility of overcoming the odds of a poor outcome with venous clot extraction if medical management fails. Neurological deterioration due to escalating intracranial pressure with impending herniation may occur rapidly, and treatment at such facilities can be life-saving.
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Affiliation(s)
- Karl A Kasischke
- Department of Neurology, University of South Florida, Tampa, FL, USA
| | - Edwin N Peguero
- Neuro-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Chakrapol Sriaroon
- Division of Pulmonary, Critical Care Medicine, and Sleep, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Natalie Moreo
- Department of Neurology, University of South Florida, Tampa, FL, USA
| | - Zeguang Ren
- Department of Neurological Surgery, University of South Florida, Tampa, FL, USA
| | - Maxim V Mokin
- Department of Neurology, University of South Florida, Tampa, FL, USA.,Department of Neurological Surgery, University of South Florida, Tampa, FL, USA
| | - David Z Rose
- Department of Neurology, University of South Florida, Tampa, FL, USA
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Bose G, Graveline J, Yogendrakumar V, Fergusson D, Dowlatshahi D. Direct oral anticoagulants in treatment of cerebral venous thrombosis: a systematic review protocol. Syst Rev 2019; 8:99. [PMID: 30999965 PMCID: PMC6474061 DOI: 10.1186/s13643-019-1022-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 04/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND PURPOSE Cerebral venous thrombosis causes disability from venous infarct and hemorrhage and potential mortality. Anticoagulation improves survival and disability outcomes, yet direct oral anticoagulants are currently not indicated in cerebral venous thrombosis due to lack of evidence, despite being on the market for nearly a decade. This systematic review will collate evidence of reported safety and efficacy of direct oral anticoagulant therapy in cerebral venous thrombosis. METHODS A search strategy was developed with a research librarian and registered on a protocol database (PROSPERO CRD42017078398). All published studies from MEDLINE and EMBASE up to February 2019 containing patients diagnosed with cerebral venous thrombosis who were treated with a direct oral anticoagulant (dabigatran, rivaroxaban, apixaban, or edoxaban) will be included. A risk of bias analysis will be performed to evaluate quality of studies overall. DISCUSSION Current guidelines in the treatment of cerebral vein thrombosis dating back to 2011 from the American Heart Association/American Stroke Association endorse the utility of anticoagulation for the treatment of cerebral vein thrombosis; however, they did not support the use of direct oral anticoagulants. Updated guidelines from the European Stroke Organization, endorsed by the European Academy of Neurology in 2017, also refute utilization of direct oral anticoagulants due to a lack of evidence. There have been nearly 10 years of experience with direct oral anticoagulants in the treatment of venous thrombosis and prevention of stroke in patients with atrial fibrillation, with purported efficacy and safety in comparison with heparins and vitamin K antagonists. Our goal is to undertake a systematic review to assess the effectiveness and safety of direct oral anticoagulants in patients with cerebral vein thrombosis to help guide clinical decision-making for patients unable to take heparins or vitamin K antagonists and to direct future studies to contribute further to an area of certain evidence-based needs. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017078398.
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Affiliation(s)
- Gauruv Bose
- Department of Medicine, University of Ottawa and The Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON K1Y 4E9 Canada
| | - Justin Graveline
- Department of Medicine, University of Ottawa and The Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON K1Y 4E9 Canada
| | - Vignan Yogendrakumar
- Department of Medicine, University of Ottawa and The Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON K1Y 4E9 Canada
| | - Dean Fergusson
- Department of Medicine, University of Ottawa and The Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON K1Y 4E9 Canada
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa and The Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON K1Y 4E9 Canada
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Asad SD, Lopetegui Lia N, Ferrigno BW, Alhabach H. A Migraneur with a Usual Headache: A Near-miss of Cerebral Venous Thrombosis. Cureus 2019; 11:e4393. [PMID: 31223551 PMCID: PMC6555492 DOI: 10.7759/cureus.4393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Cerebral venous thrombosis (CVT), while rare, is a challenging diagnosis. It can be easily missed as the presenting symptom can be just a mild headache. However, if missed and left untreated, it can lead to multiple complications, even death. There are certain risk factors that should make one suspect CVT, such as pregnancy, puerperium, use of oral contraceptive pills (OCPs) or known underlying hypercoagulable disorder, to name a few. Imaging is required for diagnosis. Anticoagulation, typically long term, is the standard treatment. We present a case of a 25-year-old male who was initially discharged after an emergency department visit with symptomatic treatment for migraine headaches, and was later found to have extensive cerebral venous sinus thrombosis. It is worth emphasizing the importance of having a broad differential diagnosis and a low threshold to obtain imaging studies when patients present with persistent headaches, even in the absence of any obvious risk factors.
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Affiliation(s)
- Syed Daniyal Asad
- Neurology, University of Connecticut School of Medicine, Farmington, USA
| | - Nerea Lopetegui Lia
- Internal Medicine, University of Connecticut School of Medicine, Farmington, USA
| | - Bryan W Ferrigno
- Neurology, University of Connecticut School of Medicine, Farmington, USA
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de la Vega Muns G, Quencer R, Ezuddin NS, Saigal G. Utility of Hounsfield unit and hematocrit values in the diagnosis of acute venous sinus thrombosis in unenhanced brain CTs in the pediatric population. Pediatr Radiol 2019; 49:234-239. [PMID: 30327829 DOI: 10.1007/s00247-018-4273-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/24/2018] [Accepted: 09/24/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cerebral venous sinus thrombosis (CVST) is a recognized cause of childhood and neonatal stroke with high morbidity and mortality and a challenging diagnosis in the pediatric population. OBJECTIVE We hypothesize that measuring Hounsfield units (HU) of blood in venous sinuses is a more reliable method to diagnose CVST and that normalizing the measured HU in relation to the patient's hematocrit levels may further improve detection of CVST in the pediatric population. MATERIALS AND METHODS We performed a retrospective chart review of 15 pediatric patients with acute CVST and 31 control patients. Regions of interest (ROIs) were plotted to measure HU values within the venous sinuses of each patient. Hounsfield unit to hematocrit (HU:Hct) ratios were also calculated. In patients with CVST, HU values were determined in thrombosed and non-thrombosed venous sinuses. Statistical analysis was performed to calculate the differences between patient and control groups and to determine optimal cutoff values for HU and HU:Hct measurements in diagnosing CVST on non-contrast brain computed tomography (CT). RESULTS A statistically significant difference in sinus attenuation and HU:Hct ratio was found between thrombosed (66.2±5.3 HU, 1.96±0.4) and non-thrombosed sinuses (47.2±4.5 HU, 1.38±0.25) in the patient group (P<0.0001), with the average attenuation difference being 19 HU. A statistically significant difference was also found between thrombosed sinuses in the patient group and sinuses (48.9±3.13 HU, 1.3±0.12) in the control group (P<0.0001). CONCLUSION Optimal cutoff values of 58 HU and HU:Hct ratios of 1.4 lead to sensitivities of 100% in diagnosing CVST.
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Affiliation(s)
- Gabriela de la Vega Muns
- Department of Radiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1611 NW 12th Ave., West Wing #279, Miami, FL, 33136, USA.
| | - Robert Quencer
- Department of Radiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1611 NW 12th Ave., West Wing #279, Miami, FL, 33136, USA
| | - Nisreen S Ezuddin
- Department of Radiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1611 NW 12th Ave., West Wing #279, Miami, FL, 33136, USA
| | - Gaurav Saigal
- Department of Radiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1611 NW 12th Ave., West Wing #279, Miami, FL, 33136, USA
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Dolapsakis C, Kranidioti E, Katsila S, Samarkos M. Cavernous sinus thrombosis due to ipsilateral sphenoid sinusitis. BMJ Case Rep 2019; 12:12/1/e227302. [PMID: 30700458 DOI: 10.1136/bcr-2018-227302] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a case of septic thrombosis of the right cavernous sinus in a diabetic woman in her late 70's due to ipsilateral sphenoid sinusitis. The diagnosis was delayed and made only after the abrupt and dramatic appearance of the manifestations of sinus thrombosis. The patient developed, among the other symptoms, right peripheral facial palsy, which is a very rare manifestation in cavernous sinus thrombosis (CST). She was treated with broad-spectrum antibiotics and enoxaparin. The day of the scheduled drainage of sphenoid sinus-24 hours after the initiation of anticoagulation-she developed fatal subarachnoid haemorrhage. Our case demonstrates the difficulty of timely diagnosis of acute sphenoid sinusitis which has emerged as the most common primary infectious source potentially leading in CST. It also underscores the uncertainty concerning the use of anticoagulation in cerebral sinus thrombosis of infectious origin.
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Affiliation(s)
| | | | - Sofia Katsila
- 3rd Department of Medicine, Evaggelismos General Hospital, Athens, Greece
| | - Michael Samarkos
- 1st Department of Medicine, Laikon Hospital, Athens, Greece.,National and Kapodistrian University of Athens - Faculty of Medicine, Athens, Greece
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Li K, Ren M, Meng R, Ding Y, Rajah GB, Wang F, Ji X. Efficacy of stenting in patients with cerebral venous sinus thrombosis-related cerebral venous sinus stenosis. J Neurointerv Surg 2018; 11:307-312. [PMID: 30389898 DOI: 10.1136/neurintsurg-2018-014328] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 10/05/2018] [Accepted: 10/08/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Venous stenting has been proven to be a safe and effective therapeutic option for patients with idiopathic intracranial hypertension (IIH) and cerebral venous sinus stenosis (CVSS). However, its use in patients with cerebral venous sinus thrombosis-related CVSS has been less reported. PURPOSE To explore the safety and efficacy of stenting for patients with cerebral venous sinus thrombosis (CVST)-related CVSS. METHODS The clinical presentation, treatment, and outcome of patients with CVST-related CVSS received venous stenting in the chronic stage after failed medical treatment were retrospectively evaluated. RESULTS A total of 17 patients with CVST-related CVSS were included. Mean pressure gradient across the CVSS decreased from 11.5±4.2 mmHg prior to stenting to 2.1±1.1 mmHg post- stenting. Mean CSF opening pressure decreased from 33.1±5.5 cmH2O to 18.7±1.7 cmH2O. Both headache and visual disturbance improved or resolved in 78% and 92% of the patients, respectively. Complications included lethal cerebellar hematoma in one case and bilateral occipital epidural hematoma in another case. One of the patients received retreatment with ventriculo-peritoneal shunting due to recurrent headache. CONCLUSION Restoring the patency of stenotic sinuses with stents in patients of CVST-related CVSS unresponsive to medical therapy in the chronic stage may improve symptoms in the majority of the patients. However, a relatively higher cerebral hemorrhage rate was observed and may be related to this pathology. Stenting in this subgroup of CVSS patients may require further evaluation with a larger and long-term study, and should be used with caution at this time.
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Affiliation(s)
- Ke Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Interventional Radiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ming Ren
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ran Meng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Gary B Rajah
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Feng Wang
- Department of Interventional Radiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Diplopia-an unheralded consequence of neck dissection: case report. Oral Maxillofac Surg 2018; 22:341-343. [PMID: 30078114 DOI: 10.1007/s10006-018-0711-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 08/02/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Neck dissection is a part of the standard surgical procedure in the management of head and neck malignancy. Diplopia following neck dissection is a rare entity; hence, its diagnosis and management strategies needed to be discussed for prevention of its grave consequences. CASE REPORT A 30-year-old male patient presented with binocular horizontal diplopia following total thyroidectomy and neck dissection. On evaluation, there was internal jugular vein (IJV) thrombosis followed by cerebral venous sinus thrombosis (CVST). After meticulous medical management with diuretics and antiplatelet drugs, diplopia resolved completely and normal vision was restored. CONCLUSION Therapeutic ligation of internal jugular vein during neck dissection may result in IJV thrombosis followed by CVST leading to raised intracranial tension (ICT). It has to be anticipated and addressed as early as possible to prevent its grave consequences like blindness and death.
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Prognosis of septic cavernous sinus thrombosis remarkably improved: a case series of 12 patients and literature review. Eur Arch Otorhinolaryngol 2018; 275:2387-2395. [PMID: 29998385 PMCID: PMC6096574 DOI: 10.1007/s00405-018-5062-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 07/05/2018] [Indexed: 11/19/2022]
Abstract
Purpose Septic cavernous sinus thrombosis (CST) is a rare complication of infections in the head and neck area. CST is notorious for its bad prognosis, with high mortality and morbidity rates described in literature. However, these rates are based on old series. We question whether the prognosis of CST is currently still as devastating. The primary purpose of this study is to assess the mortality and morbidity of CST. Methods Using the databases of all relevant specialties in our tertiary referral hospital, we collected all the patients treated for CST in the period 2005–2017. In addition, a PubMed search, using the mesh term ‘cavernous sinus thrombosis’, was performed. Results We found 12 patients with CST in the study period. Of the 12 patients, 11 survived and 9 recovered without any permanent deficits. Seven patients were treated with anticoagulation, and in none of the patients we saw hemorrhagic complications. In literature, older articles describe higher mortality rates (14–80%), but more recent articles report mortality and morbidity rates similar to our results. Conclusions The prognosis of CST nowadays is more favorable than previously described. Anticoagulation seems to be a safe addition to antibiotic and surgical treatment, at least in patients without central nervous system infection.
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Zhang S, Hu Y, Li Z, Huang D, Zhang M, Wang C, Wang Z. Endovascular treatment for hemorrhagic cerebral venous sinus thrombosis: experience with 9 cases for 3 years. Am J Transl Res 2018; 10:1611-1619. [PMID: 30018704 PMCID: PMC6038069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/25/2018] [Indexed: 06/08/2023]
Abstract
AIM We experienced a series of patients with hemorrhagic CVST, who were successfully treated with endovascular treatment (EVT). The aim was to explore the best scheme for the future through our treatment data of hemorrhagic CVST. MATERIAL AND METHODS A retrospective analysis was conducted, selecting nine hemorrhagic CVST patients, who were mainly treated with EVT. Characteristics of hemorrhagic CVST were recorded, including risk factors, thrombus location, presenting symptoms, and treatment details included type of EVT. We also recorded clinical outcomes, degree of sinus recanalization, thrombus recurrences, periprocedural complications, degree of neurological deficit at last follow-up. RESULTS Catheter thrombolysis and mechanical thrombectomy were applied in all of the nine hemorrhagic CVST patients, stent retriever was used in 7 patients, one of them combined with balloon-assisted thrombectomy. Besides EVT, two patients accepted emergency surgical decompression, one in the local hospital, and the other in our hospital. The follow-up duration ranged from 4 to 28 months. All of them have a neurological and symptomatic improvement, 6 patients have a good outcome, the rest 3 patients have a poor outcome, no thrombus recurrences and death in them. Seven patients had complete recanalization and two patients had partial recanalization at last follow-up. CONCLUSION EVT is an effective and safe procedure for potentially catastrophic hemorrhagic cerebral venous sinus thrombosis.
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Affiliation(s)
- Shizhong Zhang
- Department of Neurosurgery, Qilu Hospital of Shandong UniversityNO. 758, Hefei Road, Shibei District, Qingdao 266035, Shangdong, China
- Department of Neurosurgery, Taian Central HospitalNO. 29, Longtan Road, Taian 271000, Shangdong, China
| | - Yanyan Hu
- Color Ultrasonic Room, Taian Central HospitalNO. 29, Longtan Road, Taian 271000, Shangdong, China
| | - Zhen Li
- Department of Neurosurgery, Taian Central HospitalNO. 29, Longtan Road, Taian 271000, Shangdong, China
| | - Dezhang Huang
- Department of Neurosurgery, Qilu Hospital of Shandong UniversityNO. 758, Hefei Road, Shibei District, Qingdao 266035, Shangdong, China
| | - Mingran Zhang
- Department of Neurosurgery, Taian Central HospitalNO. 29, Longtan Road, Taian 271000, Shangdong, China
| | - Chenglong Wang
- Department of Neurosurgery, Qilu Hospital of Shandong UniversityNO. 758, Hefei Road, Shibei District, Qingdao 266035, Shangdong, China
| | - Zhigang Wang
- Department of Neurosurgery, Qilu Hospital of Shandong UniversityNO. 758, Hefei Road, Shibei District, Qingdao 266035, Shangdong, China
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Azeemuddin M, Awais M, Mubarak F, Rehman A, Baloch NUA. Prevalence of subarachnoid haemorrhage among patients with cranial venous sinus thrombosis in the presence and absence of venous infarcts. Neuroradiol J 2018; 31:496-503. [PMID: 29890915 DOI: 10.1177/1971400918783060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Introduction In patients with cranial venous sinus thrombosis, the occurrence of subarachnoid haemorrhage in association with haemorrhagic venous infarcts is a well described phenomenon. However, the presence of subarachnoid haemorrhage in patients with cranial venous sinus thrombosis in the absence of a haemorrhagic venous infarct is exceedingly rare. Methods We retrospectively reviewed charts and scans of all patients who had cranial venous sinus thrombosis confirmed by magnetic resonance venography at our hospital between September 2004 and May 2015. The presence of subarachnoid haemorrhage was ascertained on fluid-attenuated inversion recovery, susceptibility-weighted imaging and/or unenhanced computed tomography scans by a single experienced neuroradiologist. Statistical analysis was performed using the Statistical Package for Social Sciences version 20. Differences in the proportion of haemorrhagic venous infarcts among patients with subarachnoid haemorrhage versus those without subarachnoid haemorrhage were compared using the chi-square test. A P value of less than 0.05 was considered significant. Results A total of 138 patients who had cranial venous sinus thrombosis were included in the study. Seventy-three (52.9%) were women and the median age of subjects was 35 (interquartile range 22-47) years. Venous infarcts and haemorrhagic venous infarcts were noted in 20/138 (14.5%) and 62/138 (44.9%) cases, respectively. Subarachnoid haemorrhage was present in 15/138 (10.9%) cases and, in three cases, subarachnoid haemorrhage occurred in the absence of a venous infarct. Haemorrhagic venous infarcts were more prevalent ( P = 0.021) among patients with subarachnoid haemorrhage (11/15) than in those without subarachnoid haemorrhage (51/123). Conclusion In patients with cranial venous sinus thrombosis, subarachnoid haemorrhage can occur even in the absence of a haemorrhagic venous infarct. The recognition of cranial venous sinus thrombosis as the underlying cause of subarachnoid haemorrhage is important to avoid misdiagnosis and inappropriate management.
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Affiliation(s)
| | - Muhammad Awais
- 1 Department of Radiology, Aga Khan University Hospital, Pakistan.,2 Department of Radiology, Dow University of Health Sciences, Pakistan
| | - Fatima Mubarak
- 1 Department of Radiology, Aga Khan University Hospital, Pakistan
| | - Abdul Rehman
- 3 Department of Biological and Biomedical Sciences, Aga Khan University, Pakistan
| | - Noor Ul-Ain Baloch
- 3 Department of Biological and Biomedical Sciences, Aga Khan University, Pakistan
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Lavin T, Holland M, Punter M. Organisation of services and clinical practice in acute cerebral venous sinus thrombosis: a UK survey. J Neurol Neurosurg Psychiatry 2018; 89:320-322. [PMID: 28710323 DOI: 10.1136/jnnp-2017-316118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 04/28/2017] [Accepted: 06/07/2017] [Indexed: 11/04/2022]
Affiliation(s)
- Timothy Lavin
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford, Greater Manchester, UK
| | - Mark Holland
- Acute Medicine, Salford Royal NHS Foundation Trust, Salford, Greater Manchester, UK
| | - Martin Punter
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford, Greater Manchester, UK.,University of Manchester Institute of Brain Behaviour and Mental Health, Manchester, Greater Manchester, UK
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