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Doskas T, Dardiotis E, Vavougios GD, Ntoskas KT, Sionidou P, Vadikolias K. Stroke risk in multiple sclerosis: a critical appraisal of the literature. Int J Neurosci 2023; 133:1132-1152. [PMID: 35369835 DOI: 10.1080/00207454.2022.2056459] [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: 04/21/2021] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
Observational studies suggest that the occurrence of stroke on multiple sclerosis (MS) patients is higher compared to the general population. MS is a heterogeneous disease that involves an interplay of genetic, environmental and immune factors. The occurrence of stroke is subject to a wide range of both modifiable and non-modifiable, short- and long-term risk factors. Both MS and stroke share common risk factors. The immune mechanisms that underlie stroke are similar to neurodegenerative diseases and are attributed to neuroinflammation. The inflammation in autoimmune diseases may, therefore, predispose to an increased risk for stroke or potentiate the effect of conventional stroke risk factors. There are, however, additional determinants that contribute to a higher risk and incidence of stroke in MS. Due to the challenges that are associated with their differential diagnosis, the objective is to present an overview of the factors that may contribute to increased susceptibility or occurrence of stroke in MSpatients by performing a review of the available to date literature. As both MS and stroke can individually detrimentally affect the quality of life of afflicted patients, the identification of factors that contribute to an increased risk for stroke in MS is crucial for the prompt implementation of preventative therapeutic measures to limit the additive burden that stroke imposes.
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Affiliation(s)
- Triantafyllos Doskas
- Department of Neurology, Athens Naval Hospital, Athens, Greece
- Department of Neurology, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Efthimios Dardiotis
- Department of Neurology, Laboratory of Neurogenetics, University Hospital of Larissa, Larissa, Greece
- Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Simion C, Campello E, Bensi E, Bellio A, Pontarin A, Spiezia L, Simioni P. Use of Glucocorticoids and Risk of Venous Thromboembolism: A Narrative Review. Semin Thromb Hemost 2021; 47:654-661. [PMID: 33893633 DOI: 10.1055/s-0040-1722270] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Glucocorticoids are potent anti-inflammatory agents that are widely used for the treatment of many inflammatory, autoimmune, and neoplastic disorders. However, their beneficial effect is associated with several side effects, including an increased risk of cardiovascular complications, such as myocardial infarction and stroke. Whether their use also contributes to a procoagulant state, and therefore increases the risk of venous thromboembolism (VTE), is still a matter of debate. As an increased risk of venous thrombotic events is described in patients with Cushing's syndrome, which is characterized by endogenous hypercortisolism, it is reasonable to speculate that the chronic administration of glucocorticoids may induce a hypercoagulable state. However, it seems virtually impossible to separate the role of the drug from the underlying condition, which itself predisposes to the development of VTE. Actually, some evidence suggests that the use of exogenous glucocorticoids for the treatment of underlying disease and its exacerbations may further amplify the risk of VTE. Moreover, a procoagulant state has also been reported in healthy participants receiving oral glucocorticoids versus placebo. We have performed a concise narrative review on available data on the influence of exogenous glucocorticoids on hemostasis and their clinical impact on the risk of VTE.
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Affiliation(s)
- Chiara Simion
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Elena Campello
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Elisa Bensi
- Division of Geriatrics, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Andrea Bellio
- Division of Geriatrics, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Anna Pontarin
- Division of Geriatrics, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Luca Spiezia
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Paolo Simioni
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
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Garg A, Rajendram P, Muccilli A, Noel de Tilly L, Micieli JA. Dural venous sinus thrombosis after lumbar puncture in a patient with idiopathic intracranial hypertension. Eur J Ophthalmol 2020; 32:1120672120970406. [PMID: 33176472 DOI: 10.1177/1120672120970406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Idiopathic intracranial hypertension (IIH) is one of the most common causes of papilloedema seen by ophthalmologists and neurologists. Patients with IIH routinely undergo lumbar puncture (LP) for diagnosis. Dural venous sinus thrombosis (DVST) is a rare complication of cerebrospinal fluid pressure (CSF)-lowering procedures such as lumbar puncture and epidural and may be an intracranial complication of IIH. CASE DESCRIPTION A 29-year-old obese woman was diagnosed with severe idiopathic intracranial hypertension (IIH) after she presented with new-onset headache, pulsatile tinnitus and blurred vision. Magnetic resonance imaging (MRI) and venography (MRV) were normal apart from signs of intracranial hypertension. Lumbar puncture (LP) revealed an opening pressure of 40 cm of water. Due to the severity of the papilloedema and vision loss, she was referred for a ventriculoperitoneal shunt and found to have venous sinus thrombosis involving the superior sagittal sinus on the pre-operative computed tomography (CT) head 5 days after the LP. CT venography (CTV) one day later and MRV 3 days later showed significant worsening as the thrombosis extended into the deep venous system. She was started on therapeutic heparin and her symptoms and vision improved and she did not develop any neurological complications. CONCLUSIONS DVST should be considered in IIH patients who have worsening papilloedema or symptoms of intracranial hypertension. Repeat venous imaging can prevent devastating consequences such as venous infarcts of haemorrhage in these patients.
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Affiliation(s)
- Anubhav Garg
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Phavalan Rajendram
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alexandra Muccilli
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lyne Noel de Tilly
- Department of Medical Imaging, Division of Neuroradiology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan A Micieli
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
- Kensington Vision and Research Centre, Toronto, Ontario, Canada
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Sabidó M, Venkatesh S, Hayward B, Aldridge J, Gillett A. Subcutaneous Interferon-β1a Does Not Increase the Risk of Stroke in Patients with Multiple Sclerosis: Analysis of Pooled Clinical Trials and Post-Marketing Surveillance. Adv Ther 2018; 35:2041-2053. [PMID: 30255416 PMCID: PMC6224000 DOI: 10.1007/s12325-018-0790-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Previous studies suggest that multiple sclerosis (MS) patients have a greater stroke risk than the general population but there is limited evidence of stroke risk in patients receiving disease-modifying treatment. We assessed stroke risk in MS patients treated with subcutaneous interferon-β1a (sc IFN-β1a) using pooled data from clinical trials and post-marketing surveillance. METHODS Seventeen phase II-IV Merck KGaA-sponsored trials of sc IFN-β1a were assessed to estimate the stroke incidence rate (IR) and IR ratio (IRR) per 100 patient-years (PY), and associated 95% confidence intervals (CI). The association of treatment duration with stroke was assessed through a Cox model. IR, IRR, and hazard ratio (HR) were adjusted by age, sex, presence of any comorbidity, and MS duration. Individual case safety reports were retrieved from the Global Patient Safety Database. The reporting rates of stroke were calculated and classified as medically confirmed or non-medically confirmed according to the source of each report. RESULTS In 17 clinical trials, 4412 patients were treated with sc IFN-β1a for a total of 10,622 PY and 1055 patients with placebo for 2005 PY. The IR/100 PY (95% CI) of stroke was 0.025 (0.004, 0.150) in sc IFN-β1a patients and 0.051 (0.008, 0.349) in placebo patients. The IRR for sc IFN-β1a vs placebo was 0.486 (0.238, 0.995) and the HR was 0.496 (0.235, 1.043) for time to stroke-related event for sc IFN-β1a treatment at any dose compared with placebo. Among sc IFN-β1a patients, the IRR in those treated for < 2 years was 0.602 (0.159, 2.277) and for ≥ 2 years 0.469 (0.196, 1.124). Analysis of the safety database showed that the overall reporting rate for stroke was 13.286/10,000 PY. CONCLUSION Safety data from both clinical trial and post-marketing settings indicate that treatment with sc IFN-β1a does not increase stroke risk in patients with MS. FUNDING Merck KGaA, Darmstadt, Germany.
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Idiopathic Intracranial Hypertension Progressing to Venous Sinus Thrombosis, Subarachnoid Hemorrhage, and Stroke. J Neuroophthalmol 2017; 38:60-64. [PMID: 28742639 DOI: 10.1097/wno.0000000000000540] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Idiopathic intracranial hypertension (IIH) is a syndrome characterized by increased intracranial pressure (ICP), the absence of structural lesions on neuroimaging, and normal cerebrospinal fluid composition. Cerebral venous sinus thrombosis (CVST) is a common cause of increased ICP and can be differentiated from IIH with magnetic resonance venography. We describe a young woman with typical IIH who underwent lumbar puncture and was treated with a short course of high-dose corticosteroids followed by acetazolamide. She subsequently developed CVST, subarachnoid hemorrhage, and stroke. Risk factors that may have resulted in CVST are discussed.
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LeVine SM. Is There an Increased Risk for Ischemic Stroke in Patients with Multiple Sclerosis, and If So, Should Preventive Treatment Be Considered? Front Neurol 2016; 7:128. [PMID: 27563297 PMCID: PMC4980612 DOI: 10.3389/fneur.2016.00128] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 07/27/2016] [Indexed: 12/14/2022] Open
Affiliation(s)
- Steven M LeVine
- Department of Molecular and Integrative Physiology, University of Kansas Medical Center , Kansas City, KS , USA
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Maurelli M, Bergamaschi R, Candeloro E, Todeschini A, Micieli G. Cerebral venous thrombosis and demyelinating diseases: report of a case in a clinically isolated syndrome suggestive of multiple sclerosis onset and review of the literature. Mult Scler 2016; 11:242-4. [PMID: 15794401 DOI: 10.1191/1352458505ms1125cr] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cerebral venous thrombosis (CVT) has been described in several cases of clinically definite multiple sclerosis (MS). In the majority of these, lumbar puncture followed by intravenous corticosteroid treatment was suspected as the cause. We report what is, to our knowledge, the first case of a patient with a multifocal clinically isolated syndrome suggestive of MS onset, who developed multiple CVT after lumbar puncture and during high-dose i.v. corticosteroid treatment. We conclude that the sequence ‘lumbar puncture followed by corticosteroid treatment’ may be a contributory risk factor for the development of CVT when associated with other risk factors.
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Affiliation(s)
- Maurizia Maurelli
- Multiple Sclerosis Centre, IRCCS C Mondino Institute of Neurology, Pavia, Italy.
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Kanaya Y, Takamatsu K, Shimoe Y, Niimi H, Kitajima I, Kuriyama M. Cerebral venous sinus thrombosis in the patient with multiple sclerosis associated with congenital antithrombin deficiency. Rinsho Shinkeigaku 2016; 56:248-54. [PMID: 27010094 DOI: 10.5692/clinicalneurol.cn-000796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report the case of a 25-year-old man with multiple sclerosis (MS) who had severe headache and unconsciousness. He suffered from optic neuritis that had started at age 6. From the age of 12 years, he had suffered from multiple sclerosis (MS) cerebral lesions that relapsed three times over for 5 years. At age 25, he showed a new lesion in the cerebellar cortex, suggesting an exacerbation of the MS. However, magnetic resonance imaging findings the next day showed cerebral venous sinus thrombosis. His laboratory findings showed low antithrombin activity. Genetic analysis revealed a single-base substitution (C>T) at the codon 359 (Arg to STOP) in the 5th exon portion of the antithrombin gene, heterozygote. In the literature review, 17 cases of multiple sclerosis associated with cerebral venous sinus thrombosis, which occurred after the lumbar puncture and the treatment with high-dose methylpredonisolone in 11 of these cases. In our case, antithrombin deficiency, hyperhomocystinemia, infection, and lumbar puncture were suggested as the risk factors.
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Affiliation(s)
- Yuhei Kanaya
- Department of Neurology, and Department of Radiology, Brain Attack Center Ota Memorial Hospital
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Postdural Puncture Superior Sagittal Sinus Thrombosis in a Juvenile Case of Clinically Isolated Syndrome. Case Rep Pediatr 2015; 2015:358164. [PMID: 26558127 PMCID: PMC4629016 DOI: 10.1155/2015/358164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 10/05/2015] [Accepted: 10/07/2015] [Indexed: 11/17/2022] Open
Abstract
Background. The causes of cerebral venous thrombosis (CVT) are manifold as is its clinical presentation. Case. We report the case of a CVT following lumbar puncture and intravenous glucocorticosteroid therapy in a female adolescent with a clinically isolated syndrome and risk factors for thrombosis. Conclusion. In adolescent patients with acute inflammatory disease undergoing lumbar puncture followed by intravenous high-dose glucocorticosteroid therapy, one should be aware of the elevated risk for thrombosis. A persistent headache with change in the headache pattern and loss of a postural component might be a sign for CVT, requiring emergency imaging of the brain.
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Isidori AM, Minnetti M, Sbardella E, Graziadio C, Grossman AB. Mechanisms in endocrinology: The spectrum of haemostatic abnormalities in glucocorticoid excess and defect. Eur J Endocrinol 2015; 173:R101-13. [PMID: 25987566 DOI: 10.1530/eje-15-0308] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 05/14/2015] [Indexed: 12/28/2022]
Abstract
Glucocorticoids (GCs) target several components of the integrated system that preserves vascular integrity and free blood flow. Cohort studies on Cushing's syndrome (CS) have revealed increased thromboembolism, but the pathogenesis remains unclear. Lessons from epidemiological data and post-treatment normalisation time suggest a bimodal action with a rapid and reversible effect on coagulation factors and an indirect sustained effect on the vessel wall. The redundancy of the steps that are potentially involved requires a systematic comparison of data from patients with endogenous or exogenous hypercortisolism in the context of either inflammatory or non-inflammatory disorders. A predominant alteration in the intrinsic pathway that includes a remarkable rise in factor VIII and von Willebrand factor (vWF) levels and a reduction in activated partial thromboplastin time appears in the majority of studies on endogenous CS. There may also be a rise in platelets, thromboxane B2, thrombin-antithrombin complexes and fibrinogen (FBG) levels and, above all, impaired fibrinolytic capacity. The increased activation of coagulation inhibitors seems to be compensatory in order to counteract disseminated coagulation, but there remains a net change towards an increased risk of venous thromboembolism (VTE). Conversely, GC administered in the presence of inflammation lowers vWF and FBG, but fibrinolytic activity is also reduced. As a result, the overall risk of VTE is increased in long-term users. Finally, no studies have assessed haemostatic abnormalities in patients with Addison's disease, although these may present as a consequence of bilateral adrenal haemorrhage, especially in the presence of antiphospholipid antibodies or anticoagulant treatments. The present review aimed to provide a comprehensive overview of the complex alterations produced by GCs in order to develop better screening and prevention strategies against bleeding and thrombosis.
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Affiliation(s)
- Andrea M Isidori
- Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK
| | - Marianna Minnetti
- Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK
| | - Emilia Sbardella
- Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK
| | - Chiara Graziadio
- Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK
| | - Ashley B Grossman
- Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK
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Observations on the brain vasculature in multiple sclerosis: A historical perspective. Mult Scler Relat Disord 2014; 3:156-62. [DOI: 10.1016/j.msard.2013.08.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 08/21/2013] [Accepted: 08/22/2013] [Indexed: 11/17/2022]
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Cerebral venous thrombosis: an unexpected complication from spinal surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 23 Suppl 2:253-6. [DOI: 10.1007/s00586-013-3147-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 12/15/2013] [Accepted: 12/19/2013] [Indexed: 10/25/2022]
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Al-Hashel JY, Ahmed SF, Alexnader KJ, Ahmed W. Cerebral venous thrombosis in a patient with clinically isolated spinal cord syndrome. Case Rep Neurol Med 2013; 2013:364869. [PMID: 24000313 PMCID: PMC3755436 DOI: 10.1155/2013/364869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 05/29/2013] [Indexed: 11/17/2022] Open
Abstract
Background. The association between cerebral venous thrombosis (CVT) and multiple sclerosis (MS) has already been reported in patients with clinically definite MS in relation to intravenous methylprednisolone (IVMP) or previously performed lumbar puncture (LP). Case Summery. We report a 29-year-old Indian female who presented with a clinically isolated spinal cord syndrome according to the revised 2010 McDonald Criteria. She developed CVT after a lumbar puncture and two days of finishing the course of IVMP. Conclusion. We conclude that the sequence of doing lumbar puncture followed by high-dose IVMP may increase the risk of CVT. A prophylactic anticoagulation may be indicated in this setting.
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Affiliation(s)
- Jasem Yousef Al-Hashel
- Neurology Department, Ibn Sina Hospital, P.O. Box 25427, 13115 Safat, Kuwait
- Kuwait University, P.O. Box 24923, 13110 Safat, Kuwait
| | - Samar Farouk Ahmed
- Neurology Department, Ibn Sina Hospital, P.O. Box 25427, 13115 Safat, Kuwait
- Minia University, P.O. Box 61519, Minia City, Minia 61111, Egypt
| | - K. J. Alexnader
- Neurology Department, Ibn Sina Hospital, P.O. Box 25427, 13115 Safat, Kuwait
| | - Walaa Ahmed
- Neurology Department, Ibn Sina Hospital, P.O. Box 25427, 13115 Safat, Kuwait
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Venous thrombosis in multiple sclerosis patients after high-dose intravenous methylprednisolone: the preventive effect of enoxaparin. THROMBOSIS 2011; 2011:785459. [PMID: 22242201 PMCID: PMC3253479 DOI: 10.1155/2011/785459] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 11/15/2011] [Accepted: 11/16/2011] [Indexed: 11/20/2022]
Abstract
Aim. This study was designed to examine the possible role of high-dose intravenous methylprednisolone (IVMP) in the development of venous thrombosis (VT). The cerebral one anecdotally had been reported in patients with relapsing remitting multiple sclerosis (RRMS) in acute attacks and the possible preventive role of enoxaparin. Material and Methods. From a pool of 520 patients, 388 patients with definite RRMS who fulfilled entry characteristics were selected and randomly received either a 5-day course of daily 1 gr IVMP or the aforementioned plus 5 days of daily subcutaneous 40 units of enoxaparin according to a predefined protocol. Results. Mean age, gender ratio, mean relapse rate, and EDSS were similar in both groups of patients (P > 0.05). Finally, 366 patients remained in the study. Of 188 patients treated with IVMP with 855 relapses, 5 developed VT (0.37% per patient per year and 0.58% per each course of IVMP) within 3 to 15 days of starting therapy. None of the 178 patients who experienced 809 relapses who received IVMP plus enoxaparin developed such complications. Conclusion. The study implies that high-dose IVMP in MS exacerbation may increase the risk of VT and prophylactic anticoagulant treatment in this setting is warranted.
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Roux D, Philippeau F, Bhageerutty K, Vieillart A, Gouttard M, Boulliat J. [Headache after lumbar puncture]. Presse Med 2011; 40:668-70. [PMID: 21419592 DOI: 10.1016/j.lpm.2011.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Revised: 01/25/2011] [Accepted: 01/26/2011] [Indexed: 11/16/2022] Open
Affiliation(s)
- Delphine Roux
- Centre hospitalier Fleyriat, service de neurologie, 01012 Bourg-en-Bresse, France
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Miglis MG, Levine DN. Intracranial Venous Thrombosis After Placement of a Lumbar Drain. Neurocrit Care 2009; 12:83-7. [DOI: 10.1007/s12028-009-9278-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Canhão P, Cortesão A, Cabral M, Ferro JM, Stam J, Bousser MG, Barinagarrementeria F. Are steroids useful to treat cerebral venous thrombosis? Stroke 2007; 39:105-10. [PMID: 18063833 DOI: 10.1161/strokeaha.107.484089] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE No randomized controlled trial has evaluated the efficacy of steroids in acute cerebral venous thrombosis (CVT). We aimed to analyze the effect of steroids on the outcome of patients in the International Study on Cerebral Veins and Dural Sinus Thrombosis (ISCVT). METHODS ISCVT is a prospective observational study that included 624 CVT patients. Death or dependence at 6 months was compared between cases (patients treated with steroids) and controls (patients not treated with steroids), using 3 designs: (1) Matched case-control study (each case matched with a control for prognostic factors); (2) Nonmatched case-control study of the ISCVT cohort; (3) Case-control study in different strata according to the number of poor prognostic variables in each patient. RESULTS One hundred and fifty (24%) patients were treated with steroids. (1) In the matched case-control study, poor outcome was similar in the two groups of patients (26/146 versus 17/149, OR=1.7; 95% CI 0.9 to 3.3, P=0.119). (2) In the ISCVT cohort, no significant difference in poor outcomes was found whether patients were treated with steroids or not (26/146 versus 60/469, OR=1.5; 95% CI 0.9 to 2.4). Patients without parenchymal lesions treated with steroids had worse prognosis than those treated without steroids (8/45 versus 9/184, OR=4.2, 95% CI 1.6 to 11.6, P=0.008). (3) Treatment with steroids was not associated with a better outcome in any strata of patients according to the number of poor prognostic factors. CONCLUSIONS Steroids in the acute phase of CVT were not useful and were detrimental in patients without parenchymal cerebral lesions. These results do not support the use of steroids in CVT (evidence level III).
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Affiliation(s)
- Patrícia Canhão
- Department of Clinical Neurosciences and Mental Health, Hospital Santa Maria, 1649-035 Lisbon, Portugal.
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Brotman DJ, Girod JP, Posch A, Jani JT, Patel JV, Gupta M, Lip GYH, Reddy S, Kickler TS. Effects of short-term glucocorticoids on hemostatic factors in healthy volunteers. Thromb Res 2006; 118:247-52. [PMID: 16005496 DOI: 10.1016/j.thromres.2005.06.006] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2005] [Revised: 06/01/2005] [Accepted: 06/09/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Increased circulating levels of hemostatic factors have been associated with arterial and venous thrombosis. Although in vitro evidence suggests that glucocorticoids may activate hemostasis and inhibit thrombolysis, no controlled in vivo studies have examined the effects of glucocorticoids on hemostatic factors. We hypothesized that a 5-day treatment course of dexamethasone would increase circulating levels of hemostatic and anti-fibrinolytic factors. METHODS We randomized 24 healthy men ages 19-39 to receive either dexamethasone 3 mg twice daily versus placebo for 5 days. Parameters examined before and after the intervention included: clotting factors VII, VIII, and XI, von Willebrand factor (vWF), D-dimer, PAI-1, soluble CD40-ligand (sCD40-ligand), and fibrinogen. RESULTS Dexamethasone tended to modestly increase clotting factors levels and fibrinogen without significantly affecting PAI-1, D-dimer or sCD40-ligand. Factor VII increased by a mean of 13% (p = 0.04 versus placebo), factor VIII by 27% (p = 0.0008), factor XI by 6% (p = 0.01), and fibrinogen by 13% (p = 0.05). CONCLUSIONS Glucocorticoids may increase the activity of clotting factors in vivo. This may contribute to the reported increased risk of thrombosis in patients with sustained exposure to glucocorticoids.
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Affiliation(s)
- Daniel J Brotman
- Department of General Internal Medicine, Cleveland Clinic Foundation, OH, USA
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Canhão P, Batista P, Falcão F. Lumbar Puncture and Dural Sinus Thrombosis – A Causal or Casual Association? Cerebrovasc Dis 2005; 19:53-6. [PMID: 15528885 DOI: 10.1159/000081912] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2004] [Accepted: 06/22/2004] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A few cases of cerebral venous thrombosis (CVT) were reported after a lumbar puncture (LP), suggesting a causal association. The purpose of our study was to document that LP might predispose to CVT by decreasing blood flow velocities (BFV) in veins or dural sinus. METHODS We performed a transcranial Doppler ultrasound study to register the mean BFV of the straight sinus (SS) before, during and after LP. RESULTS Thirteen patients were studied. LP induced a decrease of 47% of mean BFV in the SS. The mean decrease of BFV was significant immediately at the end (p = 0.003), 30 min after (p = 0.015) and more than 6 h after LP (p = 0.008). CONCLUSIONS LP induced a sustained decrease of mean BFV in the SS. The decrease of venous blood flow is a possible mechanism contributing to the occurrence of CVT.
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Affiliation(s)
- Patrícia Canhão
- Neurology Department, Hospital de Santa Maria, PT-1649 Lisboa, Portugal.
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Altenwerth B, Brandenburg VM, Nolden-Koch M, Block F, Frank RD. Effect of intravenous high-dose methylprednisolone on coagulation and fibrinolysis markers. Thromb Haemost 2005. [DOI: 10.1055/s-0037-1614776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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Vandenberghe N, Debouverie M, Anxionnat R, Clavelou P, Bouly S, Weber M. Cerebral venous thrombosis in four patients with multiple sclerosis. Eur J Neurol 2003; 10:63-6. [PMID: 12534995 DOI: 10.1046/j.1468-1331.2003.00513.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report four new cases of cerebral venous thrombosis (CVT) occurring in patients with multiple sclerosis (MS). Each patient had undergone lumbar puncture at varying times prior to clinical presentation (4 days to over 1 year). Only two of the patients had received intravenous (i.v.) methylprednisolone 48 h prior to CVT and were under oral contraception, a risk factor for cerebral thrombophlebitis. The other two patients had not undergone recent lumbar puncture, were not taking corticosteroids and did not present vascular risk factors. The patients all had normal routine blood work-ups and none had thrombophilia. All patients dramatically improved with full systemic heparinization. Minor sequelae were noticed in two patients. The pathogenesis underlying the occurrence of CVT in MS patients remains unclear and we discuss the relationship between lumbar puncture, steroid treatment and CVT.
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Affiliation(s)
- N Vandenberghe
- Departments of Neurology and Neuroradiology, Nancy, France
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