A review of hereditary and acquired coagulation disorders in the aetiology of ischaemic stroke

Blood Coagulation and Thrombotic Disorders following SARS-CoV-2 Infection and COVID-19 Vaccination

Although abundant data confirm the efficacy and safety profile of the developed vaccines against COVID-19, there are still some concerns regarding vaccination in high-risk populations. This is especially valid for patients susceptible to thrombotic or bleeding events and hesitant people due to the fear of thrombotic incidents following vaccination. This narrative review focuses on various inherited and acquired thrombotic and coagulation disorders and the possible pathophysiologic mechanisms interacting with the coagulation system during immunization in view of the currently available safety data regarding COVID-19 vaccines. Inherited blood coagulation disorders and inherited thrombotic disorders in the light of COVID-19, as well as blood coagulation and thrombotic disorders and bleeding complications following COVID-19 vaccines, along with the possible pathogenesis hypotheses, therapeutic interventions, and imaging for diagnosing are discussed in detail. Lastly, the lack of causality between the bleeding and thrombotic events and COVID-19 vaccines is debated, but still emphasizes the importance of vaccination against COVID-19, outweighing the minimal risk of potential rare adverse events associated with coagulation.

Prognostic significance of international normalised ratio and prothrombin time in Chinese acute ischaemic stroke patients

BACKGROUND

We investigated the association between international normalised ratio (INR) and prothrombin time (PT) levels on hospital admission and in-hospital outcomes in acute ischaemic stroke (AIS) patients.

METHODS

A total of 3175 AIS patients enrolled from December 2013 to May 2014 across 22 hospitals in Suzhou city were included. We divided patients into four groups according to their level of admission INR: (<0.92), Q2 (0.92-0.98), Q3 (0.98-1.04) and Q4 (≥1.04) and PT. Logistic regression models were used to estimate the effect of INR and PT on death or major disability (modified Rankin Scale score (mRS)>3), death and major disability (mRS scores 4-5) separately on discharge in AIS patients.

RESULTS

Having an INR level in the highest quartile (Q4) was associated with an increased risk of death or major disability (OR 1.69; 95% CI 1.23 to 2.31; P-trend=0.001), death (OR, 2.64; 95% CI 1.12 to 6.19; P-trend=0.002) and major disability on discharge (OR, 1.56; 95% CI 1.13 to 2.15; P-trend=0.008) in comparison to Q1 after adjusting for potential covariates. Moreover, in multivariable logistic regression models, having a PT level in the highest quartile also significantly increased the risk of death (OR, 2.38; 95% CI 1.06 to 5.32; P-trend=0.006) but not death or major disability (P-trend=0.240), major disability (P-trend=0.606) on discharge.

CONCLUSIONS

High INR at admission was independently associated with death or major disability, death and major disability at hospital discharge in AIS patients and increased PT was also associated with death at hospital discharge.

The Hemoglobin, Albumin, Lymphocyte, and Platelet (HALP) Score Is Associated With Poor Outcome of Acute Ischemic Stroke

Background: The combined index of hemoglobin, albumin, lymphocyte, and platelet (HALP) is considered a novel score to reflect systemic inflammation and nutritional status. This study aimed to investigate the association between HALP score and poor outcome in patients with acute ischemic stroke (AIS). Methods: Consecutive AIS patients within 24 h after onset were prospectively enrolled. Poor outcome was a combination of a new stroke event (ischemic and hemorrhagic) and all-cause death within 90 days and 1 year. The association between HALP score and poor outcome was analyzed using Cox proportional hazards. Results: A total of 1,337 patients were included. Overall, 60 (4.5%) and 118 (8.8%) patients experienced poor outcome within 90 days and 1 year, respectively. Patients in the highest tertile of HALP score had a lower risk of poor outcome within 90 days and 1 year (hazard ratio: 0.25 and 0.42; 95% confidence intervals: 0.11-0.57 and 0.25-0.69, P for trend <0.01 for all) compared with those in the lowest tertile after adjusting relevant confounding factors. Adding HALP score to the conventional risk factors improved prediction of poor outcome in patients with AIS within 90 days and 1 year (net reclassification index, 48.38 and 28.95%; integrated discrimination improvement, 1.51 and 1.51%; P < 0.05 for all). Conclusions: Increased HALP score was associated with a decreased risk of recurrent stroke and death within 90 days and 1 year after stroke onset, suggesting that HALP score may serve as a powerful indicator for AIS.

Terminal Phase Components of the Clotting Cascade in Patients with End-Stage Renal Disease Undergoing Hemodiafiltration or Hemodialysis Treatment

Hemostasis disorder in patients with end-stage renal disease (ESRD) is frequently associated with bleeding diathesis but it may also manifest in thrombotic complications. Analysis of individual coagulation and fibrinolytic factors may shed light on the background of this paradox situation. Here we explored components essential for fibrin formation/stabilization in ESRD patients being on maintenance hemodiafiltration (HDF) or hemodialysis (HD). Pre-dialysis fibrinogen, factor XIII (FXIII) antigen concentrations and FXIII activity were elevated, while α₂-plasmin inhibitor (α₂PI) activity decreased. The inflammatory status, as characterized by C-reactive protein (CRP) was a key determinant of fibrinogen concentration, but not of FXIII and α₂PI levels. During a 4-h course of HDF or HD, fibrinogen concentration and FXIII levels gradually elevated. When compensated for the change in plasma water, i.e., normalized for plasma albumin concentration, only FXIII elevation remained significant. There was no difference between HDF and HD treatments. Individual HDF treatment did not influence α₂PI activity, however after normalization it decreased significantly. HD treatment had a different effect, α₂PI activities became elevated but the elevation disappeared after normalization. Elevated fibrinogen and FXIII levels in ESRD patients might contribute to the increased thrombosis risk, while decreased α₂PI activity might be associated with elevated fibrinolytic potential.

Cardiovascular Diseases And Psychiatric Disorders During The Diagnostic Workup Of Suspected Hematological Malignancy

Background

Little attention has been given to the risk of cardiovascular and psychiatric comorbidities during the clinical evaluation of a suspected hematological malignancy.

Methods

Based on Skåne Healthcare Register, we performed a population-based cohort study of 1,527,449 individuals residing during 2005-2014 in Skåne, Sweden. We calculated the incidence rate ratios (IRRs) of cardiovascular diseases or psychiatric disorders during the diagnostic workup of 5495 patients with hematological malignancy and 18,906 individuals that underwent a bone marrow aspiration or biopsy or lymph node biopsy without receiving a diagnosis of any malignancy ("biopsied individuals"), compared to individuals without such experience (i.e., reference).

Results

There was a higher rate of cardiovascular diseases during the diagnostic workup of patients with hematological malignancy (overall IRR, 3.3; 95% CI, 2.9 to 3.8; greatest IRR for embolism and thrombosis, 8.1; 95% CI, 5.2 to 12.8) and biopsied individuals (overall IRR, 4.9; 95% CI, 4.6 to 5.3; greatest IRR for stroke, 37.5; 95% CI, 34.1 to 41.2), compared to reference. Similarly, there was a higher rate of psychiatric disorders during the diagnostic workup of patients with hematological malignancy (IRR, 2.1; 95% CI, 1.5 to 2.8) and biopsied individuals (IRR, 3.1; 95% CI, 2.9 to 3.4). The rate increases were greater around the time of diagnosis or biopsy, compared to thereafter, for both outcomes.

Conclusion

There were higher rates of cardiovascular diseases and psychiatric disorders during the diagnostic workup of a suspected hematological malignancy, regardless of the final diagnosis.

[Rare causes of stroke-a frequent stroke etiology]

As a whole, rare stroke causes represent a frequent stroke etiology. Since rare stroke causes affect primarily young patients, early diagnosis and treatment are of high socioeconomic relevance. In our everyday clinical practice, cervical artery dissection, which is the most common stroke etiology among patients < 45 years, and vasculitis are particularly important. In the case of vasculitis, devastating disease courses and potentially harmful treatment options complicate clinical decision-making. Non-vasculitic vasculopathies, infections, hematological disorders, coagulation disorders, metabolic disorders and malignancies are further rare causes of stroke with variable clinical manifestations, thus impeding an early diagnosis. If eligible, patients with rare stroke causes should be considered for thrombectomy. Except for infective endocarditis, most rare stroke causes are not per se a contraindication to thrombolysis, so that eligible patients should also be considered for thrombolysis. Evidence based recommendations for the secondary prevention of most rare stroke causes are still missing. In many cases, treatment regimens are adapted to the patients' individual risk of stroke recurrence and bleeding complications.

Patent foramen ovale treatment strategy: an Italian large prospective study

AIM

There is still controversy regarding the benefit of percutaneous closure of patent foramen ovale (PFO) among patients with cryptogenic stroke. Here we aimed to evaluate the factors associated with treatment choice and predictors of adverse events in patients with cryptogenic stroke or transient ischemic attack (TIA) and PFO.

METHODS

Of 418 consecutive patients with PFO and cryptogenic stroke or TIA, 262 underwent percutaneous PFO closure, whereas 156 were medically treated. Multivariable logistic regression models were developed to evaluate factors influencing the treatment strategy and predictors of outcome, a composite of stroke, TIA or all-cause mortality.

RESULTS

Patients with large interatrial right-to-left shunt were more likely treated with percutaneous closure [odds ratio (OR) = 4.79, 95% confidence interval (2.73-8.42); P < 0.0001], whereas those with multiple cerebrovascular accident (CVA) risk factors were more likely treated medically [OR = 0.15 (0.03-0.60); P = 0.023]. Age greater than 55 years [OR = 2.70 (1.05-6.88); P = 0.04], previous CVAs [OR = 2.49 (1.03-6.02); P = 0.02] and atrial septal aneurism [ASA, OR = 2.64 (1.09-6.39); P = 0.02], but not percutaneous closure of PFO [OR = 1.10 (0.44-2.74); P = 0.81], were independent predictors of outcome.

CONCLUSION

Among patients with cryptogenic stroke and PFO, the presence of large interatrial right-to-left shunt and multiple CVA risk factors influenced the treatment choice. Older age, multiple previous CVAs and ASA, but not PFO closure, independently predicted the composite outcome of cryptogenic stroke, TIA or all-cause mortality.

The management of stroke in antiphospholipid syndrome

Ischemic stroke is one of the most common complications of the antiphospholipid syndrome (APS). Because of the relative lack of definitive prospective studies, there is still some debate as to whether the persistent presence of antiphospholipid antibodies (aPLs) increases the risk of recurrent stroke. There is more evidence for aPLs as a risk factor for first stroke. The mechanisms of ischemic stroke are considered to be thrombotic and embolic. APS patients with thrombotic stroke frequently have other, often conventional vascular risk factors. Transesophageal echocardiogram is strongly recommended in APS patients with ischemic stroke because of the high yield of valvular abnormalities. The appropriate management of thrombosis in patients with APS is still controversial because of limited randomized clinical trial data. This review discusses the current evidence for antithrombotic therapy in patients who are aPL positive but do not fulfill criteria for APS, and in APS patients. Alternative and emerging therapies including low molecular weight heparin, new oral anticoagulants (including direct thrombin inhibitors), hydroxychloroquine, statins, and rituximab, are also addressed.

Recurrent stroke on imaging and presumed paradoxical embolism: a cross-sectional analysis

OBJECTIVE

To identify whether factors supporting a diagnosis of paradoxical embolism (i.e., venous thrombosis or Valsalva maneuver) are associated with radiologic markers of recurrent strokes in patients with patent foramen ovale (PFO) and cryptogenic stroke (CS). Such clinical indicators of paradoxical embolism are commonly viewed as risk factors for CS recurrence, but precise risk estimates are lacking.

METHODS

Data from the prospective Tufts PFO Registry collected at the time of the index CS were analyzed. We defined the following radiologic markers of stroke recurrence: 1) strokes of different radiologic ages and 2) silent strokes (detected on MRI but without symptoms preceding the index event). We examined the association between the radiologic endpoints and the clinical indicators of paradoxical embolism with multivariate logistic regression models, adjusting for age and gender.

RESULTS

Data were available for 224 subjects. Strokes of different radiologic ages were not associated with the thrombosis-predisposing conditions (1.2 [95% confidence interval 0.5-2.7]), the Valsalva maneuver (1.3 [0.6-3.1]), or the presence of either of these factors. No statistically significant association was found in subgroups stratified by anatomic location of the index stroke or for the outcome of silent strokes.

CONCLUSIONS

Our negative findings do not lend support to using the presence of clinical indicators of paradoxical embolism as an indication for percutaneous PFO closure. Factors that support a paradoxical embolism mechanism may be different from those that predict paradoxical embolism recurrence. Further investigations with clinical follow-up and larger sample sizes are needed to reach more precise estimates for the associations examined.

Prothrombotic genetic risk factors in stroke: a possible different role in pediatric and adult patients

The role of thrombophilia in the pathogenesis of stroke is still controversial, especially in the pediatric stroke. In order to examine the role of common thrombophilic mutations in children and adults with stroke, a case-control study was carried out in a group of 80 children and 73 younger adult patients. The control groups encompassed 100 healthy children and 120 healthy blood donors. Our results showed no significant differences in the frequency of factor V (FV) Leiden, FII G20210A, and methylenetetrahydrofolate reductase (MTHFR) C677T variants between patient groups and corresponding controls. According to our results, carriers of 677CT genotype have 3.62 higher risks to develop stroke in children than in adults (P < .001). The obtained data indicate that heterozygosity for MTHFR C677T variant represents a possible important risk factor for pediatric stroke and suggest a different role of this gene variant in etiology of stroke in pediatric and adult patients.

Current proceedings of childhood stroke

Stroke is a sudden onset neurological deficit due to a cerebrovascular event. In children, the recognition of stroke is often delayed due to the low incidence of stroke and the lack of specific assessment measures to this entity. The causes of pediatric stroke are significantly different from that of adult stroke. The lack of safety and efficiency data in the treatment is the challenge while facing children with stroke. Nearly half of survivors of pediatric stroke may have neurologic deficits affecting functional status and quality of life. They may cause a substantial burden on health care resources. Hence, an accurate history, including onset and duration of symptoms, risk factors, and a complete investigation, including hematologic, neuroimaging, and metabolic studies is the key to make a corrective diagnosis. A prompt and optimal treatment without delay may minimize the damage to the brain.