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Schön M, Infante J, Pinho E Melo T, Lacerda JF, Ferro JM. Cerebral venous thrombosis as a first presentation of a high-risk acute myeloid leukaemia. Acta Neurol Belg 2024; 124:1111-1112. [PMID: 38148428 DOI: 10.1007/s13760-023-02467-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/18/2023] [Indexed: 12/28/2023]
Affiliation(s)
- Miguel Schön
- Stroke Unit, Department of Neurosciences and Mental Health (Neurology), Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal.
| | - Joana Infante
- Hematology and Transplantation Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Faculdade de Medicina, Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisbon, Portugal
| | - Teresa Pinho E Melo
- Stroke Unit, Department of Neurosciences and Mental Health (Neurology), Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Faculdade de Medicina, Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisbon, Portugal
| | - João F Lacerda
- Hematology and Transplantation Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Faculdade de Medicina, Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisbon, Portugal
| | - José M Ferro
- Faculdade de Medicina, Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisbon, Portugal
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Crispino P. Hemorrhagic Coagulation Disorders and Ischemic Stroke: How to Reconcile Both? Neurol Int 2023; 15:1443-1458. [PMID: 38132972 PMCID: PMC10745771 DOI: 10.3390/neurolint15040093] [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: 10/15/2023] [Revised: 11/22/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023] Open
Abstract
Coagulation and fibrinolytic system disorders are conditions in which the blood's ability to clot is impaired, resulting in an increased risk of thrombosis or bleeding. Although these disorders are the expression of two opposing tendencies, they can often be associated with or be a consequence of each other, contributing to making the prognosis of acute cerebrovascular events more difficult. It is important to recognize those conditions that are characterized by dual alterations in the coagulation and fibrinolytic systems to reduce the prognostic impact of clinical conditions with difficult treatment and often unfortunate outcomes. Management of these individuals can be challenging, as clinicians must balance the need to prevent bleeding episodes with the potential risk of clot formation. Treatment decisions should be made on an individual basis, considering the specific bleeding disorder, its severity, and the patient's general medical condition. This review aims to deal with all those forms in which coagulation and fibrinolysis represent two sides of the same media in the correct management of patients with acute neurological syndrome. Precision medicine, personalized treatment, advanced anticoagulant strategies, and innovations in bleeding control represent future directions in the management of these complex pathologies in which stroke can be the evolution of two different acute events or be the first manifestation of an occult or unknown underlying pathology.
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Affiliation(s)
- Pietro Crispino
- Medicine Unit, Santa Maria Goretti Hospital, Via Scaravelli Snc, 04100 Latina, Italy
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3
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Ninan GA, Miraclin T A, Karumathil S, Prasad JD, Kumar S, Bal D, Nair A, Ahmed SA, Appaswamy Thirumal P, George B, Sivadasan A, Aaron S. Interventions in cerebrovascular emergencies among patients with Paroxysmal nocturnal haemoglobinuria - A word of caution. J Stroke Cerebrovasc Dis 2023; 32:107305. [PMID: 37677898 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107305] [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: 02/15/2023] [Revised: 06/14/2023] [Accepted: 08/10/2023] [Indexed: 09/09/2023] Open
Abstract
INTRODUCTION Paroxysmal nocturnal haemoglobinuria (PNH) is a clonal hematopoietic disorder, where there is deficiency of glycosylphosphatidylinositol (GPI) anchored proteins in the cell membrane, leading to increased complement sensitivity of red blood cells, intravascular hemolysis and vascular inflammation. Arterial and venous strokes in patients with PNH are a rarity posing significant diagnostic and therapeutic challenges. We report our experience with management of PNH patients with cerebrovascular emergencies. METHODS We report 2 patients with PNH, one who was previously diagnosed with PNH and had arterial stroke, the other had an index presentation of cerebral venous sinus thrombosis (CVT) and was subsequently diagnosed with PNH. We also present the systematic review of literature reporting similar cases, highlighting the challenges in management. RESULTS Both patients presented to our centre with cerebrovascular emergency. The first patient was a diagnosed with PNH, and presented with left hemispheric infarction caused by thrombosis of middle cerebral artery. He was thrombolysed and underwent mechanical thrombectomy, which was unsuccessful in view of repeated re - thrombosis of the vessel. The patient survived with significant disability. The second patient had severe cerebral venous sinus thrombosis with large right hemispheric hemorrhagic venous infarction. She underwent emergency decompressive hemicraniectomy complicated by massive blood loss and disseminated intravascular coagulation. She subsequently had recurrent life threatening intracranial bleed secondary to platelet transfusions, thrombocytopenia, and use of contrast agents. She progressed to develop Budd Chiari syndrome and was initiated on Eculuzimab. She became transfusion independent, however remained in minimally conscious state and succumbed to sepsis. CONCLUSIONS Management of arterial and venous strokes is complex in patients with PNH. Invasive procedures and platelet transfusions are to be avoided in acute thrombosis, till robust evidence is available establishing the safety of the same in patients with PNH. Eculuzimab is a promising option, but far from reach for patients in developing countries.
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Affiliation(s)
- George Abraham Ninan
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Angel Miraclin T
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sujith Karumathil
- Department of Clinical Haematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - John Davis Prasad
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sarath Kumar
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Deepti Bal
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Aditya Nair
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Shaikh Atif Ahmed
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Biju George
- Department of Clinical Haematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ajith Sivadasan
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sanjith Aaron
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
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Mallio CA, Bernetti C, Castiello G, Gangemi E, Tomarchio V, Annibali O, Rigacci L, Van Goethem J, Parizel PM, Beomonte Zobel B, Quattrocchi CC. Neuroradiology of acute pathologies in adults with hematologic malignancies: a pictorial review. Quant Imaging Med Surg 2023; 13:7530-7551. [PMID: 37969623 PMCID: PMC10644134 DOI: 10.21037/qims-22-1201] [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: 11/01/2022] [Accepted: 02/20/2023] [Indexed: 11/17/2023]
Abstract
Hematopoietic and lymphoid tumors are a heterogeneous group of diseases including lymphomas, multiple myeloma (MM), and leukemias. These diseases are associated with systemic involvement and various clinical presentations including acute neurological deficits. Adult patients with hematologic malignancies (HM) are at risk for developing a wide array of acute conditions involving the nervous system. HM in adults may present as tumoral masses responsible for mass effect, possibly resulting in acute neurological signs and symptoms caused by tumor growth with compression of central nervous system (CNS) structures. Moreover, as result of the hematologic disease itself or due to systemic treatments, hematologic patients are at risk for vascular pathologies, such as ischemic, thrombotic, and hemorrhagic disorders due to the abnormal coagulation status. The onset of these disorders is often with acute neurologic signs or symptoms. Lastly, it is well known that patients with HM can have impaired function of the immune system. Thus, CNS involvement due to immune-related diseases such as mycotic, parasitic, bacterial, and viral infections linked to immunodeficiency, together with immune reconstitution inflammatory syndrome, are frequently seen in hematologic patients. Knowledge of the etiology and expected CNS imaging findings in patients with HM is of great importance to reach a fast and correct diagnosis and guide treatment choices. In this manuscript, we review the computed tomography (CT) and magnetic resonance findings of these conditions which can be related to the disease itself and/or to their treatments.
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Affiliation(s)
- Carlo A. Mallio
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, Roma, Italy
- Operative Research Unit of Diagnostic Imaging, Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Caterina Bernetti
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, Roma, Italy
- Operative Research Unit of Diagnostic Imaging, Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Gennaro Castiello
- U.O.S. Diagnostica per Immagini, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | - Emma Gangemi
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Valeria Tomarchio
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, Roma, Italy
- Operative Research Unit of Hematology and Stem Cell Transplantation, Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Ombretta Annibali
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, Roma, Italy
- Operative Research Unit of Hematology and Stem Cell Transplantation, Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Luigi Rigacci
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, Roma, Italy
- Operative Research Unit of Hematology and Stem Cell Transplantation, Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Johan Van Goethem
- Department of Radiology, Antwerp University Hospital, Edegem, Belgium
| | - Paul M. Parizel
- David Hartley Chair of Radiology, Royal Perth Hospital & University of Western Australia, Perth, WA, Australia
| | - Bruno Beomonte Zobel
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, Roma, Italy
- Operative Research Unit of Diagnostic Imaging, Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
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Zhou Y, Jiang H, Wei H, Xiao X, Liu L, Ji X, Zhou C. Cerebral venous thrombosis in patients with autoimmune disease, hematonosis or coronavirus disease 2019: Many familiar faces and some strangers. CNS Neurosci Ther 2023; 29:2760-2774. [PMID: 37365966 PMCID: PMC10493677 DOI: 10.1111/cns.14321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/24/2023] [Accepted: 06/09/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Cerebral venous thrombosis, a rare stroke, is characterized by neurological dysfunction caused by bleeding and/or infarction resulting from venous sinus thrombosis, the so-called venous stroke. Current guidelines recommend anticoagulants as first-line therapy in the treatment of venous stroke. With complicated causes of cerebral venous thrombosis, treatment is difficult, especially when combined with autoimmune diseases, blood diseases, and even COVID-19. AIMS This review summarizes the pathophysiological mechanisms, epidemiology, diagnosis, treatment, and clinical prognosis of cerebral venous thrombosis combined with autoimmune diseases, blood diseases, or infectious diseases such as COVID-19. CONCLUSION A systematic understanding of particular risk factors that should not be neglected when unconventional cerebral venous thrombosis occurs and for a scientific understanding of pathophysiological mechanisms, clinical diagnosis, and treatment, thus contributing to knowledge on special types of venous stroke.
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Affiliation(s)
- Yifan Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
| | - Huimin Jiang
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
| | - Huimin Wei
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Engineering MedicineBeihang UniversityBeijingChina
| | - Xuechun Xiao
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Engineering MedicineBeihang UniversityBeijingChina
| | - Lu Liu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xunming Ji
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
- Department of Neurosurgery, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Chen Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
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Rael S, Webb M, Brown RD, Ruff MW, Keser Z, Sener U. Safety of intravenous thrombolysis for ischemic stroke in patients with hematologic malignancies: A single institution experience. J Stroke Cerebrovasc Dis 2023; 32:107294. [PMID: 37562180 PMCID: PMC10530002 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/13/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Data on safety of thrombolysis for acute ischemic stroke (AIS) in patients with hematologic malignancy is not well established. We report our single institution experience with thrombolysis in this patient population. METHODS We identified patients with pathology-confirmed hematologic malignancy from 2000-2022. Primary exposure was presence of AIS and receipt of intravenous (IV) thrombolysis. Primary outcome was safety of IV thrombolysis in this patient population. Safety was measured through imaging review for hemorrhagic transformation, post-stroke mortality, and modified Rankin Scale (mRS) at 90 days. RESULTS Among 45,894 patients with hematologic malignancy, 1,099 (2.4%) were identified as having a suspected AIS. Twenty (1.8%) received IV tissue plasminogen activator (tPA) for AIS, three underwent endovascular intervention, and 17 had AIS confirmed on MRI. Two patients with confirmed AIS experienced hemorrhagic transformation, one of which was symptomatic. Most patients (n=10, 59%) were functionally independent (mRS 0-2) at 90 days post-stroke, including all patients with active hematologic malignancy at the time of stroke (n=3). Four patients died within 90 days of AIS. None of these deaths were patients with active hematologic malignancy at the time of stroke. CONCLUSIONS Without other contraindications, IV alteplase should be considered for management of AIS in patients with hematologic malignancy. The safety profile of tPA administration in this patient population may be similar to the general population, whether underlying hematologic malignancy is active or in remission.
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Affiliation(s)
- Sofia Rael
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Mason Webb
- Department of Hematology and Oncology, Mayo Clinic, Rochester, MN, USA
| | - Robert D Brown
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Michael W Ruff
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Zafer Keser
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Ugur Sener
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
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Shalabi F, Aladdin S, Molad J, Itsekzon-Hayosh Z, Sacagiu T, Honig A, Halevi H, Orion D, Gomori JM, Cohen JE, Leker RR. Effects of tumor type on outcomes in patients with large vessel occlusion stroke and cancer. J Stroke Cerebrovasc Dis 2023; 32:107288. [PMID: 37542761 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107288] [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: 04/03/2023] [Revised: 07/09/2023] [Accepted: 07/31/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND Large vessel occlusions (LVO) stroke is associated with cancer. Whether this association differs among patients with LVO that undergo endovascular thrombectomy (EVT) according to cancer type remains unknown. PATIENTS AND METHODS Data from consecutive patients that underwent EVT for LVO at three academic centers were pulled and analyzed retrospectively. Patients with LVO and solid tumors were compared to those with hematological tumors. Associations of cancer type with 90-day functional outcome and mortality were calculated in multivariable analyses. RESULTS Of the 154 patients with cancer and LVO that underwent EVT (mean age 74±11, 43% men, median NIHSS 15), 137 had solid tumors (89%) and 17 (11%) had hematologic tumors. Patients with solid cancer did not significantly differ from those with hematological malignancy in demographics, risk factor profile, stroke severity and subtype, and procedural variables. Outcome parameters including rates of favorable target recanalization and favorable outcome or mortality at discharge and 90 days post stroke were similar. Safety parameters including rates of symptomatic intracranial hemorrhage also did not differ between the groups. On regression analyses, controlling for various prognostic variables cancer type was not associated with mortality or favorable outcomes. CONCLUSIONS Our study suggests that the safety and efficacy of EVT in patients with malignancy does not depend on cancer type. Patients with malignancy should be considered for EVT regardless of cancer type.
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Affiliation(s)
- F Shalabi
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - S Aladdin
- Department of Neurology, Sheeba Medical Center, Ramat Gan Israel
| | - J Molad
- Department of Neurology, Sheeba Medical Center, Ramat Gan Israel
| | | | - T Sacagiu
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - A Honig
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - H Halevi
- Department of Neurology, Sheeba Medical Center, Ramat Gan Israel; Department of Neurology, Tel Aviv Sourasaky Medical Center, Tel Aviv, Israel
| | - D Orion
- Department of Neurology, Sheeba Medical Center, Ramat Gan Israel
| | - J M Gomori
- Departments of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J E Cohen
- Departments of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronen R Leker
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Aderinto N, Olatunji D, Abdulbasit M, Edun M. The essential role of neuroimaging in diagnosing and managing cerebrovascular disease in Africa: a review. Ann Med 2023; 55:2251490. [PMID: 37643607 PMCID: PMC10496522 DOI: 10.1080/07853890.2023.2251490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 07/11/2023] [Accepted: 08/20/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Cerebrovascular disease is a significant cause of morbidity and mortality in Africa, and using neuroimaging techniques has improved the diagnosis and management of this disease. However, there is a lack of comprehensive reviews of the role and effectiveness of neuroimaging techniques in the African context. METHODS We reviewed the literature to evaluate the role of neuroimaging in diagnosing and managing cerebrovascular disease in Africa. Our search included electronic databases such as PubMed, Scopus, and Google Scholar from 2000 to April 2023. We included peer-reviewed studies written in English that reported on the use of neuroimaging in diagnosing and managing cerebrovascular disease in African populations. We excluded non-peer-reviewed articles, letters, editorials, and studies unrelated to cerebrovascular disease, neuroimaging, or Africa. A total of 102 potential articles were identified; after applying our exclusion criteria and removing duplicated articles, 51 articles were reviewed. RESULTS Our findings suggest that neuroimaging techniques such as CT, MRI, and Skull x-ray play a crucial role in diagnosing and managing cerebrovascular disease in Africa. CT and MRI were the most commonly used techniques, with CT being more widely available and less expensive than MRI. However, challenges to using neuroimaging in Africa include the high cost of equipment and maintenance, lack of trained personnel, and inadequate infrastructure. These challenges limit the widespread use of neuroimaging in diagnosing and managing cerebrovascular disease in Africa. CONCLUSION Neuroimaging techniques are essential for diagnosing and managing cerebrovascular disease in Africa, but challenges to their use must be addressed to improve healthcare outcomes. Our policy recommendations can help improve the availability and accessibility of neuroimaging services in Africa.
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Affiliation(s)
- Nicholas Aderinto
- Department of Medicine and Surgery, Ladoke Akintola University of Technology, Nigeria
| | - Deji Olatunji
- Department of Medicine and Surgery, University of Ilorin, Nigeria
| | - Muili Abdulbasit
- Department of Medicine and Surgery, Ladoke Akintola University of Technology, Nigeria
| | - Mariam Edun
- Department of Medicine and Surgery, University of Ilorin, Nigeria
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Thirugnanasambandam RP, Maraikayar FM, Liu M, Elbashir K, Muthu J. Fat Embolization Syndrome Secondary to Steroid Treatment in a Case of Sickle Cell Vaso-Occlusive Crisis. Case Rep Hematol 2023; 2023:5530870. [PMID: 37434655 PMCID: PMC10332925 DOI: 10.1155/2023/5530870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/13/2023] [Accepted: 06/25/2023] [Indexed: 07/13/2023] Open
Abstract
Fat embolization syndrome (FES) is often seen as a complication of fractures and has been known to cause respiratory failure, rashes of the skin, thrombocytopenia, and neurological damage. Nontraumatic FES is uncommon and occurs due to bone marrow necrosis. Vaso-occlusive crisis in sickle cell patients secondary to steroid therapy is a rare entity and not widely acknowledged. We report a case of FES secondary to steroid therapy administered for a patient with intractable migraine. FES is an uncommon yet serious complication that occurs due to bone marrow necrosis and is usually associated with increased mortality or damaging neurologic sequelae for the surviving patient. Our patient was initially admitted for intractable migraine and worked up to rule out any acute emergency conditions. She was then given steroids for her migraine which did not subside with the initial treatment. Her condition worsened, and she developed respiratory failure along with altered mental status requiring care in the intensive care unit (ICU). Imaging studies showed microhemorrhages throughout the cerebral hemispheres, brainstem, and cerebellum. The imaging of her lungs confirmed severe acute chest syndrome. The patient also had hepatocellular and renal injuries indicative of multiorgan failure. The patient was treated with a red cell exchange transfusion (RBCx) leading to an almost complete recovery in a few days. The patient, however, had residual neurological sequelae with the presence of numb chin syndrome (NCS). This report thus highlights the need to recognize potential multiorgan failure secondary to steroid treatment and the importance of initiating treatment with red cell exchange transfusions to decrease the risk of such complications secondary to steroids.
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Affiliation(s)
| | | | - Marie Liu
- Medical Student, SUNY Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Khalid Elbashir
- Department of Adult Sickle Cell Practice, NYC Health + Hospitals/Kings County, Brooklyn, NY 11203, USA
| | - John Muthu
- Department of Adult Sickle Cell Practice, NYC Health + Hospitals/Kings County, Brooklyn, NY 11203, USA
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Pankaj P, Panda CK, Karim HMR, Bala S, Bidwaikar A. Ischemic Stroke as the Presenting Feature for Non-acute Promyelocytic Leukemia Variant of Acute Myeloid Leukemia: A Case Report. Cureus 2023; 15:e41083. [PMID: 37519500 PMCID: PMC10377751 DOI: 10.7759/cureus.41083] [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: 06/27/2023] [Indexed: 08/01/2023] Open
Abstract
Acute myeloid leukemia (AML) patients encounter complications mainly due to their underlying disease or chemotherapy. Although they are at high risk for both hemorrhagic and thrombotic complications, thrombotic vascular complication as an initial manifestation is less common and rarely reported, especially in non-acute promyelocytic leukemia (non-APML). A 58-year-old female with no co-morbidity presented with fever, decreased appetite, headache, and weakness in her left upper and lower limbs. Laboratory findings showed hyperleukocytosis with 90% blast cells and thrombocytopenia (50,000/dl). While investigated and conservatively managed, she developed a seizure and loss of consciousness on the same day and was admitted to the intensive care unit. Computed tomography showed a massive right infarct in the middle cerebral artery territory with a significant midline shift. Flow cytometry indicated the diagnosis of non-APML; chemotherapy, platelet transfusion, unfractionated heparin, mechanical ventilation, and other supportive treatments were started. While managing this case, we faced challenges in decision-making on thrombolysis, craniotomy, and chemotherapy. The case highlights the salient points and dilemmas in managing such an acutely ill patient in critical care.
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Affiliation(s)
- Priya Pankaj
- Anaesthesiology, Critical Care, and Pain Medicine, All India Institute of Medical Sciences, Raipur, Chhattisgarh, IND
| | - Chinmaya K Panda
- Anaesthesiology, Critical Care, and Pain Medicine, All India Institute of Medical Sciences, Raipur, Chhattisgarh, IND
| | - Habib Md R Karim
- Anaesthesiology, Critical Care, and Pain Medicine, All India Institute of Medical Sciences, Raipur, Chhattisgarh, IND
| | - Saroj Bala
- Clinical Haematology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, IND
| | - Aditya Bidwaikar
- Anaesthesiology, Critical Care, and Pain Medicine, All India Institute of Medical Sciences, Raipur, Chhattisgarh, IND
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Krebs-Drouot L, Karpathiou G, Scolan V, Bidat-Callet C, Boyer B, Péoc'h M. Death due to unsuspected acute myeloid leukaemia: an unusual forensic diagnosis. Forensic Sci Med Pathol 2023; 19:60-66. [PMID: 35984604 DOI: 10.1007/s12024-022-00516-y] [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] [Accepted: 08/05/2022] [Indexed: 11/30/2022]
Abstract
Acute myeloid leukaemia (AML) is a rare haematologic cancer with a rapid increase in blast cells, which need to be rapidly diagnosed and treated. The aim of this report is to analyse the rare phenomenon of AML diagnosed at autopsy after sudden death. We report three cases of AML and perform a literature review using the mesh terms "sudden death" and "leukaemia". We report the cases of three young women diagnosed with AML only after autopsy. We found seven articles which reported sudden death due to AML diagnosed at autopsy. Diagnosis of AML during autopsy is rare but can raise forensic issues. A complete autopsy with pathology analysis is needed.
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Affiliation(s)
- Lila Krebs-Drouot
- Forensic Medicine Department, Grenoble Alpes University Hospital, La Tronche, Grenoble, France.
| | - Georgia Karpathiou
- Pathology Department, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Virginie Scolan
- Forensic Medicine Department, Grenoble Alpes University Hospital, La Tronche, Grenoble, France
| | - Carolyne Bidat-Callet
- Forensic Medicine Department, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Baptiste Boyer
- Forensic Medicine Department, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Michel Péoc'h
- Pathology Department, University Hospital of Saint-Etienne, Saint-Etienne, France
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Jameie M, Heydari S, Ghabaee M, Amirifard H. Two ischemic stroke events within 48 h: a case report of an unusual presentation of thrombotic thrombocytopenic purpura. BMC Neurol 2023; 23:47. [PMID: 36709264 PMCID: PMC9883936 DOI: 10.1186/s12883-023-03073-1] [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] [Received: 11/30/2021] [Accepted: 01/16/2023] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) considers a rare cause of ischemic stroke (IS). We reported a case of a newly diagnosed patient with acquired immune-mediated TTP (iTTP), in whom two IS events developed during 48 h. CASE PRESENTATION A 59-year-old diabetic male was presented to the hospital 24 h after symptoms onset, including left hemiparesis, dysarthria, and decreased consciousness. A brain CT scan was performed with the suspicion of acute IS, indicating infarct lesions in the right middle cerebral artery (MCA) territory. The patient was not eligible for thrombolytic therapy due to admission delay. Over the next 24 h, the patient's neurological condition deteriorated, and the second brain CT scan showed new ischemic lesions in the left MCA territory. Initial laboratory evaluation indicated thrombocytopenia without evidence of anemia. However, in the following days, thrombocytopenia progressed, and microangiopathic hemolytic anemia (MAHA) developed. The ADAMTS-13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity and inhibitors assay confirmed the diagnosis of iTTP. The patient underwent plasma exchange activity and inhibitors assay confirmed the diagnosis of iTTP. The patient underwent and pulse IV methylprednisolone. Rituximab was also added due to the refractory course of the disease. After a prolonged hospital course, he had considerable neurologic recovery and was discharged. CONCLUSIONS Clinicians should consider two points. First, TTP should be considered in any patient presenting with IS and having thrombocytopenia or anemia without other symptoms of TTP. Second, worsening the patient's condition during hospitalization may indicate a new stroke and should be investigated immediately.
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Affiliation(s)
- Melika Jameie
- grid.411705.60000 0001 0166 0922Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran ,grid.411746.10000 0004 4911 7066Neuroscience Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Sanaz Heydari
- grid.414574.70000 0004 0369 3463Neurology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojdeh Ghabaee
- grid.411705.60000 0001 0166 0922Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamed Amirifard
- grid.411705.60000 0001 0166 0922Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
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Norouzi-Barough L, Asgari Khosroshahi A, Gorji A, Zafari F, Shahverdi Shahraki M, Shirian S. COVID-19-Induced Stroke and the Potential of Using Mesenchymal Stem Cells-Derived Extracellular Vesicles in the Regulation of Neuroinflammation. Cell Mol Neurobiol 2023; 43:37-46. [PMID: 35025001 PMCID: PMC8755896 DOI: 10.1007/s10571-021-01169-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 11/09/2021] [Indexed: 02/07/2023]
Abstract
Ischemic stroke (IS) is a known neurological complication of COVID-19 infection, which is associated with high mortality and disability. Following IS, secondary neuroinflammation that occurs can play both harmful and beneficial roles and lead to further injury or repair of damaged neuronal tissue, respectively. Since inflammation plays a pivotal role in the pathogenesis of COVID-19-induced stroke, targeting neuroinflammation could be an effective strategy for modulating the immune responses following ischemic events. Numerous investigations have indicated that the application of mesenchymal stem cells-derived extracellular vesicles (MSC-EVs) improves functional recovery following stroke, mainly through reducing neuroinflammation as well as promoting neurogenesis and angiogenesis. Therefore, MSC-EVs can be applied for the regulation of SARS-CoV-2-mediated inflammation and the management of COVID-19- related ischemic events. In this study, we have first described the advantages and disadvantages of neuroinflammation in the pathological evolution after IS and summarized the characteristics of neuroinflammation in COVID-19-related stroke. Then, we have discussed the potential benefit of MSC-EVs in the regulation of inflammatory responses after COVID-19-induced ischemic events.
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Affiliation(s)
- Leyla Norouzi-Barough
- Acquired Immunodeficiency Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Ali Gorji
- Epilepsy Research Center, Department of Neurosurgery, Westfälische Wilhelms-Universitat Münster, Munster, Germany
- Shefa Neuroscience Research Center, Khatam Alanbia Hospital, Tehran, Iran
| | - Fariba Zafari
- Cellular and Molecular Research Center, Research Institute for Prevention of Non- Communicable Disease, Qazvin University of Medical Sciences, Qazvin, Iran
| | | | - Sadegh Shirian
- Department of Pathology, School of Veterinary Medicine, Shahrekord University, Shahrekord, Iran.
- Shiraz Molecular Pathology Research Center, Dr. Daneshbod Pathol Lab, Shiraz, Iran.
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14
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Shimoyama T, Yamaguchi H, Kimura K, Suzuki F, Hayashi T, Wakita S. Clinical characteristics and management of headache in patients with myeloproliferative neoplasms. Front Neurol 2022; 13:1051093. [PMID: 36561301 PMCID: PMC9764390 DOI: 10.3389/fneur.2022.1051093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/08/2022] [Indexed: 12/12/2022] Open
Abstract
Background Headache is frequently reported as a neurological manifestation of myeloproliferative neoplasms (MPNs), including polycythemia vera and essential thrombocythaemia. This study sought to clarify the clinical characteristics and response to treatment of headaches in patients with MPNs. Methods We prospectively studied 137 patients with MPNs. The following information was gathered to assess the features of headache at baseline and at follow-up (>6 months): (1) average duration of headache attacks, (2) number of headache days per month, (3) numerical rating scale (NRS), (4) Headache Impact Test-6 (HIT-6), and (5) Migraine Disability Assessment (MIDAS). We compared those parameters for headaches between the baseline and follow-up interviews according to the management. Results Thirty-seven (27.0%) patients had headache. The prevalence of headaches gradually decreased with increasing age (Age ≤ 49 years: 61.0%, 50-59 years: 38.5%, 60-69 years: 17.2%, 70-79 years: 5.1%, and ≥80 years: 0.0%, P < 0.001). Multiple logistic regression analysis showed that younger age, but not platelet counts or the JAK2 V617F mutation, was independently associated with headaches (Odds Ratios 2.004, 95% confidence intervals 1.293-3.108, P = 0.002). Scintillating scotomas were present in 22 (59.5%) of 37 patients with headaches, while four patients developed sudden headaches that lasted for only 0-10 min. Follow-up interviews were available for 31 (83.8%) of 37 patients with headaches. Twenty-one (67.7%) patients were treated with low-dose aspirin (100 mg once daily) [low-dose aspirin alone: n = 9; combined cytoreductive therapy: n = 12] for headache management. All parameters for headache [average duration of headache attacks, number of headache days per month, NRS score, HIT-6 score, and MIDAS score (all P < 0.001)] were significantly improved at follow-up in patients taking low-dose aspirin. However, there were no significant differences in these parameters of headaches in patients who did not receive low-dose aspirin. Conclusion Headaches is common in patients with MPNs, particularly in younger patients. MPN-related headaches may be managed by using low-dose aspirin and controlling MPNs.
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Affiliation(s)
- Takashi Shimoyama
- Department of Neurology, Nippon Medical School, Tokyo, Japan,*Correspondence: Takashi Shimoyama
| | | | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Fumiaki Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | | | - Satoshi Wakita
- Department of Hematology, Nippon Medical School, Tokyo, Japan
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15
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Kelly MA, Singh J, Balabanov A, Wadina A, Dasovic B. Challenging Cases in Cerebrovascular Disease. Semin Neurol 2022; 42:758-766. [PMID: 36417992 DOI: 10.1055/a-1985-7000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Disorders involving the vascular system of the brain are numerous and sundry. Atherosclerotic thromboembolism of large vessels and lacunar infarctions of small vessel disease are well known. Brain infarction due to cardioembolism is common as well, and even more so when diligently sought. Rupture of intracranial blood vessels results in subarachnoid and intraparenchymal hemorrhage. We present four cases of stroke of uncommon cause and remind clinicians to be open minded to the many possible causes of stroke, in particular because early recognition and treatment is often critical. Case 1 discusses a patient with inflammatory cerebral amyloid angiopathy. The presentation, ability to recur, and current treatment considerations are reviewed. Case 2 discusses microangiopathic thrombotic angiopathy. Diagnosis and treatment are considered. An association with interferon therapy and the evolving terminology of this and related conditions are discussed. Case 3 discusses intracranial hemorrhage secondary to acute promyelocytic leukemia. Patients with acute leukemias require aggressive management of their coagulopathy, thrombocytopenia, and the disease itself. Finally, Case 4 discusses ischemic stroke due to a paradoxical embolism in the setting of a patent foramen ovale (PFO). Both medical and surgical management of a PFO for stroke prevention are considered.
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Affiliation(s)
- Michael A Kelly
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, Illinois
| | - Jasmine Singh
- Department of Neurology, University of California San Diego Ringgold Standard Institution, La Jolla, California
| | - Alexandra Balabanov
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, Illinois
| | - Adam Wadina
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, Illinois
| | - Braden Dasovic
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, Illinois
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16
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Kalff H, Cario H, Holzhauer S. Iron deficiency anemia and thrombosis risk in children-revisiting an old hypothesis. Front Pediatr 2022; 10:926925. [PMID: 35979407 PMCID: PMC9376258 DOI: 10.3389/fped.2022.926925] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
Iron deficiency anemia has a high prevalence in children and has repeatedly been implicated as a risk factor for arterial and venous thrombosis. As an effective therapy for iron deficiency anemia is available, understanding the association between this form of anemia and the potentially severe thrombosis phenotype is of major clinical interest. Recent findings shed light on pathophysiology of hypercoagulability resulting from iron-restricted erythropoiesis. Specifically, an animal model of induced iron deficiency allowed identifying multiple mechanisms, by which iron deficiency anemia results in increased thrombus formation and thrombus progression both in arterial and venous thrombosis. These findings complement and support conclusions derived from clinical data. The purpose of this mini review is to summarize current evidence on the association of iron deficiency anemia and thrombosis. We want to increase the awareness of iron deficiency as a risk factor for thrombosis in the pediatric population. We discuss how novel pathophysiological concepts can be translated into the clinical settings and suggest clinical studies on prevention and treatment strategies in high-risk patient groups.
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Affiliation(s)
- Hannah Kalff
- Department of Pediatric Hematology and Oncology, Charité University Medicine, Berlin, Germany
| | - Holger Cario
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Susanne Holzhauer
- Department of Pediatric Hematology and Oncology, Charité University Medicine, Berlin, Germany
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17
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Park JK, Lee EJ, Kim DE, Lee HJ. Carotid Vessel Wall MRI Findings in Acute Cerebral Infarction Caused by Polycythemia Vera: A Case Report. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2022; 83:178-183. [PMID: 36237364 PMCID: PMC9238195 DOI: 10.3348/jksr.2021.0106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/12/2021] [Accepted: 08/23/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Jun Kyeong Park
- Department of Radiology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Eun Ja Lee
- Department of Radiology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Hyun Jung Lee
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
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18
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Cao YY, Cao J, Bi ZJ, Xu SB, Liu CC. Hemorrhagic transformation after acute ischemic stroke caused by polycythemia vera: Report of two case. World J Clin Cases 2021; 9:7551-7557. [PMID: 34616825 PMCID: PMC8464450 DOI: 10.12998/wjcc.v9.i25.7551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/12/2021] [Accepted: 07/19/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Polycythemia vera (PV) is a chronic myeloproliferative disorder characterized by an increase in red blood cells in the peripheral blood. Previous work has reported the occurrence of thrombosis or hemorrhage arising in the cerebral vasculature secondary to PV. However, hemorrhagic transformation after PV-associated acute ischemic stroke has not been previously described.
CASE SUMMARY We herein present two cases of PV where hemorrhagic transformation occurred after an acute ischemic stroke. Case 1 was a 57-year-old woman with a history of hypertension who was admitted for left-sided weakness. Case 2 was a 68-year-old man who was admitted for a 10-d sudden left arm weakness. Imaging examinations for the two patients revealed hemorrhagic transformation after acute ischemic stroke. Both patients had JAK-2-V617F mutation and received antiplatelet therapy. Both of them had a good prognosis during the follow-up.
CONCLUSION This report suggested that hemorrhagic transformation may occur in acute ischemic stroke caused by PV. Antiplatelet drugs do not seem to influence the long-term outcomes in such patients. Future research should focus on establishing a standard antiplatelet treatment strategy for this condition.
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Affiliation(s)
- Ya-Yun Cao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan 430000, Hubei Province, China
| | - Jie Cao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
| | - Zhua-Jin Bi
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
| | - Sha-Bei Xu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
| | - Chen-Chen Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
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