Value of the D-dimer test in diagnosing deep vein thrombosis in rehabilitation inpatients

Prevalence and Risk Factors of Deep Venous Thrombosis in Intensive Inpatient Neurorehabilitation Unit

Venous thromboembolism (VTE) (deep vein thrombosis and its complication, pulmonary embolism) is a major cause of morbidity and mortality in hospitalized patients and about 7% of these cases are due to immobility secondary to a neurological impairment. Acquired brain injury (ABI) has also been recognized as one of the main risk factors for VTE. Numerous epidemiological studies have been conducted to assess the risk factors for VTE in institutionalized polytrauma patients, although there is a lack of information about neurorehabilitation wards. Since VTE is often undiagnosed, this prospective study aimed to determine the prevalence and clinical characteristics of lower-limb deep venous thrombosis (DVT) in ABI patients at neurorehabilitation admission.

METHODS

ABI patients were screened for DVT on admission to the intensive rehabilitation unit (IRU) with compression ultrasonography and basal D-dimer assay and were daily clinically monitored until discharge. A total of 127 consecutive ABI patients (mean age: 60.1 ± 17.6 years; 63% male; time from event: 30.9 ± 22.1 days; rehabilitation time in IRU: 84.6 ± 58.4 days) were enrolled.

RESULTS

On admission to the IRU, the DVT prevalence was about 8.6%. The mean D-dimer level in patients with DVT was significantly higher than in patients without DVT (6 ± 0.9 vs. 1.97 ± 1.61, p-value = 0.0001). ABI patients with DVT did not show any significant clinical characteristics with respect to ABI without DVT, although a prevalence of hemorrhagic strokes and patients originating from the Intensive Care Unit and Neurosurgery ward was revealed. During the rehabilitation period, patients with DVT showed a significant difference in pharmacological DVT prophylaxis (high prevalence of nadroparin with 27.3% vs. 1.7%, p-value = 0.04) and a prevalence of transfers in critical awards (36% versus 9.5% of patients without DVT, p-value = 0.05). The mortality rate was similar in the two groups.

CONCLUSIONS

Our research offers a more comprehensive view of the clinical development of DVT patients and confirms the prevalence rate of DVT in ABI patients as determined upon IRU admission. According to our findings, screening these individuals regularly at the time of rehabilitation admission may help identify asymptomatic DVT quickly and initiate the proper treatment to avoid potentially fatal consequences. However, to avoid time-consuming general ultrasonography observation, a more precise selection of patients entering the rehabilitation ward is required.

Extensive Lower Limb Deep Vein Thrombosis Provoked by Gastroenteritis-Induced Dehydration: A Case Report for Unusual Precipitating Factor

The incidence of deep vein thrombosis (DVT) has been related to a number of risk factors, including genetic and acquired prothrombotic conditions, infections, inflammatory diseases, hematologic disorders, trauma, and drug use. Dehydration is a known independent risk factor for the development of thrombosis; however possibly insufficient evidence to form a strong association. The purpose of this case report is to present a 30-year-old male with DVT provoked by acute gastroenteritis-induced dehydration. The patient presented to the emergency department (ED) with a recent history of watery diarrhea for four days, for which he was diagnosed with gastroenteritis and managed at an outpatient care facility. The patient visited the ED again with a complaint of a one-day history of progressively worsening continuous pain in his left lower calf associated with swelling. The ultrasound-Doppler/duplex scan for the left lower limb venous system showed negative augmentation signs and non-compressibility of the deep venous system with partial occlusion/echogenic thrombosis extending from the external iliac vein, saphenofemoral junction, superficial femoral vein, popliteal vein, anterior tibial vein, and posterior tibial artery vena comitans. The patient was diagnosed with acute extensive DVT (multiple emboli). Patient care (medical treatment plan/therapeutic anticoagulation) was started in the ED and continued in the Critical Care Unit for close monitoring and care for a couple of days, after which he was transferred to the ward and then discharged in stable condition. He was prescribed a three-month course of appropriate medication regimen. This rare case presentation is a reminder to emergency physicians that dehydration might induce DVT and all patients, regardless of age, diagnosis or comorbidities, should always be risk assessed upon presentation and discharge, and prophylaxis should be provided according to their risk profile.

Hemostatic parameters in patients with spinal cord injury in subacute and chronic phase of the rehabilitation

Objective: The goal of this study was to measure hemostatic markers after SCI.Design: Assesing changes in coagulation and fibrynilitic system in SCI patients in different time post injury to Cross-sectional study.Setting: Rehabilitation Department of the Bydgoszcz University Hospital, Poland from 2011 to 2017.Participants: SCI patient during acute and chronic rehabilitation (N = 88).Outcome Measures: Assesing following parameters: platelet counts and levels of D-dimer, antithrombin III (ATIII), tissue factor (TF), tissue factor pathway inhibitor (TFPI) and the inflammatory marker, C-reactive protein (CRP).Interventions: Eighty-eight SCI patients were divided into three groups based on the time elapsed from injury: group I (three weeks to three months), group II (three to twelve months) and group III (more than twelve months). All patients underwent ultrasonography (US) to detect acute or chronic recanalized deep vein thrombosis (DVT). Platelet counts and levels of D-dimer, ATIII, TF, TFPI and CRP were assessed. TF and TFPI levels were measured in the control group of forty healthy individuals without SCI, the rest of the parameters were compared to laboratory norms.Results: D-dimer levels were significantly higher in group I compared to group II (P = .0002) and group III (P < .001). Group II had higher D-dimer levels than group III (P = .032). TFPI levels were higher in group II compared with group III (P = .0041) and control group (P = .000033). TF was significantly higher in all the SCI groups compared with the control group (P < .001).Conclusions: D-dimer and TF levels were still elevated twelve months after SCI. TF levels were also elevated over 12 months after inury. The results may indicate that sub-acute and even chronic SCI patients have disturbed coagulation and fibrynolitic system.

Massive Edema of the Lower Limbs in Patients after Spinal Cord Injury-One Picture, Different Diagnoses

Diagnosis of the cause of massive edema of the lower limbs in patients after spinal cord injury (SCI) can be difficult because of loss of pain sensation, commonly occurring in this group of patients. This paper reviews several different pathologies that can lead to lower-limb edema and the associated diagnostic difficulties. We present four cases of patients with massive edemas of lower limbs at different times after SCI undergoing treatment in the Department of Rehabilitation, University Hospital in Bydgoszcz, Poland. All patients had a lack of pain sensation in the lower limbs and significantly elevated levels of D-dimer. In two cases, deep vein thrombosis (DVT) and intramuscular hematomas (IHs) were diagnosed. IHs were probably a consequence of antithrombotic treatments implemented due to the occurrence of DVT. Heterotopic ossification (HO) was diagnosed in a third case, and, in another patient, who was hospitalized for the longest period after injury, we found humeral bone fractures. Heterotopic ossification, intramuscular haematomas, and bone fractures of the lower limb can mimic DVT. Careful observation of the edema evolution is recommended, as the onset of new symptoms may indicate a different cause of edema from that initially established.

Clinical Factors Associated with Deep Vein Thrombosis in Rehabilitation Patients Suspected of Thromboembolism after Cerebral Infarction

The aim of this study is to investigate the association between characteristics of cerebral infarction lesion (vascular territory, etiology, and size), functional status and the occurrence of thromboembolism in patients suspected of having thromboembolism in a rehabilitation setting after cerebral infarction. Cerebral infarction patients who were suspected of having thromboembolism and who had undergone deep vein thrombosis (DVT) evaluation were included in analyses. Of the total 916 cerebral infarction patients, 65 patients were suspected of having DVT; 27 patients belonged to the DVT group and 38 patients belonged to the non-DVT group. The DVT (+) group was more likely to have a higher ratio of female, previous DVT history, middle cerebral artery (MCA) infarction, large arterial disease, modified Rankin Scale (mRS) score 5, abnormal speech and higher D-dimer. In multivariate logistic regression analysis, female sex, MCA infarction and mRS score 5 were significantly associated with the occurrence of thromboembolism in patients suspected of having thromboembolism. In contrast, other functional status, cerebral infarction etiology (Trial of ORG 10172 in Acute Stroke Treatment [TOAST] classification), and infarct volume were not associated with the occurrence of thromboembolism. In this study, female gender, MCA infarction, and mRS score 5 could be potential risk factors for thromboembolism in rehabilitation patients after cerebral infarction.

Update on traumatic acute spinal cord injury. Part 2

The aim of treatment in acute traumatic spinal cord injury is to preserve residual neurologic function, avoid secondary injury, and restore spinal alignment and stability. In this second part of the review, we describe the management of spinal cord injury focusing on issues related to short-term respiratory management, where the preservation of diaphragmatic function is a priority, with prediction of the duration of mechanical ventilation and the need for tracheostomy. Surgical assessment of spinal injuries based on updated criteria is discussed, taking into account that although the type of intervention depends on the surgical team, nowadays treatment should afford early spinal decompression and stabilization. Within a comprehensive strategy in spinal cord injury, it is essential to identify and properly treat patient anxiety and pain associated to spinal cord injury, as well as to prevent and ensure the early diagnosis of complications secondary to spinal cord injury (thromboembolic disease, gastrointestinal and urinary disorders, pressure ulcers).

D-dimer screening for deep venous thrombosis in traumatic cervical spinal injuries

BACKGROUND CONTEXT

Deep venous thrombosis (DVT) in spinal cord injury (SCI) patients is a life-threatening comorbidity. Despite its seriousness, prophylaxis and screening for DVT in SCI patients are still not sophisticated.

PURPOSE

This study aimed to define the epidemiology and incidence of DVT in acute traumatic cervical SCI in a Japanese population, determine the best timing for DVT screening, and determine the optimal D-dimer threshold level for use as an easy and minimally invasive screening tool.

STUDY DESIGN

This is a prospective clinical study.

PATIENT SAMPLE

The patient sample included acute traumatic cervical SCI patients who were admitted to our facility within 2 weeks after injury.

OUTCOME MEASURE

Multivariate logistic regression was performed for outcome measure.

METHODS

We enrolled 268 patients (223 men and 45 women), from April 2007 to December 2012. After excluding early drop-out patients, 211 patients remained. Assessment for neurological status and blood chemistry, especially blood coagulation levels (prothrombin time, prothrombin time-international normalized ratio, activated partial thromboplastin time, and serum D-dimer), was performed every week until 1 month after injury. Ultrasonography was performed for DVT detection every 2 weeks.

RESULTS

Deep venous thromboses were detected in 22 patients (10.4% of patients studied). All DVT-positive patients demonstrated severe paralysis classified as C or greater on the American Spinal Injury Association (ASIA) Impairment Scale. Multivariate logistic regression of clinical and laboratory parameters revealed that only the D-dimer level at 2 weeks after injury was an accurate predictor of DVT formation. The optimal threshold of D-dimer for prediction was determined to be 16 μg/dL. The sensitivity and specificity for detecting DVT were 77.3% and 69.2%, respectively.

CONCLUSIONS

D-dimer levels may be used to predict the likelihood of DVT development in patients with acute cervical SCI. Furthermore, the optimal timing for screening test by D-dimer is 2 weeks after injury, and optimal threshold level for D-dimer for diagnosing DVT is 16 μg/dL. Such a screening test would be cost-efficient and simple to administer and could then be followed with additional investigations, such as ultrasonography or venography.

D-dimer: An Overview of Hemostasis and Fibrinolysis, Assays, and Clinical Applications

D-dimer is the smallest fibrinolysis-specific degradation product found in the circulation. The origins, assays, and clinical use of D-dimer will be addressed. Hemostasis (platelet and vascular function, coagulation, fibrinolysis, hemostasis) is briefly reviewed. D-dimer assays are reviewed. The D-dimer is very sensitive to intravascular thrombus and may be markedly elevated in disseminated intravascular coagulation, acute aortic dissection, and pulmonary embolus. Because of its exquisite sensitivity, negative tests are useful in the exclusion venous thromboembolism. Elevations occur in normal pregnancy, rising two- to fourfold by delivery. D-dimer also rises with age, limiting its use in those >80 years old. There is a variable rise in D-dimer in active malignancy and indicates increased thrombosis risk in active disease. Elevated D-dimer following anticoagulation for a thrombotic event indicates increased risk of recurrent thrombosis. These and other issues are addressed.

Usefulness of the computed tomography venography for evaluation of leg edema including deep vein thrombosis in rehabilitation patients

Objective

To investigate the usefulness of computed tomography venography (CTV) for evaluation of leg swelling, especially deep vein thrombosis (DVT), in rehabilitation patients.

Methods

A hundred twenty-three patients, who had performed CTV performed because of suspected DVT in our clinic, were enrolled. We performed chart reviews retrospectively and categorized CTV findings as follows: DVT distal to inguinal ligament and no compression lesion; DVT proximal to inguinal ligament and no compression lesion; DVT distal to inguinal ligament and anatomical variant (for example, May-Thurner syndrome); DVT due to compression of mass (cancer or cyst); DVT and other incidental abnormal finding; and no DVT and other possible causes of leg swelling.

Results

DVTs were found in 65 (53%) patients. DVTs were found at distal level (thigh or lower leg) to inguinal ligament in 47 patients. DVTs were found at proximal to inguinal ligament, usually undetectable with duplex ultrasonography, in 6 patients. DVTs caused by external compression, such as femoral vein and cancer mass, were found in 12 patients (10%), which are also not easily detected with duplex ultrasonography. Other various causes of leg edema without DVT were found in 22 (18%) patients.

Conclusion

CTV can evaluate more extensively venous problems in the pelvis and abdomen and detect other possible causes of leg swelling. Therefore, CTV can be a useful tool not only for easy detection of DVT but also for evaluating differential diagnosis of leg edema in rehabilitation patients.

Deep vein thrombosis in a young marathon athlete

STUDY DESIGN

Resident's case problem.

BACKGROUND

A 21-year-old athletic male college student presented to a direct-access physical therapy clinic with complaints of left calf pain 4 days in duration. After initial examination, a working diagnosis of calf strain was formulated. Three days following initial examination, the patient reported 80% improvement in symptoms and was performing activities of daily living pain free. Four weeks later, the patient returned with complaints of reoccurring calf pain. The patient's signs, symptoms, and history at subsequent follow-up no longer presented a consistent clinical picture of calf strain; therefore, a D-dimer assay was ordered to rule out a deep vein thrombosis (DVT).

DIAGNOSIS

The D-dimer was elevated so the patient was admitted to the hospital and started on low-molecular-weight heparin. A compression ultrasound revealed an extensive left superficial femoral and popliteal DVT in this otherwise healthy athlete.

DISCUSSION

Lower extremity DVT is a serious and potentially fatal disorder. Physical therapists need to be diagnostically vigilant for vascular pathology in all patients with extremity pain and swelling. Employing the best current evidenced-based screening tools to rule out vascular pathology, such as deep and superficial vein pathology, should be the goal of every clinician. The Wells score is one such screening tool that has proven to be beneficial in this area. This case report presents a dilemma in diagnosis and illustrates the importance of revisiting differential diagnoses with each patient encounter. Clinicians must consider the possibility of a DVT with every patient seen with posterior leg pain.

LEVEL OF EVIDENCE

Diagnosis, level 4. doi:10.2519/jospt.2011.3823.

The value of blood D-dimer test in the diagnosis of walk-in patients with venous thromboembolism

Venous thromboembolism (VTE) and related pulmonary thromboembolism are life-threatening diseases that require efficient diagnosis and clinical management. While the diagnosis and treatment of VTE in hospitalized patients has been extensively studied, less has been reported on walk-in patients with VTE. Here we report on four outpatients with VTE that were efficiently diagnosed using the blood D-dimer test and successfully treated.

Early ambulation after total knee arthroplasty prevents patients with osteoarthritis and rheumatoid arthritis from developing postoperative higher levels of D-dimer

This study aimed to clarify the therapeutic effects of postoperative ambulation after total knee arthroplasty (TKA) on deep venous thrombosis (DVT) in patients with osteoarthritis (OA) and rheumatoid arthritis (RA) after TKA. Subjects of this study were thirty-seven inpatients (21 inpatients: OA, 16 inpatients: RA) undergoing TKA (32 female and 5 male). Subjects were divided into two groups, deep venous thrombosis (DVT) group (n=25) and non-DVT group (N group, n=12). The cutoff value was 10.0 microg/ml plasma D-dimer level measured on 7(th) postoperative day. The N group was below the cutoff value. Another cutoff value divided into two groups, ambulatory group (n=26) and non-ambulatory group (n=11). Ambulatory group was the date of ambulation beginning below 7(th) day. Statistical analysis confirmed that all subjects showed a significant correlation to the date of ambulation. Postoperative ambulation beginning had strong association with the level of D-dimer (r=0.71). Group comparison showed that the non-ambulatory group had significant higher values of D-dimer than ambulatory group (P=0.022). Typical case supported these results. Postoperative early ambulation within a week after TKA kept patients with OA and RA after TKA lower level of D-dimer.

Deep vein thrombosis in stroke patients admitted to a rehabilitation unit in Singapore

BACKGROUND

Studies have shown that deep vein thrombosis (DVT) is common after an acute stroke. Less common are studies documenting DVT in stroke patients admitted to rehabilitation. The purpose of this study was to determine the frequency and risk factors of DVT in stroke patients admitted to a rehabilitation unit in Singapore.

METHODS

A prospective observational single-center study of patients with ischemic and hemorrhagic stroke with lower limb paresis admitted to a rehabilitation center in Singapore. The screening protocol consisted of quantitative D-dimer assay (DDA) within 24-48 h of rehabilitation admission followed by duplex ultrasound scan of the paretic lower extremity if DDA level was elevated (equal or greater than 0.34 microg/ml).

RESULTS

Altogether, 341 patients were screened at a mean of 23 days poststroke. One hundred and ninety-eight (58.1%) patients had an elevated DDA and all underwent ultrasound scans. The frequency of lower limb DVT was 9% (18) - seven proximal and 11 distal. DVT was significantly related to higher D-dimer levels (P=0.029) and cortical strokes (P=0.004), but not to age, gender, race, nature of stroke, atrial fibrillation, severity of lower limb weakness, and ambulatory and functional status. No patients had clinical pulmonary embolism during rehabilitation.

CONCLUSIONS

Lower limb DVT is uncommon in stroke patients admitted to rehabilitation in Singapore. Future research should include evaluation of the cost-effectiveness of such a screening protocol.

Venous thromboembolism after spinal cord injury

OBJECTIVE

To review systematically the published literature on the treatment of deep venous thromboembolism after spinal cord injury (SCI).

DATA SOURCES

MEDLINE/PubMed, CINAHL, EMBASE, and PsycINFO databases were searched for articles addressing the treatment of deep venous thromboembolism post-SCI. Randomized controlled trials (RCTs) were assessed for methodologic quality using the Physiotherapy Evidence Database Scale, while non-RCTs were assessed using the Downs and Black evaluation tool.

STUDY SELECTION

Studies included RCTs, non-RCTS, cohort, case-control, case series, pre-post, and postinterventional studies. Case studies were included only when no other studies were available.

DATA EXTRACTION

Data extracted included demographics, the nature of the study intervention, and study results.

DATA SYNTHESIS

Levels of evidence were assigned to the interventions using a modified Sackett scale.

CONCLUSIONS

Twenty-three studies met inclusion criteria. Thirteen studies examined various pharmacologic interventions for the treatment or prevention of deep venous thrombosis in patients with SCI. There was strong evidence to support the use of low-molecular-weight heparin in reducing venous thrombosis events, and a higher adjusted dose of unfractionated heparin was found to be more effective than 5000 units administered every 12 hours, although bleeding complications were more common. Nonpharmacologic treatments were also reviewed, but again limited evidence was found to support these treatments.

Deep venous thrombosis in stroke patients during rehabilitation phase

PURPOSE

The purpose of this study was to examine the incidence, factors, and effects of antiplatelet and anticoagulant agents on sub-acute and chronic ischemic stroke patients during the rehabilitation phase for rates of deep venous thrombosis (DVT) from the perspective for rehabilitation medicine.

METHODS

In this study of 272 patients undergoing rehabilitation for completed cerebral infarction, multiple circumference measurements of calf and thigh along with presence or absence of symptoms (congestion, swelling, skin redness, warmth, pain, pigmentation, fever and/or Homan sign or Luck's sign) documented in the physical examination were recorded in all patients. Patients with these symptoms suggestive of DVT were included for D-dimer assay and venous duplex ultrasonography to confirm presence of DVT.

RESULTS

DVT was documented in 24 patients (8.8%), most of whom displayed distal DVT on the hemiparetic side. A significant association was seen between occurrence of DVT and more severe lower limb paresis, manifesting as gait disturbance, severe calf muscle spasticity, use of ankle-foot orthosis (AFO). A significant increase in development of DVT was associated with severe spasticity in hemiparetic calf muscles (odds ratio (OR) 28.2; 95% confidence interval (CI), 6.9-113.5). Cilostazol seemed to be the only effective antiplatelet drug for preventing DVT in cerebral infarction patients.

CONCLUSION

Incidence of DVT in the rehabilitation phase following stroke was not low, which was predominant as distal DVT on the hemiparetic side. Lower limb paresis, gait disturbance, calf muscle spasticity and use of AFO contributed to occurrence of DVT. It is likely that micro-injuries in the venous endothelium due to spasticity and AFO might cause DVT. Cilostazol seems effective for protecting against venous endothelial damage following DVT.

Prevalence and risk factors of asymptomatic lower extremity deep venous thrombosis in Asian neurorehabilitation admissions in Singapore

OBJECTIVE

To determine the local prevalence and risk factors of asymptomatic lower limb deep venous thrombosis (DVT) among neurorehabilitation admissions.

DESIGN

A prospective observational single-center study.

SETTING

Tertiary rehabilitation center affiliated to a public hospital.

PARTICIPANTS

A total of 419 Asian neurorehabilitation admissions with a mean of 26 days to rehabilitation.

INTERVENTION

Admission screening protocol included quantitative D-dimer assay within 24 to 48 hours of rehabilitation admission and targeted hemiplegic/weaker lower-extremity venous duplex ultrasonography was performed if D-dimer assay level was elevated at 0.34 microg/mL or higher.

MAIN OUTCOME MEASURES

There were 251 (59.9%) men, and the subjects were predominantly Chinese (76.6%). Subjects had a mean age of 59+/-15 years. Admitting diagnoses included ischemic stroke (212), hemorrhagic stroke and subarachnoid hemorrhage (129), traumatic brain injury (59), and nontraumatic brain injury (19). The screening protocol included a quantitative D-dimer assay within 24 to 48 hours of rehabilitation admission, and hemiplegic/weaker lower-extremity venous duplex ultrasonography was performed if D-dimer assay level was elevated at 0.34 microg/mL or higher.

RESULTS

Altogether, 247 (58.9%) patients had an elevated D-dimer assay, and all underwent venous duplex ultrasonography. The incidence of lower-limb DVT was 5.01% (21), including 11 proximal and 10 distal DVT. No patients had clinical pulmonary embolism. Using 247 venous duplex ultrasonography results for analyses of correlates with logistic regression analyses, no significant demographic or clinical predictive factors for DVT were found.

CONCLUSIONS

This study confirms that asymptomatic lower limb DVT is indeed uncommon in Asian neurorehabilitation admissions. Possible reasons include genetic or ethnic protective factors, early walking initiated at rehabilitation, and timing of the admission protocol (median of 14 days postevent) when the maximal thrombotic risk was on the decline.

Dalteparin vs low-dose unfractionated heparin for prophylaxis against clinically evident venous thromboembolism in acute traumatic spinal cord injury: a retrospective cohort study

BACKGROUND

When venous thromboembolism (VTE) includes deep-vein thrombosis (DVT) and pulmonary embolism (PE), patients with acute traumatic spinal cord injury (SCI) have the highest incidence of VTE among all hospitalized groups, with PE the third most common cause of death. Although low-molecular-weight heparin (LMWH) outperforms low-dose unfractionated heparin (LDUH) in other patient populations, the evidence in SCI remains less robust.

OBJECTIVE

To determine whether the efficacy for LMWH shown in previous SCI surveillance studies (eg, routine Doppler ultrasound) would translate into real-world effectiveness in which only clinically evident VTE is investigated (ie, after symptoms or signs present).

METHODS

A retrospective cohort study was conducted of 90 patients receiving LMWH dalteparin (5,000 U daily) or LDUH (5,000 U twice daily) for VTE prophylaxis after acute traumatic SCI. The incidence of radiographically confirmed VTE was primarily analyzed, and secondary outcomes included complications of bleeding and heparin-induced thrombocytopenia.

RESULTS

There was no statistically significant association (p = 0.7054) between the incidence of VTE (7.78% overall) and the type of prophylaxis received (LDUH 3/47 vs dalteparin 4/43). There was no significant differences in complications, location of VTE, and incidence of fatal PE. Paraplegia (as opposed to tetraplegia) was the only risk factor identified for VTE.

CONCLUSIONS

There continues to be an absence of definitive evidence for dalteparin (or other LMWH) over LDUH as the choice for VTE prophylaxis in patients with SCI. Novel approaches to VTE prophylaxis are urgently required for this population, whose risk of fatal PE has not decreased over the last 25 years.

The value of the D-Dimer assay for predicting vein thrombosis in rehabilitation patients receiving prophylactic low molecular weight heparin doses

PURPOSE

Early diagnosis and treatment of venous thrombosis biocontact="no" are essential in preventing pulmonary embolism (PE) and reducing the risk of recurrence. The objective was to assess the usefulness of the D-Dimer testing to rule out symptomatic VT in populations of patients receiving heparin in prophylactic doses.

METHODS

One hundred and twenty-three rehabilitation patients with medium or high risk for VT were investigated. Patients were affected by acquired cerebral diseases (n=31), severe brain damage (n=32) or orthopaedic surgical sequelae for major joint replacement or multiple limb fractures (n=60). All patients were receiving prophylactic heparin doses. D-Dimer levels were assessed using Dimertest Latex Agglutination Assay in citrated plasma. Single blinded compression Doppler Ultrasound (DUS) examination was performed in conformity with international standards.

RESULTS

In this specific setting, good sensitivity and specificity of the D-Dimer test was confirmed in patients with acquired cerebral diseases during rehabilitation, whereas false positive results were found in most patients who had undergone major joint replacement, until several weeks after surgery.

CONCLUSIONS

In rehabilitation patients receiving prophylactic heparin doses, the D-Dimer test seems to confirm high sensitivity and high negative predictive value for VT and PE. Relevant clinical variables seem to reduce the usefulness of the D-Dimer test as a screening tool for VT, at least in orthopaedic patients with joint prosthesis.

Role of screening tests for deep venous thrombosis in asymptomatic adults with acute spinal cord injury: an evidence-based analysis

STUDY DESIGN

Systematic review.

OBJECTIVE

To examine the evidence to support practice guidelines for screening for DVT in asymptomatic adults with acute traumatic spinal cord injury (SCI) who undergo pharmacologic thromboprophylaxis.

SUMMARY OF BACKGROUND DATA

Despite the fact that pharmacologic thromboprophylaxis has been widely used since the 1980s, deep venous thrombosis (DVT) and subsequent pulmonary embolism (PE) still account for approximately 10% of deaths during the first year following SCI.

METHODS

MEDLINE and EMBASE were searched from the earliest achievable date to December 2005. We only included clinical studies that used a screening test for DVT and the gold standard diagnostic tests for DVT (i.e., lower limb venography) and for PE (i.e., lung arteriogram) in adults with traumatic SCI who underwent drug thromboprophylaxis during the acute stage after SCI.

RESULTS

The search yielded 188 articles, of which 9 articles fulfilled the criteria to be included in our review. Screening for DVT was performed in 3 randomized clinical trials and 6 case series. The protocol of these studies included the use of D-Dimer (1 of 9), I-labeled fibrinogen (2 of 9), ultrasound (1 of 9), impedance plethysmography (1 of 9), impedance plethysmography and Doppler in combination (1 of 9), Duplex (1 of 9) or venography (2 of 9) as screening test for DVT. Based on the pooled data of these studies, asymptomatic DVT was detected in 16.9% of SCI population. Only 4 studies reported the occurrence of PE in 4.4% of cases.

CONCLUSION

There is insufficient evidence to support (or refute) a recommendation for routine screening for DVT in adults with acute traumatic SCI under thromboprophylaxis. However, there is level II-2 evidence that screening could detect asymptomatic DVT in 22.7% of those individuals. Although additional investigation is needed, we hypothesize that weekly screening for DVT during the first 13 weeks post-SCI could detect most of the asymptomatic DVT events in this patient population. D-Dimer, ultrasound, and MR venography could be considered as potentially useful screening tests for DVT in the SCI population in future research studies.

Venous thromboembolism in acute spinal cord injury patients

BACKGROUND

The western literature on deep vein thrombosis (DVT) and pulmonary embolism (PE) following spinal cord injury (SCI) report an alarmingly high incidence, necessitating thromboprophylaxis. The literature on incidence from the Asian subcontinent is scanty and from India is almost nonexistent.

MATERIALS AND METHODS

Seventy hospitalized acute SCI patients presenting within five days of the injury were included in the present analysis. Forty-two cases were subjected to color Doppler studies and 28 cases had to be subjected to venography due to lack of facility at some point of time. The clinical course of the patients was closely observed during the period of hospitalization. All except 14 were managed nonoperatively. Thromboprophylaxis was not given to any patient at any stage; however, treatment was instituted in those showing the features of DVT on investigations.

RESULTS

Twelve patients died during the period of hospitalization. Deep vein thrombosis could be detected in seven patients only, three in the proximal and four in the distal segment of the lower limb and of these three died. Based on the clinical course and positive investigation report in favor of DVT, we presumed that the cause of death in these three patients was pulmonary embolism. In the other nine, in the absence of an autopsy report, the cause of deaths was considered as pulmonary infection, asphyxia, diaphragmatic paralysis, hematemesis, cervicomedullary paralysis etc. Clinical features to diagnose DVT were of little help.

CONCLUSIONS

There is a much lower incidence (10%) of DVT and PE following spinal cord injury (SCI) in India than what is reported from the western countries. Higher age group and quadriplegia were the only factors which could be correlated. Deep vein thrombosis extending proximal to the knee was significant. In the absence of autopsy and other screening tests like D-dimer test or 125I fibrogen uptake study, the true incidence of venous thromboembolism remains uncertain. Noninvasive screening of all patients for the detection of deep vein thrombosis in SCI patients is strongly recommended.

Current approaches and controversial issues in the diagnosis of deep vein thrombosis via duplex Doppler ultrasound

Duplex and color Doppler sonography (DUS) is currently the technique of choice for the diagnosis of deep venous thrombosis (DVT) in symptomatic patients, because it has proven safe and cost-effective, with a very high sensitivity and specificity (96% and 98%, respectively) for the diagnosis of proximal DVT. Several issues regarding its method and clinical indications remain controversial, however. Although isolated calf vein thrombosis does not seem to have a significant adverse outcome in the short term, scanning the calf only in patients with localized symptoms or signs is cost-effective. Bilateral examination is indicated in high-risk patients or when screening asymptomatic patients. When negative, a complete DUS examination of the proximal and distal veins, at least down to the level of the popliteal trifurcation, allows withholding anticoagulant therapy without the risk of major complications. This examination may be repeated if signs or symptoms worsen. Some populations of asymptomatic patients at high risk of DVT may benefit from DUS screening. Bilateral DUS examination of lower limb veins should be performed as the initial examination in the workflow of pulmonary embolism only in patients with risk factors for DVT. Recurrent thrombosis is a challenging diagnosis for all imaging modalities. A diagnostic strategy combining clinical probability score and D-dimer test may refine the selection of patients. The pitfalls and limitations of venous DUS are related to vein anatomy, flow changes, technical issues, and operator expertise.

Usefulness of a latex agglutination assay for FDP D-dimer to demonstrate the presence of postmortem blood

D-dimer, a specific fragment resulting from degradation of cross-linked fibrin, is an essential marker for the diagnosis of disseminated intravascular coagulation (DIC). Rapid assay for D-dimer using monoclonal antibody coated-latex particles might be useful for discriminating between postmortem and antemortem blood in bloodstains. We tried to detect D-dimer in nine postmortem blood samples by the rapid latex agglutination assay and to quantify them automatically using the latex photometric immunoassay system. The results showed that all samples were positive and that their amounts of D-dimer were 335-2,800 microg/ml (the normal blood level, <1 microg/ml; the pathogenic blood level with DIC, 1-100 microg/ml). Next, nine stains made of postmortem blood were examined by the rapid latex agglutination assay. The result showed that only one case (D-dimer 335 microg/ml blood) showed weak positive while the others (D-dimer 600-2,800 microg/ml blood) were positive. The present study indicates that the latex agglutination assay for D-dimer can be useful to demonstrate the presence of postmortem blood.

Deep vein thrombosis and pulmonary embolism in an ambulatory chronic stroke patient

PURPOSE

Deep vein thrombosis (DVT) is a well-known complication of stroke and frequently develops in acute stroke patients. Immobility in stroke patients increases the risk of DVT and pulmonary embolism (PE). The incidence of DVT in non-ambulatory stroke patients is more frequent than the incidence in ambulatory stroke patients. We report a case of DVT and PE in an ambulatory chronic stroke patient.

METHOD

Initial physical examination showed heat and swelling of hemiplegic leg. The patient was only able to ambulate with the assist of a monocane and a plastic leaf spring orthosis due to ankle dorsiflexor weakness. The patient was treated with anticoagulation and inferior vena cava filter placement.

RESULTS

After long-term anticoagulation, follow-up studies revealed satisfactory resolution of DVT and PE.

CONCLUSIONS

We present a case of DVT and PE which developed during the chronic stage of stroke, 2 years from the onset of stroke, and review the cause of DVT.