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Aguiar de Sousa D, Lucas Neto L. Advances in Cerebral Venous Thrombosis. Stroke 2024; 55:2169-2172. [PMID: 38511323 DOI: 10.1161/strokeaha.123.044266] [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] [Indexed: 03/22/2024]
Affiliation(s)
- Diana Aguiar de Sousa
- Stroke Center, Centro Hospitalar Universitário Lisboa Central, Portugal (D.A.d.S.)
- Instituto de Anatomia, Faculdade de Medicina, Universidade de Lisboa, Portugal (D.A.d.S., L.L.N.)
- L Lopes Lab, Instituto de Medicina Molecular JLA, Lisbon, Portugal (D.A.d.S.)
| | - Lia Lucas Neto
- Instituto de Anatomia, Faculdade de Medicina, Universidade de Lisboa, Portugal (D.A.d.S., L.L.N.)
- Department of Neuroradiology, Centro Hospitalar Lisboa Norte, Lisbon, Portugal (L.L.N.)
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Bücke P, Henkes H, Kaesmacher J, Heldner MR, Scutelnic A, Arnold M, Meinel TR, Cimpoca A, Horvath T, Henkes E, Bäzner H, Hellstern V. Early Versus Late Initiation of Endovascular Therapy in Patients with Severe Cerebral Venous Sinus Thrombosis. Neurocrit Care 2024:10.1007/s12028-024-02046-7. [PMID: 39042279 DOI: 10.1007/s12028-024-02046-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 06/07/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Endovascular therapy (EVT) for severe cerebral venous sinus thrombosis (CVST) is controversial in terms of indication and clinical benefit. The impact of delay of EVT on functional recovery is unclear. This study aimed to investigate the effect of early versus late initiation of EVT in severe CVST. METHODS From prospective EVT and CVST registries, patients with CVST diagnosed between January 2010 and December 2022 were retrospectively identified for this multicenter collaboration. EVT was considered in severe CVST with features prone to a poor prognosis. We compared early (< 24 h) with late (> 24 h) initiation of EVT after the presentation in the emergency department and subsequent CVST diagnosis. Outcome parameters included functional independence (modified Rankin Scale [mRS] score 0-2) at 90 days, mRS score at discharge, in-hospital mortality, and mortality at 3 months. RESULTS Of 363 patients with CVST, 45 (12.4%; 31 [early EVT] vs. 14 [late EVT]) were included in this study. We found a higher proportion of patients with functional independence at 3 months among early versus late EVT (66.7% vs. 27.3%; odds ratio [OR] 5.3; 95% confidence interval 1.02-25; p = 0.036). In multivariate logistic regression, late EVT was inversely correlated with functional independence (OR 0.17 [0.04-0.83]; p = 0.011). The mortality rate was 16.7% versus 36.4% (mRS 6 at 3 months, OR 0.34, 95% confidence interval 0.07-1.75; p = 0.217) at 90 days for early versus late EVT. CONCLUSIONS We observed a higher rate of functional independence in patients with early EVT. These preliminary findings must be confirmed in subsequent randomized controlled trials evaluating a "time-is-brain" paradigm for EVT in CVST.
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Affiliation(s)
- Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse 16, 3010, Bern, Switzerland.
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Germany
- Medical Faculty, Universität Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Johannes Kaesmacher
- Institute for Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse 16, 3010, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse 16, 3010, Bern, Switzerland
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse 16, 3010, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse 16, 3010, Bern, Switzerland
| | - Thomas R Meinel
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse 16, 3010, Bern, Switzerland
| | - Alexandru Cimpoca
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Germany
| | - Thomas Horvath
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse 16, 3010, Bern, Switzerland
| | - Elina Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Germany
| | - Hansjörg Bäzner
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Germany
| | - Victoria Hellstern
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Germany
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Sadeghi Hokmabadi E, Daei Sorkhabi A, Sarkesh A, Sadigh-Eteghad S, Mehdizadehfar E, Sadeghpoor Y, Farhoudi M. Efficacy and safety of direct oral anticoagulants versus warfarin in the treatment of cerebral venous sinus thrombosis. Acta Neurol Belg 2024:10.1007/s13760-024-02586-x. [PMID: 38985242 DOI: 10.1007/s13760-024-02586-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 05/14/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Given the evolving application and promising outcomes of direct oral anticoagulants (DOACs) in various thromboembolic conditions, we aimed to compare the efficacy and safety of DOACs with warfarin in the post-acute treatment of cerebral venous sinus thrombosis (CVST) using clinical and radiological parameters. METHODS A total of 140 CVST patients were enrolled, with 95 receiving warfarin and 45 receiving DOACs as post-acute treatment. Clinical and imaging parameters of the patients in follow-up visits were investigated, including the last modified Rankin Scale (mRS), venous thromboembolic events, CVST recurrence, mortality rate, recanalization status, and hemorrhagic events, to compare the efficacy and safety of treatment between the two groups. RESULTS At baseline, patients' assessments using two prognostic scores, ISCVT-RS and IN-REvASC, revealed that there was no statistically significant difference in the distribution of prognostic risk categories between the warfarin and DOACs groups. Following acute therapy, patients in the warfarin and DOACs groups were followed up for the median of 359 and 325 days, respectively. Analysis to compare the efficacy of warfarin and DOACs revealed no significant difference in last mRS scores, CVST recurrence rate, venous thromboembolic events, and recanalization status between the two groups. Additionally, there was no statistically significant difference in the risk of hemorrhagic events between warfarin and DOACs groups. CONCLUSION Our findings show that DOACs have comparable safety and efficacy in the post-acute treatment of CVST patients; however, large-scale randomized controlled trials are required to validate our findings.
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Affiliation(s)
- Elyar Sadeghi Hokmabadi
- Neurosciences Research Center (NSRC), Department of Neurology, Imam‑Reza hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amin Daei Sorkhabi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Aila Sarkesh
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saeed Sadigh-Eteghad
- Neurosciences Research Center (NSRC), Department of Neurology, Imam‑Reza hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Elham Mehdizadehfar
- Neurosciences Research Center (NSRC), Department of Neurology, Imam‑Reza hospital, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Yalda Sadeghpoor
- Neurosciences Research Center (NSRC), Department of Neurology, Imam‑Reza hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehdi Farhoudi
- Neurosciences Research Center (NSRC), Department of Neurology, Imam‑Reza hospital, Tabriz University of Medical Sciences, Tabriz, Iran
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Coutinho JM, van de Munckhof A, Aguiar de Sousa D, Poli S, Aaron S, Arauz A, Conforto AB, Krzywicka K, Hiltunen S, Lindgren E, Sánchez van Kammen M, Shu L, Bakchoul T, Belder R, van den Berg R, Boumans E, Cannegieter S, Cano-Nigenda V, Field TS, Fragata I, Heldner MR, Hernández-Pérez M, Klok FA, Leker RR, Lucas-Neto L, Molad J, Nguyen TN, Saaltink DJ, Saposnik G, Sharma P, Stam J, Thijs V, van der Vaart M, Werring DJ, Wong Ramos D, Yaghi S, Yeşilot N, Tatlisumak T, Putaala J, Jood K, Arnold M, Ferro JM. Reducing the global burden of cerebral venous thrombosis: An international research agenda. Int J Stroke 2024; 19:599-610. [PMID: 38494462 PMCID: PMC11292977 DOI: 10.1177/17474930241242266] [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: 01/31/2024] [Accepted: 03/04/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Due to the rarity of cerebral venous thrombosis (CVT), performing high-quality scientific research in this field is challenging. Providing answers to unresolved research questions will improve prevention, diagnosis, and treatment, and ultimately translate to a better outcome of patients with CVT. We present an international research agenda, in which the most important research questions in the field of CVT are prioritized. AIMS This research agenda has three distinct goals: (1) to provide inspiration and focus to research on CVT for the coming years, (2) to reinforce international collaboration, and (3) to facilitate the acquisition of research funding. SUMMARY OF REVIEW This international research agenda is the result of a research summit organized by the International Cerebral Venous Thrombosis Consortium in Amsterdam, the Netherlands, in June 2023. The summit brought together 45 participants from 15 countries including clinical researchers from various disciplines, patients who previously suffered from CVT, and delegates from industry and non-profit funding organizations. The research agenda is categorized into six pre-specified themes: (1) epidemiology and clinical features, (2) life after CVT, (3) neuroimaging and diagnosis, (4) pathophysiology, (5) medical treatment, and (6) endovascular treatment. For each theme, we present two to four research questions, followed by a brief substantiation per question. The research questions were prioritized by the participants of the summit through consensus discussion. CONCLUSIONS This international research agenda provides an overview of the most burning research questions on CVT. Answering these questions will advance our understanding and management of CVT, which will ultimately lead to improved outcomes for CVT patients worldwide.
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Affiliation(s)
- Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Diana Aguiar de Sousa
- Stroke Center, Centro Hospitalar Universitário Lisboa Central, Institute of Anatomy, Faculdade de Medicina, Universidade de Lisboa, and L Lopes Lab, Instituto de Medicina Molecular JLA, Lisbon, Portugal
| | - Sven Poli
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | | | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Adriana B Conforto
- LIM-44, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Sini Hiltunen
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Liqi Shu
- Brown University, Providence, RI, USA
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
| | - Rosalie Belder
- Netherlands Thrombosis Foundation, Voorschoten, The Netherlands
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | | | - Suzanne Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vanessa Cano-Nigenda
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Isabel Fragata
- Stroke Center, Centro Hospitalar Universitário Lisboa Central, Institute of Anatomy, Faculdade de Medicina, Universidade de Lisboa, and L Lopes Lab, Instituto de Medicina Molecular JLA, Lisbon, Portugal
- NOVA Medical School, Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Mirjam R Heldner
- Inselspital Bern, University Hospital and University of Bern, Bern, Switzerland
| | | | - Frederikus A Klok
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Ronen R Leker
- Hadassah—Hebrew University Medical Center, Jerusalem, Israel
| | - Lia Lucas-Neto
- North Lisbon University Hospital Center and Lisbon Medical School, Lisbon, Portugal
| | | | | | | | - Gustavo Saposnik
- Stroke Outcomes & Decision Neuroscience Research Unit, University of Toronto, Toronto, ON, Canada
| | - Pankaj Sharma
- Royal Holloway University of London, London, United Kingdom
| | - Jan Stam
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | | | - David J Werring
- UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Diana Wong Ramos
- Portugal AVC-União de Sobreviventes, Familiares e Amigos, Portugal
| | | | - Nilüfer Yeşilot
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Jukka Putaala
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Marcel Arnold
- Inselspital Bern, University Hospital and University of Bern, Bern, Switzerland
| | - José M Ferro
- Hospital da Luz, University of Lisbon, Lisbon, Portugal
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Ma H, Gu Y, Bian T, Song H, Liu Z, Ji X, Duan J. Dabigatran etexilate versus warfarin in cerebral venous thrombosis in Chinese patients (CHOICE-CVT): An open-label, randomized controlled trial. Int J Stroke 2024; 19:635-644. [PMID: 38353219 DOI: 10.1177/17474930241234749] [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] [Indexed: 02/27/2024]
Abstract
BACKGROUND The efficacy and safety of dabigatran etexilate for Chinese patients with cerebral venous thrombosis (CVT) has not been well established. METHODS CHOICE-CVT was an exploratory, single-center, randomized, open-label study in the National Center for Neurological Disorders involving Chinese patients with CVT aged 18 to 80 years who were randomly assigned (1:1) to either dabigatran etexilate or warfarin. Oral anticoagulants were initiated after 10-15 days of LMWH. The primary efficacy and safety endpoints included the number of patients with recurrent CVT and/or deep venous thrombosis (DVT) and major clinical bleeding within 180 days. Secondary efficacy endpoints included venous recanalization and change in papilledema at day 180. Secondary safety outcomes comprised death, clinical nonmajor bleeding, and any bleeding. The study was registered with ClinicalTrials.gov under NCT03930940. RESULTS Between October 2017 and February 2023, a total of 89 patients were enrolled and randomly assigned to receive either dabigatran etexilate (n = 44) or warfarin (n = 45). At day 180, the dabigatran etexilate group showed a statistically nonsignificant but likely clinically significant number of patients with recurrent CVT and/or DVT (8 (18.2%; 95% CI, 6.3-30.0) vs 3 (6.7%; 95% CI, 0.0-14.2), p = 0.099, with a power (1-β) of 38.401%) compared with the warfarin group. The dabigatran etexilate group showed a comparable number of patients with clinical major bleeding (0 (0) vs 0 (0) p = 1.000), and clinical nonmajor bleeding (1 (2.3%; 95% CI, 0.0-6.9) vs 1 (2.2%; 95% CI, 0.0-6.7)) but demonstrated a lower risk of any bleeding (1 (2.3%; 95% CI, 0.0-6.9) vs 9 (20.0%; 95% CI, 7.8-32.2)) compared with the warfarin group. Most patients in both groups achieved venous recanalization according to the Modified Qureshi scale (27 (75%; 95% CI, 60.1-89.9) in the dabigatran etexilate group vs 34 (82.9%; 95% CI, 70.9-95.0) in the warfarin group) and exhibited improvement in papilledema as per the Frisén classification (35 (97.2%; 95% CI, 91.6-100.0) in the dabigatran etexilate group vs 37 (88.1%, 95% CI, 77.9-98.3) in the warfarin group). CONCLUSIONS These findings regarding efficacy and safety support the consideration of dabigatran etexilate therapy as a viable treatment option for Chinese patients with CVT.
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Affiliation(s)
- Hongrui Ma
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yaqin Gu
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tingting Bian
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Fengtai You'anmen Hospital, Beijing, China
| | - Haiqing Song
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhi Liu
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jiangang Duan
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Schuchardt FF, Lützen N, Küchlin S, Reich M, Lagrèze WA, Mast H, Weigel M, Meckel S, Urbach H, Weiller C, Harloff A, Demerath T. Clinical value of neuroimaging indicators of intracranial hypertension in patients with cerebral venous thrombosis. Neuroradiology 2024; 66:1161-1176. [PMID: 38676750 DOI: 10.1007/s00234-024-03363-6] [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: 10/19/2023] [Accepted: 04/19/2024] [Indexed: 04/29/2024]
Abstract
PURPOSE Intracranial hypertension (IH) frequently complicates cerebral venous thrombosis (CVT). Distinct neuroimaging findings are associated with IH, yet their discriminative power, reversibility and factors favoring normalization in prospective CVT patients are unknown. We determined test performance measures of neuroimaging signs in acute CVT patients, their longitudinal change under anticoagulation, association with IH at baseline and with recanalization at follow-up. METHODS We included 26 consecutive acute CVT patients and 26 healthy controls. Patients were classified as having IH based on CSF pressure > 25 cmH2O and/or papilledema on ophthalmological examination or ocular MRI. We assessed optic nerve sheath diameter (ONSD), optic nerve tortuousity, bulbar flattening, lateral and IVth ventricle size, pituitary configuration at baseline and follow-up, and their association with IH and venous recanalization. RESULTS 46% of CVT patients had IH. ONSD enlargement > 5.8 mm, optic nerve tortuousity and pituitary grade ≥ III had highest sensitivity, ocular bulb flattening and pituitary grade ≥ III highest specificity for IH. Only ONSD reliably discriminated IH at baseline. Recanalization was significantly associated with regressive ONSD and pituitary grade. Other neuroimaging signs tended to regress with recanalization. After treatment, 184.9 ± 44.7 days after diagnosis, bulbar flattening resolved, whereas compared with controls ONSD enlargement (p < 0.001) and partially empty sella (p = 0.017), among other indicators, persisted. CONCLUSION ONSD and pituitary grading have a high diagnostic value in diagnosing and monitoring CVT-associated IH. Given their limited sensitivity during early CVT and potentially persistent alterations following IH, neuroimaging indicators can neither replace CSF pressure measurement in diagnosing IH, nor determine the duration of anticoagulation.
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Affiliation(s)
- Florian F Schuchardt
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Niklas Lützen
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sebastian Küchlin
- Eye Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Reich
- Eye Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolf A Lagrèze
- Eye Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hansjörg Mast
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Weigel
- Translational Imaging in Neurology (ThINk) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Allschwil, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
- Division of Radiological Physics, Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Stephan Meckel
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute of Diagnostic and Interventional Neuroradiology, RKH Kliniken Ludwigsburg, Ludwigsburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Cornelius Weiller
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Harloff
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Theo Demerath
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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7
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Weller J, Krzywicka K, van de Munckhof A, Dorn F, Althaus K, Bode FJ, Bandettini di Poggio M, Buck B, Kleinig T, Cordonnier C, Dizonno V, Duan J, Elkady A, Chew BLA, Garcia-Esperon C, Field TS, Legault C, Morin Martin M, Michalski D, Pelz J, Schoenenberger S, Nagel S, Petruzzellis M, Raposo N, Skjelland M, Zimatore DS, Aaron S, Sanchez van Kammen M, Aguiar de Sousa D, Lindgren E, Jood K, Scutelnic A, Heldner MR, Poli S, Arauz A, Conforto AB, Putaala J, Tatlisumak T, Arnold M, Coutinho JM, Günther A, Zimmermann J, Ferro JM. Endovascular treatment of cerebral sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia. Eur Stroke J 2024; 9:105-113. [PMID: 37771138 PMCID: PMC10916823 DOI: 10.1177/23969873231202363] [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: 07/06/2023] [Accepted: 09/03/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION There is little data on the role of endovascular treatment (EVT) of cerebral venous sinus thrombosis (CVST) due to vaccine-induced immune thrombotic thrombocytopenia (VITT). Here, we describe clinical characteristics and outcomes of CVST-VITT patients who were treated with EVT. PATIENTS AND METHODS We report data from an international registry of patients who developed CVST within 28 days of SARS-CoV-2 vaccination, reported between 29 March 2021 and 6 March 2023. VITT was defined according to the Pavord criteria. RESULTS EVT was performed in 18/136 (13%) patients with CVST-VITT (92% aspiration and/or stent retrieval, 8% local thrombolysis). Most common indications were extensive thrombosis and clinical or radiological deterioration. Compared to non-EVT patients, those receiving EVT had a higher median thrombus load (4.5 vs 3). Following EVT, local blood flow was improved in 83% (10/12, 95% confidence interval [CI] 54-96). One (6%) asymptomatic sinus perforation occurred. Eight (44%) patients treated with EVT also underwent decompressive surgery. Mortality was 50% (9/18, 95% CI 29-71) and 88% (8/9, 95% CI 25-66) of surviving EVT patients achieved functional independence with a modified Rankin Scale score of 0-2 at follow-up. In multivariable analysis, EVT was not associated with increased mortality (adjusted odds ratio, 0.66, 95% CI 0.16-2.58). DISCUSSION AND CONCLUSION We describe the largest cohort of CVST-VITT patients receiving EVT. Half of the patients receiving EVT died during hospital admission, but most survivors achieved functional independence.
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Affiliation(s)
- Johannes Weller
- Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | | | - Felix J Bode
- Department of Neurology, University Hospital Bonn, Bonn, Germany
| | | | - Brian Buck
- Division of Neurology, University of Alberta Hospital, Edmonton, AB, Canada
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 – LilNCog – Lille Neuroscience & Cognition, Lille, France
| | - Vanessa Dizonno
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Jiangang Duan
- Department of Neurology and Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ahmed Elkady
- Department of Neurology, Saudi German Hospital, Jeddah, Saudi Arabia
| | | | | | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Catherine Legault
- Division of Neurology, McGill University Health Centre, Montreal, QC, Canada
| | - Mar Morin Martin
- Department of Neurology, Hospital Complex of Toledo, Toledo, Spain
| | | | - Johann Pelz
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | | | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Marco Petruzzellis
- Neuroradiology Unit, Azienda Ospedaliera Consorziale Policlinico di Bari, Italy
| | - Nicolas Raposo
- Department of Neurology, Hôpital Pierre-Paul Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France and Inserm, Toulouse NeuroImaging Center, Université de Toulouse, Toulouse, France
| | - Mona Skjelland
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | | | - Sanjith Aaron
- Neurology Unit, Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Mayte Sanchez van Kammen
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Diana Aguiar de Sousa
- CEEM and Institute of Anatomy, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
- Stroke Centre, Lisbon Central University Hospital, Lisbon, Portugal
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, Tuebingen, Germany and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia, Mexico City, Mexico
| | - Adriana B Conforto
- Hospital das Clinicas/São Paulo University and Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - José M Ferro
- Centro de Estudas Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Portugal
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Saposnik G, Bushnell C, Coutinho JM, Field TS, Furie KL, Galadanci N, Kam W, Kirkham FC, McNair ND, Singhal AB, Thijs V, Yang VXD. Diagnosis and Management of Cerebral Venous Thrombosis: A Scientific Statement From the American Heart Association. Stroke 2024; 55:e77-e90. [PMID: 38284265 DOI: 10.1161/str.0000000000000456] [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] [Indexed: 01/30/2024]
Abstract
Cerebral venous thrombosis accounts for 0.5% to 3% of all strokes. The most vulnerable populations include young individuals, women of reproductive age, and patients with a prothrombotic state. The clinical presentation of cerebral venous thrombosis is diverse (eg, headaches, seizures), requiring a high level of clinical suspicion. Its diagnosis is based primarily on magnetic resonance imaging/magnetic resonance venography or computed tomography/computed tomographic venography. The clinical course of cerebral venous thrombosis may be difficult to predict. Death or dependence occurs in 10% to 15% of patients despite intensive medical treatment. This scientific statement provides an update of the 2011 American Heart Association scientific statement for the diagnosis and management of cerebral venous thrombosis. Our focus is on advances in the diagnosis and management decisions of patients with suspected cerebral venous thrombosis. We discuss evidence for the use of anticoagulation and endovascular therapies and considerations for craniectomy. We also provide an algorithm to optimize the management of patients with cerebral venous thrombosis and those with progressive neurological deterioration or thrombus propagation despite maximal medical therapy.
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Dias L, João Pinto M, Maia R, Albuquerque L, Carvalho M. Post cerebral venous thrombosis headache - Prevalence, mechanisms and risk factors. J Clin Neurosci 2024; 119:205-211. [PMID: 38141436 DOI: 10.1016/j.jocn.2023.12.005] [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: 04/16/2023] [Revised: 12/03/2023] [Accepted: 12/07/2023] [Indexed: 12/25/2023]
Abstract
INTRODUCTION Headache after cerebral venous thrombosis (post-CVT headache [PCH]) is a common complaint during follow-up. Risk factors and their pathophysiology are not well known. We studied PCH prevalence in CVT patients, its pathophysiology, and possible risk factors. MATERIALS AND METHODS We performed a retrospective observational study of patients admitted to a tertiary hospital between 2006 and 2019 with CVT and at least one follow-up appointment. We diagnosed PCH when patients reported headaches during the follow-up visit. Recanalization was retrospectively assessed by two neuroradiologists using the first available follow-up MRI/ MRV, and the PRIORITy-CVT study classification. RESULTS Of 131 patients, sixty (60/131, 45.8 %) reported PCH at the 3-month follow-up. Of these PCH, 9 had previous migraine (9/60, 5.0 %) and 13 previous tension-type headaches (13/60, 21.6 %), before CVT. Forty-four (44/60, 73.3 %) PCH patients had de novo headache: 21 (21/60, 35.0 %) de novo tension-type headaches; 6 (6/60, 10.0 %) de novo migraine; 6 [(6/60, 10.0 %) secondary headache disorders: 3 due to dural arteriovenous fistula, 2 due to intracranial hypertension, and 1 recurrent CVT], and 11 other headache types. Most patients had at least partial recanalization, with no difference in PCH frequency amongst recanalization subgroups (p = 0.598). Premorbid depression (p = 0.009, OR 7.9, 95 % CI 1.6-31.4) increased the odds ratio of PCH, while superior sagittal sinus thrombosis (p = 0.005, OR 0.15, 95 % CI 0.03-0.56) decreased it. DISCUSSION Our study shows that PCH is a common finding after CVT and elucidates potential risk factors. PCH is common in patients with previous or de novo primary headache. In PCH patients without previous headache, secondary causes of headache, namely related to CVT complications, should be excluded. PCH is also increased in patients with premorbid depression. There was no statistically significant difference in PCH amongst the PRIORITy-CVT recanalization subgroups, but most patients had at least partial recanalization.
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Affiliation(s)
- Leonor Dias
- Neurology Department, Centro Hospitalar Universitário de São João, 4200-319, Porto, Portugal; Department of Clinical Neurosciences and Mental Health, Porto Medical Faculty (FMUP), 4200-319, Porto, Portugal.
| | - Maria João Pinto
- Neurology Department, Centro Hospitalar Universitário de São João, 4200-319, Porto, Portugal; Department of Clinical Neurosciences and Mental Health, Porto Medical Faculty (FMUP), 4200-319, Porto, Portugal.
| | - Rúben Maia
- Neurorradiology Department, Centro Hospitalar Vila Nova de Gaia/ Espinho, 4434-502, Vila Nova de Gaia, Portugal.
| | - Luís Albuquerque
- Neuroradiology Department, Centro Hospitalar Universitário de São João, 4200-319, Porto, Portugal.
| | - Marta Carvalho
- Neurology Department, Centro Hospitalar Universitário de São João, 4200-319, Porto, Portugal; Department of Clinical Neurosciences and Mental Health, Porto Medical Faculty (FMUP), 4200-319, Porto, Portugal.
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10
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Scutelnic A, van de Munckhof A, Krzywicka K, van Kammen MS, Lindgren E, Cordonnier C, Kleinig TJ, Field TS, Poli S, Lemmens R, Middeldorp S, Aaron S, Borhani-Haghighi A, Arauz A, Kremer Hovinga JA, Günther A, Putaala J, Wasay M, Conforto AB, de Sousa DA, Jood K, Tatlisumak T, Ferro JM, Coutinho JM, Arnold M, Heldner MR. Sex differences in cerebral venous sinus thrombosis after adenoviral vaccination against COVID-19. Eur Stroke J 2023; 8:1001-1010. [PMID: 37434312 PMCID: PMC10345391 DOI: 10.1177/23969873231185213] [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: 03/19/2023] [Accepted: 06/13/2023] [Indexed: 07/13/2023] Open
Abstract
INTRODUCTION Cerebral venous sinus thrombosis associated with vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) is a severe disease with high mortality. There are few data on sex differences in CVST-VITT. The aim of our study was to investigate the differences in presentation, treatment, clinical course, complications, and outcome of CVST-VITT between women and men. PATIENTS AND METHODS We used data from an ongoing international registry on CVST-VITT. VITT was diagnosed according to the Pavord criteria. We compared the characteristics of CVST-VITT in women and men. RESULTS Of 133 patients with possible, probable, or definite CVST-VITT, 102 (77%) were women. Women were slightly younger [median age 42 (IQR 28-54) vs 45 (28-56)], presented more often with coma (26% vs 10%) and had a lower platelet count at presentation [median (IQR) 50x109/L (28-79) vs 68 (30-125)] than men. The nadir platelet count was lower in women [median (IQR) 34 (19-62) vs 53 (20-92)]. More women received endovascular treatment than men (15% vs 6%). Rates of treatment with intravenous immunoglobulins were similar (63% vs 66%), as were new venous thromboembolic events (14% vs 14%) and major bleeding complications (30% vs 20%). Rates of good functional outcome (modified Rankin Scale 0-2, 42% vs 45%) and in-hospital death (39% vs 41%) did not differ. DISCUSSION AND CONCLUSIONS Three quarters of CVST-VITT patients in this study were women. Women were more severely affected at presentation, but clinical course and outcome did not differ between women and men. VITT-specific treatments were overall similar, but more women received endovascular treatment.
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Affiliation(s)
- Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Thalia S Field
- Devision of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, Canada
| | - Sven Poli
- Department of Neurology & Stroke, University Hospital Tuebingen, Eberhard-Karls University, Tuebingen, Germany
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sanjith Aaron
- Department of Neurosciences, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | | | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suárez, Mexico City
| | - Johanna A Kremer Hovinga
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | | | - Diana Aguiar de Sousa
- Lisbon Central University Hospital and Faculdade de Medicina da Universidade de Lisboa, Portugal
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - José M Ferro
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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11
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Glineur M, Dusart A, Cavez N, Tancredi I, Bellante F. Can mechanical thrombectomy be effective in deep cerebral venous thrombosis worsening on anticoagulant? Insight from two cases. J Stroke Cerebrovasc Dis 2023; 32:107398. [PMID: 37839301 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107398] [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: 08/07/2023] [Revised: 09/21/2023] [Accepted: 09/26/2023] [Indexed: 10/17/2023] Open
Abstract
OBJECTIVE Cerebral venous thrombosis (CVT) is a rare condition whose clinical presentation can range from simple headaches to severe impairment of alertness. Some clinical forms, such as involvement of the deep venous system, are associated with a poorer clinical prognosis despite well-managed anticoagulation. The role and timing of rescue mechanical thrombectomy for these patients is not well established. METHOD Clinical and imaging follow-up are discussed according to our treatment decision. RESULTS We describe two cases with deep venous system thrombosis that were treated unsuccessfully with optimal anticoagulation, with a spectacular clinical and radiological response after mechanical thrombectomy (MT). CONCLUSION These cases demonstrate that, despite the negative results of the TO-ACT trial, MT could be considered as a rescue treatment in some clinical forms of deteriorating CVT despite optimal anticoagulation.
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Affiliation(s)
- Marine Glineur
- Service de neurologie, Hôpital Erasme, Brussels, Belgium; Service de neurologie, CHU de Charleroi, Chaussée de Bruxelles, 140, Charleroi 6042, Belgium
| | - Anne Dusart
- Service de neurologie, CHU de Charleroi, Chaussée de Bruxelles, 140, Charleroi 6042, Belgium
| | - Nicolas Cavez
- Service de neurologie, CHU de Charleroi, Chaussée de Bruxelles, 140, Charleroi 6042, Belgium
| | - Illario Tancredi
- Service de neurologie, CHU de Charleroi, Chaussée de Bruxelles, 140, Charleroi 6042, Belgium
| | - Flavio Bellante
- Service de neurologie, CHU de Charleroi, Chaussée de Bruxelles, 140, Charleroi 6042, Belgium.
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12
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Field TS, Dizonno V, Almekhlafi MA, Bala F, Alhabli I, Wong H, Norena M, Villaluna MK, King-Azote P, Ratnaweera N, Mancini S, Van Gaal SC, Wilson LK, Graham BR, Sposato LA, Blacquiere D, Dewar BM, Boulos MI, Buck BH, Odier C, Perera KS, Pikula A, Tkach A, Medvedev G, Canfield C, Mortenson WB, Nadeau JO, Alshimemeri S, Benavente OR, Demchuk AM, Dowlatshahi D, Lanthier S, Lee AYY, Mandzia J, Suryanarayan D, Weitz JI, Hill MD. Study of Rivaroxaban for Cerebral Venous Thrombosis: A Randomized Controlled Feasibility Trial Comparing Anticoagulation With Rivaroxaban to Standard-of-Care in Symptomatic Cerebral Venous Thrombosis. Stroke 2023; 54:2724-2736. [PMID: 37675613 PMCID: PMC10615774 DOI: 10.1161/strokeaha.123.044113] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/14/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Emerging data suggest that direct oral anticoagulants may be a suitable choice for anticoagulation for cerebral venous thrombosis (CVT). However, conducting high-quality trials in CVT is challenging as it is a rare disease with low rates of adverse outcomes such as major bleeding and functional dependence. To facilitate the design of future CVT trials, SECRET (Study of Rivaroxaban for Cerebral Venous Thrombosis) assessed (1) the feasibility of recruitment, (2) the safety of rivaroxaban compared with standard-of-care anticoagulation, and (3) patient-centered functional outcomes. METHODS This was a phase II, prospective, open-label blinded-end point 1:1 randomized trial conducted at 12 Canadian centers. Participants were aged ≥18 years, within 14 days of a new diagnosis of symptomatic CVT, and suitable for oral anticoagulation; they were randomized to receive rivaroxaban 20 mg daily, or standard-of-care anticoagulation (warfarin, target international normalized ratio, 2.0-3.0, or low-molecular-weight heparin) for 180 days, with optional extension up to 365 days. Primary outcomes were annual rate of recruitment (feasibility); and a composite of symptomatic intracranial hemorrhage, major extracranial hemorrhage, or mortality at 180 days (safety). Secondary outcomes included recurrent venous thromboembolism, recanalization, clinically relevant nonmajor bleeding, and functional and patient-reported outcomes (modified Rankin Scale, quality of life, headache, mood, fatigue, and cognition) at days 180 and 365. RESULTS Fifty-five participants were randomized. The rate of recruitment was 21.3 participants/year; 57% of eligible candidates consented. Median age was 48.0 years (interquartile range, 38.5-73.2); 66% were female. There was 1 primary event (symptomatic intracranial hemorrhage), 2 clinically relevant nonmajor bleeding events, and 1 recurrent CVT by day 180, all in the rivaroxaban group. All participants in both arms had at least partial recanalization by day 180. At enrollment, both groups on average reported reduced quality of life, low mood, fatigue, and headache with impaired cognitive performance. All metrics improved markedly by day 180. CONCLUSIONS Recruitment targets were reached, but many eligible participants declined randomization. There were numerically more bleeding events in patients taking rivaroxaban compared with control, but rates of bleeding and recurrent venous thromboembolism were low overall and in keeping with previous studies. Participants had symptoms affecting their well-being at enrollment but improved over time. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03178864.
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Affiliation(s)
- Thalia S Field
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Vanessa Dizonno
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Mohammed A Almekhlafi
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
| | - Fouzi Bala
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
- Department of Radiology, Tours University Hospital, France (F.B.)
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
| | - Hubert Wong
- School of Population and Public Health, and Centre for Health Outcomes and Evaluative Sciences (H.W., M.N.), University of British Columbia, Canada
| | - Monica Norena
- School of Population and Public Health, and Centre for Health Outcomes and Evaluative Sciences (H.W., M.N.), University of British Columbia, Canada
| | - Maria Karina Villaluna
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Princess King-Azote
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Namali Ratnaweera
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Steven Mancini
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Stephen C Van Gaal
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Laura K Wilson
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Brett R Graham
- Division of Neurology, University of Saskatchewan College of Medicine, Saskatoon, Canada (B.R.G.)
| | - Luciano A Sposato
- Department of Clinical Neurosciences, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada (L.A.S., J.M.)
| | - Dylan Blacquiere
- Ottawa Stroke Program, Ottawa Hospital Research institute, University of Ottawa, Canada (D.B., B.M.D., D.D.)
| | - Brian M Dewar
- Ottawa Stroke Program, Ottawa Hospital Research institute, University of Ottawa, Canada (D.B., B.M.D., D.D.)
| | - Mark I Boulos
- Sunnybrook Research Institute, Division of Neurology (M.I.B.), University Health Network, University of Toronto, Canada
| | - Brian H Buck
- Division of Neurology, University of Alberta, Edmonton, Canada (B.H.B.)
| | - Celine Odier
- Département de Neurosciences, Centre Hospitalier d'Université de Montréal, Université de Montréal, Canada (C.O.)
| | - Kanjana S Perera
- Population Health Research Institute and Division of Neurology, McMaster University, Hamilton, Canada (K.S.P.)
| | - Aleksandra Pikula
- Krembil Brain Institute (A.P.), University Health Network, University of Toronto, Canada
| | - Aleksander Tkach
- Kelowna General Hospital, Interior Health Authority, Canada (A.T.)
| | - George Medvedev
- Royal Columbian Hospital, Fraser Health Authority, New Westminster, Canada (G.M.)
| | - Carolyn Canfield
- Department of Family Practice, Innovation Support Unit (C.C.), University of British Columbia, Vancouver, Canada
| | - W Ben Mortenson
- Department of Occupational Science and Occupational Therapy (W.B.M.), University of British Columbia, Vancouver, Canada
| | | | | | - Oscar R Benavente
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
| | - Dar Dowlatshahi
- Ottawa Stroke Program, Ottawa Hospital Research institute, University of Ottawa, Canada (D.B., B.M.D., D.D.)
| | - Sylvain Lanthier
- Hôpital de Sacre-Coeur de Montréal, Département de Neurosciences, Université de Montréal, Canada (S.L.)
| | - Agnes Y Y Lee
- Division of Hematology (A.Y.Y.L.), University of British Columbia, Vancouver, Canada
| | - Jennifer Mandzia
- Department of Clinical Neurosciences, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada (L.A.S., J.M.)
| | - Deepa Suryanarayan
- Division of Hematology, Cumming School of Medicine (D.S.), University of British Columbia, Vancouver, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Canada (J.I.W.)
| | - Michael D Hill
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
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Bakradze E, Shu L, Henninger N, Prabhakaran S, Siegler JE, De Marchis GM, Giles JA, Dittrich T, Heldner MR, Antonenko K, Kam W, Liebeskind DS, Simpkins AN, Nguyen TN, Yaghi S, Liberman AL. Delayed Diagnosis in Cerebral Venous Thrombosis: Associated Factors and Clinical Outcomes. J Am Heart Assoc 2023; 12:e030421. [PMID: 37753785 PMCID: PMC10727263 DOI: 10.1161/jaha.123.030421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/04/2023] [Indexed: 09/28/2023]
Abstract
Background Identifying factors associated with delayed diagnosis of cerebral venous thrombosis (CVT) can inform future strategies for early detection. Methods and Results We conducted a retrospective cohort study including all participants from ACTION-CVT (Anticoagulation in the Treatment of Cerebral Venous Thrombosis) study who had dates of neurologic symptom onset and CVT diagnosis available. Delayed diagnosis was defined as CVT diagnosis occurring in the fourth (final) quartile of days from symptom onset. The primary study outcome was modified Rankin Scale score of ≤1 at 90 days; secondary outcomes included partial/complete CVT recanalization on last available imaging and modified Rankin Scale score of ≤2. Logistic regression analyses were used to identify independent variables associated with delayed diagnosis and to assess the association of delayed diagnosis and outcomes. A total of 935 patients were included in our study. Median time from symptom onset to diagnosis was 4 days (interquartile range, 1-10 days). Delayed CVT diagnosis (time to diagnosis >10 days) occurred in 212 patients (23%). Isolated headache (adjusted odds ratio [aOR], 2.36 [95% CI, 1.50-3.73]; P<0.001), older age (aOR by 1 year, 1.02 [95% CI, 1.004-1.03]; P=0.01), and papilledema (aOR, 2.00 [95% CI, 1.03-3.89]; P=0.04) were associated with diagnostic delay, whereas higher National Institutes of Health Stroke Scale score was inversely associated with diagnostic delay (aOR by 1 point, 0.95 [95% CI, 0.89-1.00]; P=0.049). Delayed diagnosis was not associated with modified Rankin Scale score of ≤1 at 90 days (aOR, 1.08 [95% CI, 0.60-1.96]; P=0.79). Conclusions In a large multicenter cohort, a quarter of included patients with CVT were diagnosed >10 days after symptom onset. Delayed CVT diagnosis was associated with the symptom of isolated headache and was not associated with adverse clinical outcomes.
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Affiliation(s)
- Ekaterina Bakradze
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamALUSA
| | - Liqi Shu
- Department of NeurologyBrown UniversityProvidenceRIUSA
| | - Nils Henninger
- Department of NeurologyUniversity of Massachusetts Chan Medical SchoolWorcesterMAUSA
- Department of PsychiatryUniversity of Massachusetts Chan Medical SchoolWorcesterMAUSA
| | | | | | - Gian Marco De Marchis
- Department of NeurologyUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - James A. Giles
- Department of NeurologyYale University School of MedicineNew HavenCTUSA
| | - Tolga Dittrich
- Department of NeurologyUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Mirjam R. Heldner
- Department of NeurologyUniversity Hospital and University of BernBernSwitzerland
| | - Kateryna Antonenko
- Department of NeurologyUniversity Hospital and University of BernBernSwitzerland
| | - Wayneho Kam
- Department of NeurologyDuke University HospitalDurhamNCUSA
| | - David S. Liebeskind
- Department of NeurologyUniversity of California at Los AngelesLos AngelesCAUSA
| | - Alexis N. Simpkins
- Department of NeurologyUniversity of FloridaGainesvilleFLUSA
- Department of NeurologyCedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Thanh N. Nguyen
- Department of NeurologyBoston University Chobanian and Avedisian School of MedicineBostonMAUSA
| | - Shadi Yaghi
- Department of NeurologyBrown UniversityProvidenceRIUSA
| | - Ava L. Liberman
- Clinical and Translational Neuroscience Unit, Department of NeurologyFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNYUSA
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14
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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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15
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van de Munckhof A, Sánchez van Kammen M, Krzywicka K, Aaron S, Aguiar de Sousa D, Antochi F, Arauz A, Barboza MA, Conforto AB, Dentali F, Galdames Contreras D, Ji X, Jood K, Heldner MR, Hernández-Pérez M, Kam W, Kleinig TJ, Kristoffersen ES, Leker RR, Lemmens R, Poli S, Yeşilot N, Wasay M, Wu TY, Arnold M, Lucas-Neto L, Middeldorp S, Putaala J, Tatlisumak T, Ferro JM, Coutinho JM. Direct oral anticoagulants for the treatment of cerebral venous thrombosis - a protocol of an international phase IV study. Front Neurol 2023; 14:1251581. [PMID: 37780701 PMCID: PMC10539579 DOI: 10.3389/fneur.2023.1251581] [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: 07/01/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction Current guidelines recommend that patients with cerebral venous thrombosis (CVT) should be treated with vitamin K antagonists (VKAs) for 3-12 months. Direct oral anticoagulants (DOACs), however, are increasingly used in clinical practice. An exploratory randomized controlled trial including 120 patients with CVT suggested that the efficacy and safety profile of dabigatran (a DOAC) is similar to VKAs for the treatment of CVT, but large-scale prospective studies from a real-world setting are lacking. Methods DOAC-CVT is an international, prospective, observational cohort study comparing DOACs to VKAs for the prevention of recurrent venous thrombotic events after acute CVT. Patients are eligible if they are 18 years or older, have a radiologically confirmed CVT, and have started oral anticoagulant treatment (DOAC or VKA) within 30 days of CVT diagnosis. Patients with an absolute contra-indication for DOACs, such as pregnancy or severe renal insufficiency, are excluded from the study. We aim to recruit at least 500 patients within a three-year recruitment period. The primary endpoint is a composite of recurrent venous thrombosis and major bleeding at 6 months of follow-up. We will calculate an adjusted odds ratio for the primary endpoint using propensity score inverse probability treatment weighting. Discussion DOAC-CVT will provide real-world data on the comparative efficacy and safety of DOACs versus VKAs for the treatment of CVT. Clinical trial registration ClinicalTrials.gov, NCT04660747.
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Affiliation(s)
- Anita van de Munckhof
- Department of Neurology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Sanjith Aaron
- Department of Neurology, Christian Medical College, Vellore, India
| | - Diana Aguiar de Sousa
- Department of Neurology, Stroke Center, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Florina Antochi
- Department of Neurology, Spitalul Universitar de Urgenţă Bucureşti, Bucharest, Romania
| | - Antonio Arauz
- Department of Neurology, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Miguel A. Barboza
- Department of Neurology, Rafael Angel Calderon Guardia Hospital, San José, Costa Rica
| | - Adriana B. Conforto
- Department of Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Xunming Ji
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Mirjam R. Heldner
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | | | - Wayneho Kam
- Department of Neurology, Duke University Hospital, Durham, NC, United States
| | - Timothy J. Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | - Ronen R. Leker
- Department of Neurology, Hadassah – Hebrew University Medical Center, Jerusalem, Israel
| | | | - Sven Poli
- Department of Neurology, Tübingen University Hospital, Tübingen, Germany
| | - Nilüfer Yeşilot
- Department of Neurology, Istanbul Tip Fakültesi, Istanbul, Turkey
| | - Mohammad Wasay
- Department of Neurology, Aga Khan University, Karachi, Pakistan
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Lia Lucas-Neto
- Department of Neuroradiology, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - José M. Ferro
- Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Jonathan M. Coutinho
- Department of Neurology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
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16
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Jiang H, Zhou C, Wei H, Wu Y, Zhou Y, Xiao X, Liu L, Li M, Duan J, Meng R, Ji X. Potential role of plasma branched-chain amino acids in the differential diagnosis of acute cerebral venous thrombosis. J Cereb Blood Flow Metab 2023; 43:1532-1543. [PMID: 37066688 PMCID: PMC10414010 DOI: 10.1177/0271678x231170037] [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: 09/06/2022] [Revised: 03/13/2023] [Accepted: 03/24/2023] [Indexed: 04/18/2023]
Abstract
Cerebral venous thrombosis (CVT) is a special and easily misdiagnosed or undiagnosed subtype of stroke. To identify specific biomarkers with a high predictive ability for the diagnosis of acute CVT, we performed metabolomic analysis in plasma samples from acute CVT patients and healthy controls and confirmed the results in validation cohorts. In the discovery stage, there were 343 differential metabolites, and the caffeine metabolism pathway and the biosynthesis pathway for the branched chain amino acids (BCAAs) valine, leucine, and isoleucine were two significant pathways between the CVT and healthy cohorts. The area under the curve (AUC) for metabolites associated with valine, leucine, and isoleucine biosynthesis was 0.934. In the validation stage, the BCAA concentrations demonstrated an AUC of 0.935 to differentiate patients with acute CVT from the control cohort. In addition, BCAAs combined with D-dimer levels were used to establish a diagnostic model for CVT, and the AUC was 0.951, showing good diagnostic efficacy of separating CVT patients from the control cohort. BCAAs as plasma biomarkers deserve to be further studied and even developed in clinical CVT management.
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Affiliation(s)
- Huimin Jiang
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Capital Medical University, Beijing, China
| | - Chen Zhou
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Capital Medical University, Beijing, China
- Neurology and Intracranial Hypertension & Cerebral Venous Disease Center, National Health Commission of China, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Huimin Wei
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Yan Wu
- Neurology and Intracranial Hypertension & Cerebral Venous Disease Center, National Health Commission of China, Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yifan Zhou
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Capital Medical University, Beijing, China
| | - Xuechun Xiao
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Lu Liu
- Neurology and Intracranial Hypertension & Cerebral Venous Disease Center, National Health Commission of China, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ming Li
- Neurology and Intracranial Hypertension & Cerebral Venous Disease Center, National Health Commission of China, Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jiangang Duan
- Neurology and Intracranial Hypertension & Cerebral Venous Disease Center, National Health Commission of China, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Emergency, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Ran Meng
- Neurology and Intracranial Hypertension & Cerebral Venous Disease Center, National Health Commission of China, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Capital Medical University, Beijing, China
- Neurology and Intracranial Hypertension & Cerebral Venous Disease Center, National Health Commission of China, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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17
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Salehi Omran S, Shu L, Chang A, Parikh NS, Zubair AS, Simpkins AN, Heldner MR, Hakim A, Kasab SA, Nguyen T, Klein P, Goldstein ED, Vedovati MC, Paciaroni M, Liebeskind DS, Yaghi S, Cutting S. Timing and Predictors of Recanalization After Anticoagulation in Cerebral Venous Thrombosis. J Stroke 2023; 25:291-298. [PMID: 37282376 PMCID: PMC10250867 DOI: 10.5853/jos.2023.00213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/13/2023] [Accepted: 03/27/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND AND PURPOSE Vessel recanalization after cerebral venous thrombosis (CVT) is associated with favorable outcomes and lower mortality. Several studies examined the timing and predictors of recanalization after CVT with mixed results. We aimed to investigate predictors and timing of recanalization after CVT. METHODS We used data from the multicenter, international AntiCoagulaTION in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT) study of consecutive patients with CVT from January 2015 to December 2020. Our analysis included patients that had undergone repeat venous neuroimaging more than 30 days after initiation of anticoagulation treatment. Prespecified variables were included in univariate and multivariable analyses to identify independent predictors of failure to recanalize. RESULTS Among the 551 patients (mean age, 44.4±16.2 years, 66.2% women) that met inclusion criteria, 486 (88.2%) had complete or partial, and 65 (11.8%) had no recanalization. The median time to first follow-up imaging study was 110 days (interquartile range, 60-187). In multivariable analysis, older age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.07), male sex (OR, 0.44; 95% CI, 0.24-0.80), and lack of parenchymal changes on baseline imaging (OR, 0.53; 95% CI, 0.29-0.96) were associated with no recanalization. The majority of improvement in recanalization (71.1%) occurred before 3 months from initial diagnosis. A high percentage of complete recanalization (59.0%) took place within the first 3 months after CVT diagnosis. CONCLUSION Older age, male sex, and lack of parenchymal changes were associated with no recanalization after CVT. The majority recanalization occurred early in the disease course suggesting limited further recanalization with anticoagulation beyond 3 months. Large prospective studies are needed to confirm our findings.
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Affiliation(s)
- Setareh Salehi Omran
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Liqi Shu
- Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, RI, USA
| | - Allison Chang
- Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, RI, USA
| | - Neal S. Parikh
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Adeel S. Zubair
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Alexis N. Simpkins
- Department of Neurology, University of Florida, Gainesville, FL, USA; and Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mirjam R. Heldner
- Department of Neurology and Stroke Research Center Bern, University of Bern and University Hospital Bern, Bern, Switzerland
| | - Arsany Hakim
- University Institute of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Inselspital, Bern, Switzerland
| | - Sami Al Kasab
- Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Thanh Nguyen
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Piers Klein
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Eric D. Goldstein
- Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, RI, USA
| | | | | | | | - Shadi Yaghi
- Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, RI, USA
| | - Shawna Cutting
- Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, RI, USA
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18
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Liberman AL. Diagnosis and Treatment of Cerebral Venous Thrombosis. Continuum (Minneap Minn) 2023; 29:519-539. [PMID: 37039408 DOI: 10.1212/con.0000000000001211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Cerebral venous thrombosis (CVT), thrombosis of the dural sinus, cerebral veins, or both, is a rare cerebrovascular disease. Although mortality rates after CVT have declined over time, this condition can result in devastating neurologic outcomes. This article reviews the latest literature regarding CVT epidemiology, details new factors associated with the development of CVT, and describes advances in CVT treatment. It also contains a discussion of future directions in the field, including novel diagnostic imaging modalities, and potential strategies to reduce the risks associated with CVT. LATEST DEVELOPMENTS The incidence of CVT may be as high as 2 per 100,000 adults per year. It remains a difficult condition to diagnose given its variable clinical manifestations and the necessity of neuroimaging for confirmation. The COVID-19 pandemic has revealed a novel CVT trigger, vaccine-induced immune thrombotic thrombocytopenia (VITT), as well as an association between COVID-19 infection and CVT. Although VITT is a very rare event, timely diagnosis and treatment of CVT due to VITT likely improves patient outcomes. Direct oral anticoagulants are currently being used to treat CVT and emerging data suggest that these agents are as safe and effective as vitamin K antagonists. The role of endovascular therapy to treat CVT, despite a recent clinical trial, remains unproven. ESSENTIAL POINTS The incidence of CVT has increased, outcomes have improved, and the use of direct oral anticoagulants to treat CVT represents an important advance in the clinical care of these patients. Rates of CVT as a complication of COVID-19 vaccines using adenoviral vectors are very low (<5 per million vaccine doses administered), with the benefits of COVID-19 vaccination far outweighing the risks.
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19
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Wang Z, Dandu C, Guo Y, Gao M, Lan D, Pan L, Zhou D, Ding Y, Ji X, Meng R. A novel score to estimate thrombus burden and predict intracranial hypertension in cerebral venous sinus thrombosis. J Headache Pain 2023; 24:29. [PMID: 36932331 PMCID: PMC10022088 DOI: 10.1186/s10194-023-01562-9] [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: 11/29/2022] [Accepted: 03/07/2023] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND Current methods to evaluate the severity of cerebral venous sinus thrombosis (CVST) lack patient-specific indexes. Herein, a novel scoring method was investigated to estimate the thrombus burden and the intracranial pressure (ICP) of CVST. METHODS In this retrospective study from January 2019 through December 2021, we consecutively enrolled patients with a first-time confirmed diagnosis of CVST by contrast-enhanced magnetic resonance venography (CE-MRV) or computed tomography venography (CTV). In these patients, a comprehensive CVST-Score was established using magnetic resonance black-blood thrombus imaging (MRBTI) to estimate the thrombus burden semi-quantitatively. The relationship between CVST-Score and ICP was explored to assess the potential of using the CVST-score to evaluate ICP noninvasively and dynamically. RESULTS A total of 87 patients were included in the final analysis. The CVST-Scores in different ICP subgroups were as follows: 4.29±2.87 in ICP<250mmH2O subgroup, 11.36±3.86 in ICP =250-330mmH2O subgroup and 14.99±3.15 in ICP>330mmH2O subgroup, respectively (p<0.001). For patients with ICP ≤330mmH2O, the CVST-Score was linearly and positively correlated with ICP (R2=0.53). The receiver operating characteristic (ROC) curves showed the optimal CVST-Score cut-off values to predict ICP ≥250mmH2O and >330mmH2O were 7.15 and 11.62, respectively (P<0.001). Multivariate analysis indicated CVST-Score as an independent predictor of ICP ≥250mmH2O (odds ratio, 2.15; 95% confidence interval, 1.49-3.10; p<0.001). CONCLUSIONS A simple and noninvasive CVST-Score can rapidly estimate the thrombus burden and predict the severity of intracranial hypertension in patients with CVST. The CVST-Score can aid in evaluating therapeutic responses and avoiding unnecessary invasive procedures at long-term follow-up.
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Affiliation(s)
- Zhongao Wang
- grid.413259.80000 0004 0632 3337Department of Neurology, National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China
- grid.24696.3f0000 0004 0369 153XAdvanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China
| | - Chaitu Dandu
- grid.254444.70000 0001 1456 7807Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan 48201 USA
| | - Yibing Guo
- grid.413259.80000 0004 0632 3337Department of Neurology, National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China
- grid.24696.3f0000 0004 0369 153XAdvanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China
| | - Meini Gao
- grid.413259.80000 0004 0632 3337Department of Neurology, National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China
- grid.24696.3f0000 0004 0369 153XAdvanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China
| | - Duo Lan
- grid.413259.80000 0004 0632 3337Department of Neurology, National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China
- grid.24696.3f0000 0004 0369 153XAdvanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China
| | - Liqun Pan
- grid.413259.80000 0004 0632 3337Department of Neurology, National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China
- grid.24696.3f0000 0004 0369 153XAdvanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China
| | - Da Zhou
- grid.413259.80000 0004 0632 3337Department of Neurology, National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China
- grid.24696.3f0000 0004 0369 153XAdvanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China
| | - Yuchuan Ding
- grid.254444.70000 0001 1456 7807Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan 48201 USA
| | - Xunming Ji
- grid.413259.80000 0004 0632 3337Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China
| | - Ran Meng
- grid.413259.80000 0004 0632 3337Department of Neurology, National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China
- grid.24696.3f0000 0004 0369 153XAdvanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China
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20
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Krzywicka K, Aguiar de Sousa D, Cordonnier C, Bode FJ, Field TS, Michalski D, Pelz J, Skjelland M, Wiedmann M, Zimmermann J, Wittstock M, Zanotti B, Ciccone A, Bandettini di Poggio M, Borhani-Haghighi A, Chatterton S, Aujayeb A, Devroye A, Dizonno V, Geeraerts T, Giammello F, Günther A, Ichaporia NR, Kleinig T, Kristoffersen ES, Lemmens R, De Maistre E, Mirzaasgari Z, Payen JF, Putaala J, Petruzzellis M, Raposo N, Sadeghi-Hokmabadi E, Schoenenberger S, Umaiorubahan M, Sylaja PN, van de Munckhof A, Sánchez van Kammen M, Lindgren E, Jood K, Scutelnic A, Heldner MR, Poli S, Kruip MJHA, Arauz A, Conforto AB, Aaron S, Middeldorp S, Tatlisumak T, Arnold M, Coutinho JM, Ferro JM. Decompressive surgery in cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia. Eur J Neurol 2023; 30:1335-1345. [PMID: 36773014 DOI: 10.1111/ene.15735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/22/2023] [Accepted: 02/02/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND AND PURPOSE Cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) is an adverse drug reaction occurring after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. CVST-VITT patients often present with large intracerebral haemorrhages and a high proportion undergoes decompressive surgery. Clinical characteristics, therapeutic management and outcomes of CVST-VITT patients who underwent decompressive surgery are described and predictors of in-hospital mortality in these patients are explored. METHODS Data from an ongoing international registry of patients who developed CVST within 28 days of SARS-CoV-2 vaccination, reported between 29 March 2021 and 10 May 2022, were used. Definite, probable and possible VITT cases, as defined by Pavord et al. (N Engl J Med 2021; 385: 1680-1689), were included. RESULTS Decompressive surgery was performed in 34/128 (27%) patients with CVST-VITT. In-hospital mortality was 22/34 (65%) in the surgical and 27/94 (29%) in the non-surgical group (p < 0.001). In all surgical cases, the cause of death was brain herniation. The highest mortality rates were found amongst patients with preoperative coma (17/18, 94% vs. 4/14, 29% in the non-comatose; p < 0.001) and bilaterally absent pupillary reflexes (7/7, 100% vs. 6/9, 67% with unilaterally reactive pupil, and 4/11, 36% with bilaterally reactive pupils; p = 0.023). Postoperative imaging revealed worsening of index haemorrhagic lesion in 19 (70%) patients and new haemorrhagic lesions in 16 (59%) patients. At a median follow-up of 6 months, 8/10 of surgical CVST-VITT who survived admission were functionally independent. CONCLUSIONS Almost two-thirds of surgical CVST-VITT patients died during hospital admission. Preoperative coma and bilateral absence of pupillary responses were associated with higher mortality rates. Survivors often achieved functional independence.
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Affiliation(s)
- Katarzyna Krzywicka
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Diana Aguiar de Sousa
- Stroke Centre, Lisbon Central University Hospital Center, Lisbon, Portugal.,CEEM and Institute of Anatomy, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Charlotte Cordonnier
- INSERM, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, University of Lille, Lille, France
| | - Felix J Bode
- Department of Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dominik Michalski
- Department of Neurology, Leipzig University Hospital, Leipzig, Germany
| | - Johann Pelz
- Department of Neurology, Leipzig University Hospital, Leipzig, Germany
| | - Mona Skjelland
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Markus Wiedmann
- Department of Surgery, Oslo University Hospital, Oslo, Norway
| | | | | | - Bruno Zanotti
- Department of Neuroscience, Neurology with Neurosurgical Activity, C. Poma Hospital, ASST di Mantova, Mantua, Italy
| | - Alfonso Ciccone
- Department of Neuroscience, Neurology with Neurosurgical Activity, C. Poma Hospital, ASST di Mantova, Mantua, Italy
| | | | | | - Sophie Chatterton
- Department of Neurology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Avinash Aujayeb
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, Cramlington, UK
| | - Annemie Devroye
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Vanessa Dizonno
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Thomas Geeraerts
- Department of Anesthesiology and Critical Care, University Toulouse 3-Paul-Sabatier, University Hospital of Toulouse, Hôpital Pierre-Paul Riquet, CHU Toulouse-Purpan, Toulouse, France
| | - Fabrizio Giammello
- Translational Molecular Medicine and Surgery, XXXVI Cycle, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy.,Stroke Unit, Department of Clinical and Experimental Medicine, Polyclinic Hospital G. Martino, Messina, Italy
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Espen S Kristoffersen
- Department of Neurology, Akershus University Hospital, Oslo, Norway.,Department of General Practice, University of Oslo, Oslo, Norway
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Emmanuel De Maistre
- Laboratoire d'Hématologie-Hémostase, Centre Hospitalier Universitaire Dijon, Dijon, France
| | - Zahra Mirzaasgari
- Department of Neurology, Firoozgar Hospital, School of Medicine, Iran University of Medical Science, Tehran, Iran
| | - Jean-Francois Payen
- Department of Anaesthesia and Intensive Care, Grenoble Alpes University Hospital, and Grenoble Alpes University, Grenoble Institut des Neurosciences, INSERM U1216, Grenoble, France
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marco Petruzzellis
- Department of Neurology, AOU Consorziale Policlinico di Bari, Bari, Italy
| | - Nicolas Raposo
- Department of Neurology, Hôpital Pierre-Paul Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,Inserm, Toulouse NeuroImaging Center, Université de Toulouse, Toulouse, France
| | - Elyar Sadeghi-Hokmabadi
- Department of Neurology, Imam-Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | | | - Padmavathy N Sylaja
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Gothenburg, Sweden
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Gothenburg, Sweden
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, Tuebingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Antonio Arauz
- National Institute of Neurology and Surgery Manuel Velasco Suarez, Mexico City, Mexico
| | - Adriana B Conforto
- Hospital das Clinicas/São Paulo University and Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Sanjith Aaron
- Neurology Unit, Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Saskia Middeldorp
- Department of Internal Medicine and Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Gothenburg, Sweden
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - José M Ferro
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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21
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Pleșa FC, Jijie A, Toma GS, Ranetti AE, Manole AM, Rotaru R, Caloianu I, Anghel D, Dulămea OA. Challenges in Cerebral Venous Thrombosis Management-Case Reports and Short Literature Review. Life (Basel) 2023; 13:life13020334. [PMID: 36836691 PMCID: PMC9964720 DOI: 10.3390/life13020334] [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: 11/25/2022] [Revised: 01/07/2023] [Accepted: 01/23/2023] [Indexed: 01/28/2023] Open
Abstract
Cerebral venous thrombosis (CVT) is a rare type of stroke, with a complex clinical presentation that can make it a diagnostic challenge for the swift initiation of anticoagulation. When a hemorrhagic transformation is added, therapeutic management becomes even more complex. We describe a series of four cases, aged between 23 and 37 years old, with cerebral venous thrombosis. They were admitted to our clinic between 2014 and 2022. All cases presented significant challenges in either diagnostic, therapeutic or etiologic evaluation, at different stages of the disease. Late complications such as epilepsy or depression and other behavioral disorders represent long-term sequelae for the patient. Therefore, through its late complications, CVT is not only an acute disease but a chronic disorder with long-term follow-up requirements. The first case of the series is of a postpartum woman with focal neurological deficit caused by CVT with hemorrhagic transformation that presented multiple thrombotic complications and severe depression. The second case is of a man with extensive cerebral thrombosis who developed bilateral papillary edema under therapeutic anticoagulation treatment. The third case is of a woman with bilateral cavernous sinus thrombosis who later developed depressive disorder and focal seizures. The fourth case is of a pregnant woman in the first trimester presenting with a steep decline in consciousness level secondary to deep cerebral vein thrombosis requiring intensive care and subsequently developing a memory disorder. For a long period of time, due to being underdiagnosed, few things were known about CVT. Nowadays, we have all the tools to diagnose, treat, and follow up cases of CVT.
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Affiliation(s)
- Florentina Cristina Pleșa
- Department of Neurology, “Dr. Carol Davila” Central Military Emergency University Hospital, 134 Calea Plevnei, 010242 Bucharest, Romania
- Department of Preclinical Disciplines, “Titu Maiorescu” University, 031593 Bucharest, Romania
| | - Alina Jijie
- Department of Neurology, “Dr. Carol Davila” Central Military Emergency University Hospital, 134 Calea Plevnei, 010242 Bucharest, Romania
| | - Gabriela Simona Toma
- Department of Radiology, “Dr. Carol Davila” Central Military Emergency University Hospital, 010242 Bucharest, Romania
| | - Aurelian Emilian Ranetti
- Department of Neurology, “Dr. Carol Davila” Central Military Emergency University Hospital, 134 Calea Plevnei, 010242 Bucharest, Romania
- Department of Endocrinology, “Dr. Carol Davila” Central Military Emergency University Hospital, 010242 Bucharest, Romania
- Correspondence:
| | - Aida Mihaela Manole
- Department of Neurology, “Dr. Carol Davila” Central Military Emergency University Hospital, 134 Calea Plevnei, 010242 Bucharest, Romania
| | - Ruxandra Rotaru
- Department of Neurology, “Dr. Carol Davila” Central Military Emergency University Hospital, 134 Calea Plevnei, 010242 Bucharest, Romania
| | - Ionuț Caloianu
- Department of Neurology, “Dr. Carol Davila” Central Military Emergency University Hospital, 134 Calea Plevnei, 010242 Bucharest, Romania
| | - Daniela Anghel
- Department of Medico-Surgical and Prophylactic Disciplines, Faculty of Medicine, “Titu Maiorescu” University, 031593 Bucharest, Romania
- Department of Internal Medicine, Central Military Emergency University Hospital, 010242 Bucharest, Romania
| | - Octaviana Adriana Dulămea
- Neurology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Neurology Department, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
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22
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Zheng SF, Zhang YB, Xie BS, Wang HJ, Fan WJ, Chen GR, Dai LS, Yu LH, Yao PS, Kang DZ. Mechanical Thrombectomy with Tandem Double Stent Retriever in Combination with Intermediate Catheter Aspiration for Refractory Severe Hemorrhagic Cerebral Venous Sinus Thrombosis. World Neurosurg 2022; 167:e990-e997. [PMID: 36058490 DOI: 10.1016/j.wneu.2022.08.123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/26/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We aimed to describe the initial experience of mechanical thrombectomy using tandem double stent retrievers combined with intermediate catheter aspiration to treat refractory severe hemorrhagic (SH)-cerebral venous sinus thrombosis (CVST). METHODS All refractory SH-CVST patients treated with mechanical thrombectomy using tandem double stent retriever (SR) combined with intermediate catheter aspiration (MT-TDSA) in our institution were retrospectively reviewed. MT-TDSA is a technique that fully engages the clot with double SRs and retrieves the clot using a double SR in combination with aspiration from an intermediate catheter. Demographics, clinical manifestation, medical history, the location of the occluded venous sinus, intraoperative details, procedure-related complications, and modified Rankin Scale (1, 6, 12 months postoperatively) were collected and analyzed. RESULTS Fourteen patients (median age, 43 years) with refractory SH-CVST were treated with MT-TDSA between January 2016 and January 2020. Ten of 14 (71.4%) had a successful intraoperative recanalization rate (>90%) using MT-TDSA. No procedure-related complications occurred. Eleven patients had good clinical outcomes (modified Rankin Scale score 0-2 at 12 months postoperatively). CONCLUSIONS MT-TDSA for refractory SH-CVST might improve clot-capturing ability and remove blood clots from cerebral venous sinuses effectively and safely, achieving good clinical outcomes.
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Affiliation(s)
- Shu-Fa Zheng
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yi-Bin Zhang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Bin-Sen Xie
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Hao-Jie Wang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wen-Jian Fan
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Guo-Rong Chen
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Lin-Sun Dai
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Liang-Hong Yu
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Pei-Sen Yao
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - De-Zhi Kang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China; Fujian Provincial Clinical Research Center for Neurological Disease, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China; Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China; Fujian Provincial Institutes of Brain Disorders and Brain Sciences, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China; Clinical research and translation center, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China.
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23
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Bourrienne M, Gay J, Mazighi M, Ajzenberg N. State of the art in cerebral venous sinus thrombosis animal models. J Thromb Haemost 2022; 20:2187-2196. [PMID: 35815379 PMCID: PMC9796510 DOI: 10.1111/jth.15816] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/28/2022] [Accepted: 07/05/2022] [Indexed: 01/01/2023]
Abstract
Cerebral venous sinus thrombosis (CVST) is an uncommon venous thromboembolic event accounting for less than 1% of strokes resulting in brain parenchymal injuries. Diagnosis and prognosis are still challenging due to highly variable clinical course and etiologies. Beyond thrombosis, different CVST-related parenchymal injuries may occur and include edema, ischemic strokes, and intra-cerebral hemorrhage (ICH; i.e., parenchymal/subdural hematomas, and subarachnoid hemorrhages), which are identified in 40%-60% of patients without clearly identified mechanisms. In this perspective, experimental animal models contribute to the understanding of initiation, propagation, and resolution of thrombosis, as well as brain-related damages. Last but not least, animal models may be useful to study new therapeutic approaches. In this review, we provide a comprehensive overview of CVST experimental models, focusing on their strengths, limits, and contribution to the current knowledge.
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Affiliation(s)
- Marie‐Charlotte Bourrienne
- Université Paris Cité & Université Sorbonne Paris Nord, INSERM U1148, LVTSF‐75018 ParisFrance
- Laboratoire d'Hématologie, AP‐HP, Hôpital BeaujonClichyFrance
| | - Juliette Gay
- Université Paris Cité & Université Sorbonne Paris Nord, INSERM U1148, LVTSF‐75018 ParisFrance
- Laboratoire d'Hématologie, AP‐HP, Hôpital Bichat Claude‐BernardParisFrance
| | - Mikaël Mazighi
- Université Paris Cité & Université Sorbonne Paris Nord, INSERM U1148, LVTSF‐75018 ParisFrance
- Département de NeurologieAP‐HP, Hôpital Lariboisière, FHU NeurovascParisFrance
| | - Nadine Ajzenberg
- Université Paris Cité & Université Sorbonne Paris Nord, INSERM U1148, LVTSF‐75018 ParisFrance
- Laboratoire d'Hématologie, AP‐HP, Hôpital Bichat Claude‐BernardParisFrance
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24
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Xiao L, Ji X, Zhao H, Luo Y, Hu S, Zhao T, Hu Z, Duan J. A novel severe cerebral venous thrombosis rat model based on semi-ligation combined with ferric chloride and thrombin. CNS Neurosci Ther 2022; 28:2129-2140. [PMID: 36000206 PMCID: PMC9627376 DOI: 10.1111/cns.13950] [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: 06/02/2022] [Revised: 07/25/2022] [Accepted: 08/05/2022] [Indexed: 02/06/2023] Open
Abstract
AIMS An applicable cerebral venous sinus thrombosis (CVST) model is imperative for exploring its pathophysiology. We established a novel severe CVST model using semi-ligation, ferric chloride, and thrombin. METHODS A total of 138 male Sprague-Dawley rats were randomly divided into semi-ligation (n = 75) and non-semi-ligation (n = 63) groups. A sham group (n = 46) was also included. We compared short-term and long-term neurological and cognitive dysfunction, mortality rates, thrombus load, venous infarction volume, the blood-brain barrier permeability, brain water content, and microglia activation among the three groups. RESULTS Thrombi involving multiple venous sinuses appeared in all semi-ligation rats within 2 days postoperatively. Compared with the non-semi-ligation group, short-term and long-term neurological dysfunction were more severe (p < 0.05), and thrombus weight, venous infarction volumes, and microglia activation were more significant (p < 0.05) in the semi-ligation group. Further, the cognitive function of the semi-ligation group significantly decreased (p < 0.05) on postoperative day 21. Cumulative mortality rates between the semi-ligation and non-semi-ligation groups did not differ significantly. CONCLUSION Semi-ligation combined with ferric chloride and thrombin can produce a severe CVST model with multiple venous sinus involvement, which is suitable for short- and long-term neurological and cognitive dysfunction assessment.
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Affiliation(s)
- Lipo Xiao
- Department of Emergency, Xuanwu HospitalCapital Medical UniversityBeijingChina,Department of Neurology and Intracranial Hypertension & Cerebral Venous Disease CenterNational Health Commission of the People's Republic of China, Xuanwu Hospital, Capital Medical UniversityBeijingChina,Department of NeurologyThe People's Hospital of QingxianCangzhouChina
| | - Xunming Ji
- Department of Neurology and Intracranial Hypertension & Cerebral Venous Disease CenterNational Health Commission of the People's Republic of China, Xuanwu Hospital, Capital Medical UniversityBeijingChina
| | - Haiping Zhao
- Cerebrovascular Diseases Research Institute and Department of NeurologyXuanwu Hospital, Capital Medical UniversityBeijingChina
| | - Yumin Luo
- Cerebrovascular Diseases Research Institute and Department of NeurologyXuanwu Hospital, Capital Medical UniversityBeijingChina
| | - Shuyuan Hu
- Department of Emergency, Xuanwu HospitalCapital Medical UniversityBeijingChina,Department of Neurology and Intracranial Hypertension & Cerebral Venous Disease CenterNational Health Commission of the People's Republic of China, Xuanwu Hospital, Capital Medical UniversityBeijingChina
| | - Tingyu Zhao
- Department of Emergency, Xuanwu HospitalCapital Medical UniversityBeijingChina,Department of Neurology and Intracranial Hypertension & Cerebral Venous Disease CenterNational Health Commission of the People's Republic of China, Xuanwu Hospital, Capital Medical UniversityBeijingChina
| | - Zeliang Hu
- Department of Pathology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Jiangang Duan
- Department of Emergency, Xuanwu HospitalCapital Medical UniversityBeijingChina,Department of Neurology and Intracranial Hypertension & Cerebral Venous Disease CenterNational Health Commission of the People's Republic of China, Xuanwu Hospital, Capital Medical UniversityBeijingChina
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25
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Hakim A, Kurmann C, Pospieszny K, Meinel TR, Shahin MA, Heldner MR, Umarova R, Jung S, Arnold M, El-Koussy M. Diagnostic Accuracy of High-Resolution 3D T2-SPACE in Detecting Cerebral Venous Sinus Thrombosis. AJNR Am J Neuroradiol 2022; 43:881-886. [PMID: 35618422 DOI: 10.3174/ajnr.a7530] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 04/12/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND PURPOSE Assessment of cerebral venous sinus thrombosis on MR imaging can be challenging. The aim of this study was to evaluate the diagnostic accuracy of high-resolution 3D T2 sampling perfection with application-optimized contrasts by using different flip angle evolution (SPACE) in patients with cerebral venous sinus thrombosis and to compare its performance with contrast-enhanced 3D T1-MPRAGE. MATERIALS AND METHODS We performed a blinded retrospective analysis of T2-SPACE and contrast-enhanced MPRAGE sequences from patients with cerebral venous sinus thrombosis and a control group. The results were compared with a reference standard, which was based on all available sequences and clinical history. Subanalyses were performed according to the venous segment involved and the clinical stage of the thrombus. RESULTS Sixty-three MR imaging examinations from 35 patients with cerebral venous sinus thrombosis and 51 examinations from 40 control subjects were included. The accuracy, sensitivity, and specificity calculated from the initial MR imaging examination for each patient were 100% each for T2-SPACE and 95%, 91%, and 98%, respectively, for contrast-enhanced MPRAGE. The interrater reliability was high for both sequences. In the subanalysis, the accuracy for each venous segment involved and if subdivided according to the clinical stage of thrombus was ≥95% and ≥85% for T2-SPACE and contrast-enhanced MPRAGE, respectively. CONCLUSIONS Both T2-SPACE and contrast-enhanced MPRAGE offer high accuracy for the detection and exclusion of cerebral venous sinus thrombosis; however, T2-SPACE showed a better overall performance and thus could be a useful tool if included in a multiparametric MR imaging protocol for the diagnosis of cerebral venous sinus thrombosis, especially in scenarios where gadolinium administration is contraindicated.
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Affiliation(s)
- A Hakim
- From the University Institute of Diagnostic and Interventional Neuroradiology (A.H., C.K., K.P., M.E.), Bern University Hospital, Inselspital, Inselspital, University of Bern, Bern, Switzerland
| | - C Kurmann
- From the University Institute of Diagnostic and Interventional Neuroradiology (A.H., C.K., K.P., M.E.), Bern University Hospital, Inselspital, Inselspital, University of Bern, Bern, Switzerland
| | - K Pospieszny
- From the University Institute of Diagnostic and Interventional Neuroradiology (A.H., C.K., K.P., M.E.), Bern University Hospital, Inselspital, Inselspital, University of Bern, Bern, Switzerland
| | - T R Meinel
- Department of Neurology (T.R.M., M.R.H., R.U., S.J., M.A.), Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - M A Shahin
- Department of Radiodiagnosis (M.A.S.), Faculty of Medicine, Cairo University Hospitals, Cairo, Egypt
| | - M R Heldner
- Department of Neurology (T.R.M., M.R.H., R.U., S.J., M.A.), Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - R Umarova
- Department of Neurology (T.R.M., M.R.H., R.U., S.J., M.A.), Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - S Jung
- Department of Neurology (T.R.M., M.R.H., R.U., S.J., M.A.), Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - M Arnold
- Department of Neurology (T.R.M., M.R.H., R.U., S.J., M.A.), Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - M El-Koussy
- From the University Institute of Diagnostic and Interventional Neuroradiology (A.H., C.K., K.P., M.E.), Bern University Hospital, Inselspital, Inselspital, University of Bern, Bern, Switzerland
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26
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Karthik Vanukuri N, Pedapati R, Shanmugam S, Hazeena P, Rangasami R, Venkatasubramanian S. Effect of recanalization on clinical outcomes in patients with cerebral venous thrombosis - An ambispective study. Eur J Radiol 2022; 153:110385. [DOI: 10.1016/j.ejrad.2022.110385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/16/2022] [Accepted: 05/25/2022] [Indexed: 11/03/2022]
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27
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Yaghi S, Shu L, Bakradze E, Salehi Omran S, Giles JA, Amar JY, Henninger N, Elnazeir M, Liberman AL, Moncrieffe K, Lu J, Sharma R, Cheng Y, Zubair AS, Simpkins AN, Li GT, Kung JC, Perez D, Heldner M, Scutelnic A, Seiffge D, Siepen B, Rothstein A, Khazaal O, Do D, Kasab SA, Rahman LA, Mistry EA, Kerrigan D, Lafever H, Nguyen TN, Klein P, Aparicio H, Frontera J, Kuohn L, Agarwal S, Stretz C, Kala N, El Jamal S, Chang A, Cutting S, Xiao H, de Havenon A, Muddasani V, Wu T, Wilson D, Nouh A, Asad SD, Qureshi A, Moore J, Khatri P, Aziz Y, Casteigne B, Khan M, Cheng Y, Mac Grory B, Weiss M, Ryan D, Vedovati MC, Paciaroni M, Siegler JE, Kamen S, Yu S, Leon Guerrero CR, Atallah E, De Marchis GM, Brehm A, Dittrich T, Psychogios M, Alvarado-Dyer R, Kass-Hout T, Prabhakaran S, Honda T, Liebeskind DS, Furie K. Direct Oral Anticoagulants Versus Warfarin in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT): A Multicenter International Study. Stroke 2022; 53:728-738. [PMID: 35143325 DOI: 10.1161/strokeaha.121.037541] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A small randomized controlled trial suggested that dabigatran may be as effective as warfarin in the treatment of cerebral venous thrombosis (CVT). We aimed to compare direct oral anticoagulants (DOACs) to warfarin in a real-world CVT cohort. METHODS This multicenter international retrospective study (United States, Europe, New Zealand) included consecutive patients with CVT treated with oral anticoagulation from January 2015 to December 2020. We abstracted demographics and CVT risk factors, hypercoagulable labs, baseline imaging data, and clinical and radiological outcomes from medical records. We used adjusted inverse probability of treatment weighted Cox-regression models to compare recurrent cerebral or systemic venous thrombosis, death, and major hemorrhage in patients treated with warfarin versus DOACs. We performed adjusted inverse probability of treatment weighted logistic regression to compare recanalization rates on follow-up imaging across the 2 treatments groups. RESULTS Among 1025 CVT patients across 27 centers, 845 patients met our inclusion criteria. Mean age was 44.8 years, 64.7% were women; 33.0% received DOAC only, 51.8% received warfarin only, and 15.1% received both treatments at different times. During a median follow-up of 345 (interquartile range, 140-720) days, there were 5.68 recurrent venous thrombosis, 3.77 major hemorrhages, and 1.84 deaths per 100 patient-years. Among 525 patients who met recanalization analysis inclusion criteria, 36.6% had complete, 48.2% had partial, and 15.2% had no recanalization. When compared with warfarin, DOAC treatment was associated with similar risk of recurrent venous thrombosis (aHR, 0.94 [95% CI, 0.51-1.73]; P=0.84), death (aHR, 0.78 [95% CI, 0.22-2.76]; P=0.70), and rate of partial/complete recanalization (aOR, 0.92 [95% CI, 0.48-1.73]; P=0.79), but a lower risk of major hemorrhage (aHR, 0.35 [95% CI, 0.15-0.82]; P=0.02). CONCLUSIONS In patients with CVT, treatment with DOACs was associated with similar clinical and radiographic outcomes and favorable safety profile when compared with warfarin treatment. Our findings need confirmation by large prospective or randomized studies.
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Affiliation(s)
- Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Liqi Shu
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | | | - Setareh Salehi Omran
- Department of Neurology, University of Colorado School of Medicine, Aurora (S.S.O.)
| | - James A Giles
- Department of Neurology, Washington University, Saint Louis, MO (J.A.G., J.Y.A.)
| | - Jordan Y Amar
- Department of Neurology, Washington University, Saint Louis, MO (J.A.G., J.Y.A.)
| | - Nils Henninger
- Department of Neurology, University of Massachusetts, Worcester. (N.H., M.E.).,Department of Psychiatry, University of Massachusetts, Worcester. (N.H.)
| | - Marwa Elnazeir
- Department of Neurology, University of Massachusetts, Worcester. (N.H., M.E.)
| | - Ava L Liberman
- Department of Neurology, Weill Cornell Medical Center, NY (A.L.L.)
| | | | - Jenny Lu
- Department of Neurology, Montefiore Medical Center, NY (K.M., J.L.)
| | - Richa Sharma
- Department of Neurology, Yale University, New Haven, CT (R.S., Y.C., A.S.Z., A.d.H.)
| | - Yee Cheng
- Department of Neurology, Yale University, New Haven, CT (R.S., Y.C., A.S.Z., A.d.H.)
| | - Adeel S Zubair
- Department of Neurology, Yale University, New Haven, CT (R.S., Y.C., A.S.Z., A.d.H.)
| | - Alexis N Simpkins
- Department of Neurology, University of Florida, Gainesville (A.N.S., G.T.L., J.C.K., D.P.)
| | - Grace T Li
- Department of Neurology, University of Florida, Gainesville (A.N.S., G.T.L., J.C.K., D.P.)
| | - Justin Chi Kung
- Department of Neurology, University of Florida, Gainesville (A.N.S., G.T.L., J.C.K., D.P.)
| | - Dezaray Perez
- Department of Neurology, University of Florida, Gainesville (A.N.S., G.T.L., J.C.K., D.P.)
| | - Mirjam Heldner
- Department of Neurology, Inselspital Universitätsspital, Bern, Switzerland (M.H., A.S., D.S., B.S.)
| | - Adrian Scutelnic
- Department of Neurology, Inselspital Universitätsspital, Bern, Switzerland (M.H., A.S., D.S., B.S.)
| | - David Seiffge
- Department of Neurology, Inselspital Universitätsspital, Bern, Switzerland (M.H., A.S., D.S., B.S.)
| | - Bernhard Siepen
- Department of Neurology, Inselspital Universitätsspital, Bern, Switzerland (M.H., A.S., D.S., B.S.)
| | - Aaron Rothstein
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (A.R., O.K., D.D.)
| | - Ossama Khazaal
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (A.R., O.K., D.D.)
| | - David Do
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (A.R., O.K., D.D.)
| | - Sami Al Kasab
- Department of Neurology, Medical University of South Carolina, Charleston (S.A.K., L.A.R.).,Department of Neurosurgery, Medical University of South Carolina, Charleston (S.A.K.)
| | - Line Abdul Rahman
- Department of Neurology, Medical University of South Carolina, Charleston (S.A.K., L.A.R.)
| | - Eva A Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati (E.A.M., P.K., Y.A., B.C.)
| | - Deborah Kerrigan
- Department of Neurology, Vanderbilt University, Nashville, TN (D.K., H.L.)
| | - Hayden Lafever
- Department of Neurology, Vanderbilt University, Nashville, TN (D.K., H.L.)
| | - Thanh N Nguyen
- Department of Neurology, Boston University School of Medicine, MA (T.N.N., P.K., H.A.)
| | - Piers Klein
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati (E.A.M., P.K., Y.A., B.C.).,Department of Neurology, Boston University School of Medicine, MA (T.N.N., P.K., H.A.)
| | - Hugo Aparicio
- Department of Neurology, Boston University School of Medicine, MA (T.N.N., P.K., H.A.)
| | | | - Lindsey Kuohn
- Department of Neurology, New York University, NY (J.F., L.K., S.A.)
| | - Shashank Agarwal
- Department of Neurology, New York University, NY (J.F., L.K., S.A.)
| | - Christoph Stretz
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Narendra Kala
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Sleiman El Jamal
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Alison Chang
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Shawna Cutting
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Han Xiao
- Department of Biostatistics, University of California Santa Barbara (H.X.)
| | - Adam de Havenon
- Department of Neurology, Yale University, New Haven, CT (R.S., Y.C., A.S.Z., A.d.H.)
| | - Varsha Muddasani
- Department of Neurology, University of Utah, Salt Lake City (V.M.)
| | - Teddy Wu
- Department of Neurology, Christchurch hospital, New Zealand (T.W., D.W.)
| | - Duncan Wilson
- Department of Neurology, Christchurch hospital, New Zealand (T.W., D.W.)
| | - Amre Nouh
- Department of Neurology, Hartford Hospital, CT (A.N., S.D.A.)
| | | | - Abid Qureshi
- Department of Neurology, University of Kansas, Kansas City (A.Q., J.M.)
| | - Justin Moore
- Department of Neurology, University of Kansas, Kansas City (A.Q., J.M.)
| | | | - Yasmin Aziz
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati (E.A.M., P.K., Y.A., B.C.)
| | - Bryce Casteigne
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati (E.A.M., P.K., Y.A., B.C.)
| | - Muhib Khan
- Department of Neurology, Spectrum Health, Michigan State University, Grand Rapids (M.K., Y.C.)
| | - Yao Cheng
- Department of Neurology, Spectrum Health, Michigan State University, Grand Rapids (M.K., Y.C.)
| | - Brian Mac Grory
- Department of Neurology, Duke University, Durham, NC (B.M.G., M.W., D.R.)
| | - Martin Weiss
- Department of Neurology, Duke University, Durham, NC (B.M.G., M.W., D.R.)
| | - Dylan Ryan
- Department of Neurology, Duke University, Durham, NC (B.M.G., M.W., D.R.)
| | | | | | - James E Siegler
- Department of Neurology, Cooper University, Camden, NJ (J.E.S., S.K., S.Y.)
| | - Scott Kamen
- Department of Neurology, Cooper University, Camden, NJ (J.E.S., S.K., S.Y.)
| | - Siyuan Yu
- Department of Neurology, Cooper University, Camden, NJ (J.E.S., S.K., S.Y.)
| | | | - Eugenie Atallah
- Department of Neurology, George Washington University, District of Columbia (C.R.L.G., E.A.)
| | - Gian Marco De Marchis
- Department of Neurology, University Hospital Basel and University of Basel, Switzerland (G.M.D.M., T.D.)
| | - Alex Brehm
- Department of interventional and diagnostic Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel and University of Basel, Switzerland (A.B., M.P.)
| | - Tolga Dittrich
- Department of Neurology, University Hospital Basel and University of Basel, Switzerland (G.M.D.M., T.D.)
| | - Marios Psychogios
- Department of interventional and diagnostic Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel and University of Basel, Switzerland (A.B., M.P.)
| | | | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, IL (R.A.-D., T.K.-H., S.P.)
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, IL (R.A.-D., T.K.-H., S.P.)
| | - Tristan Honda
- Department of Neurology, University of California at Los Angeles (T.H., D.S.L.)
| | - David S Liebeskind
- Department of Neurology, University of California at Los Angeles (T.H., D.S.L.)
| | - Karen Furie
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
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Gorman JB, Field TS. ACTION-CVT: Are the Findings ACTIONable? Stroke 2022; 53:739-741. [PMID: 35143324 DOI: 10.1161/strokeaha.122.038564] [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] [Indexed: 11/16/2022]
Affiliation(s)
- Johnathon B Gorman
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Canada
| | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Canada
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Abstract
Purpose of Review Cerebral venous thrombosis (CVT) is a rare cause of stroke that most commonly affects younger women. Here, we review new literature relevant to the management and prognosis of individuals with CVT and ongoing areas of uncertainty. Recent Findings Direct-acting oral anticoagulants (DOACs) are being increasingly integrated into routine care but are not yet recommended by guidelines. Recent randomized clinical trials and available case series offer reassuring safety data. Routine use of endovascular therapy is not associated with improved outcomes. The relationship between recanalization and prognosis is uncertain. Summary The evidence base for management of CVT continues to improve. Ongoing areas of uncertainty include duration of therapy and whether certain subgroups of patients may benefit from neurointervention or personalized approaches to antithrombotic strategy. The state of knowledge will continue to benefit from large collaborative international efforts, and integration of patient partnerships to identify research priorities.
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30
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Nagaraja D. Recanalisation and outcome in cerebral venous-sinus thrombosis. Ann Indian Acad Neurol 2022; 25:177-178. [PMID: 35693679 PMCID: PMC9175422 DOI: 10.4103/aian.aian_957_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 11/15/2022] Open
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31
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Li X, Wang G, Yan K, Yin S, Wang H, Wang Y, Bai X, Shen Y. The Incidence, Risk Factors, and Patterns of Peripherally Inserted Central Catheter-Related Venous Thrombosis in Cancer Patients Followed Up by Ultrasound. Cancer Manag Res 2021; 13:4329-4340. [PMID: 34103988 PMCID: PMC8179741 DOI: 10.2147/cmar.s301458] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/14/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose A peripherally inserted central catheter (PICC) is associated with venous thromboembolism (VTE) especially in patients suffering from cancer. We analyzed the incidence, risk factors, and patterns of PICC-related VTE in cancer patients. Patients and Methods Patients with cancer who underwent PICC placement were evaluated retrospectively. Routine, prospective ultrasound post-PICC placement was used for asymptomatic and symptomatic patients to identify VTE. Multivariable logistic regression models with odds ratios (ORs) were used to examine VTE risk factors. Results Of 2353 PICCs placed, 165 patients (7.01%) developed PICC-related VTE with a median thrombosis time of 12 days. After adjustment of multivariable analysis, patients with PICC-related VTE were more likely to have a ratio of PICC diameter:vein diameter >0.35 (adjusted OR, 1.689; 95% CI, 1.023–2.789) and high level of triglycerides (1.561; 1.096–2.223). The prevalence of A (adjusted OR, 1.680; 95% CI, 1.009–2.798), B (1.835; 1.137–2.961), and AB (3.275; 1.840–5.829) blood group was significantly higher than that of the O blood group in VTE patients. Venous recanalization was observed in 44.8% (74/165) patients after anticoagulation therapy, and more often in patients with combined deep VTE than in patients with isolated superficial VTE (OR, 17.942; 95% CI, 5.427–59.316). The recanalization time was 20±5 (range, 10–31) days. Conclusion The non-O blood group, larger ratio of PICC diameter:vein diameter, and high level of triglycerides were significantly associated with PICC-related VTE. Almost half of cases of PICC-related deep VTE could be reversed by anticoagulation treatment.
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Affiliation(s)
- Xiang Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Ultrasound, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| | - Guodong Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), ICU, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| | - Kun Yan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Ultrasound, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| | - Shanshan Yin
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Ultrasound, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| | - Hongzhi Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), ICU, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| | - Yanjie Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Ultrasound, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| | - Xiumei Bai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Ultrasound, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| | - Yanfen Shen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), ICU, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
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32
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Abelhad NI, Qiao W, Garg N, Rojas-Hernandez CM. Thrombosis and bleeding outcomes in the treatment of cerebral venous thrombosis in cancer. Thromb J 2021; 19:37. [PMID: 34074321 PMCID: PMC8171031 DOI: 10.1186/s12959-021-00292-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 05/17/2021] [Indexed: 02/21/2023] Open
Abstract
Background There is a need for clinical outcome data of cerebral venous thrombosis (CVT) in cancer patients. We examined the recanalization, thrombosis recurrence and major bleeding during CVT treatment in a cancer exclusive adult population. Methods We performed a retrospective review of cancer associated CVT identified through an institutional data warehouse. The primary endpoint was radiological and comprised the evaluation of thrombus recanalization at 12 months. Secondary endpoints were clinical and included rates of bleeding complications and recurrence of CVT. Variables were compared across subgroups of study outcomes. The backward stepdown procedure was used to identify variables for the final logistic model regarding thrombosis and bleeding outcomes. Results The population included forty-five patients, slightly predominant of male adults (55.6%) with a median age of 54.5 years. Solid malignancies comprised 64.4% of cases. A total of 31 cases were treated with anticoagulation. CVT recanalization was documented in almost 60% of cases. The cerebral venous thrombosis recurrence or propagation rate at 12 months was 15.6%. Major bleeding complications were observed in 15 patients. Conclusions Our findings are suggestive of a narrow therapeutic index of anticoagulation in cancer-CVT. Careful monitoring of anticoagulation effect and bleeding complications are of utmost clinical relevance in cancer patients. Further larger and controlled studies are needed to confirm our observations.
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Affiliation(s)
- Nadia I Abelhad
- Department of Medicine, University of Texas Health Science Center at Houston, Houston, USA
| | - Wei Qiao
- Department of Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, USA
| | - Naveen Garg
- Department of Diagnostic Radiology, Division of Diagnostic Imaging, University of Texas M.D. Anderson Cancer Center, Houston, USA
| | - Cristhiam M Rojas-Hernandez
- Section of Benign Hematology, Department of Medicine, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd. Suite 1464, TX, Houston, USA.
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33
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Dubey AK, Kalita J, Chaudhary SK, Misra UK. Impact of anticoagulation status on recanalization and outcome of cerebral venous thrombosis. J Clin Neurosci 2021; 89:43-50. [PMID: 34119293 DOI: 10.1016/j.jocn.2021.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/23/2021] [Accepted: 04/17/2021] [Indexed: 11/26/2022]
Abstract
Effective anticoagulation status may determine the recanalization and outcome of cerebral venous thrombosis (CVT). We report impact of anticoagulation status on recanalization and outcome of CVT. This is a retrospective study on 126 patients with CVT diagnosed on magnetic resonance venography (MRV). Their clinical features and risk factors were noted. The data were retrieved from a prospectively maintained registry, and international normalized ratio (INR) was noted after discharge till 3 months. All the patients were on acenocoumarol. Based on INR value, patients were categorized as Group A (effective anticoagulation INR within the therapeutic range or above) and Group B (ineffective anticoagulation INR > 50% below the therapeutic range). A repeat MRV at 3 months was done for recanalization. Outcome at 3 months was evaluated using modified Rankin Scale (mRS), and categorized as good (mRS ≤ 2) and poor (mRS 2 or more) 101(80.2%) patients were in group A and 25(19.8%) in group B. Their demographic, risk factors, magnetic resonance imaging (MRI) and MRV findings were comparable. On repeat MRV, recanalization occurred in 22/24(91.7%); 15(88%) in group A and 7(100%) in group B. Recanalization was independent of coagulation status. Seven (5.6%) patients died and 107(84.9%) had good outcome; 85(84.2%) in group A and 22(88%) in group B. Kaplan Meier analysis also did not reveal survival or good outcome benefits between the groups. In CVT, outcome and recanalization at 3 months are not dependent on coagulation status. Further prospective studies are needed regarding duration of anticoagulant and its impact on recanalization and outcome.
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Affiliation(s)
- Ashish K Dubey
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow, Uttar Pradesh 226014, India
| | - Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow, Uttar Pradesh 226014, India.
| | - Sarvesh K Chaudhary
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow, Uttar Pradesh 226014, India
| | - Usha K Misra
- Apollo Medics Super-specialty Hospitals and Senior consultant neurologist, Vivekanand Polyclinic, and Institute of Medical science, Lucknow 226001, India
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34
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Ferro JM, Bendszus M, Jansen O, Coutinho JM, Dentali F, Kobayashi A, Aguiar de Sousa D, Neto LL, Miede C, Caria J, Huisman H, Diener HC. Recanalization after cerebral venous thrombosis. A randomized controlled trial of the safety and efficacy of dabigatran etexilate versus dose-adjusted warfarin in patients with cerebral venous and dural sinus thrombosis. Int J Stroke 2021; 17:189-197. [PMID: 33724104 DOI: 10.1177/17474930211006303] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The effect of different anticoagulants on recanalization after cerebral venous thrombosis has not been studied in a randomized controlled trial. METHODS RE-SPECT CVT (ClinicalTrials.gov number: NCT02913326) was a Phase III, prospective, randomized, parallel-group, open-label, multicenter, exploratory trial with blinded endpoint adjudication. Acute cerebral venous thrombosis patients were allocated to dabigatran 150 mg twice daily, or dose-adjusted warfarin, for 24 weeks, after 5-15 days' treatment with unfractionated or low-molecular-weight heparin. A standardized magnetic resonance protocol including arterial spin labeling, three-dimensional time-of-flight venography, and three-dimensional contrast-enhanced magnetic resonance angiography was obtained at the end of the treatment period. Cerebral venous recanalization at six months was assessed by two blinded adjudicators, using the difference in a score of occluded sinuses and veins (predefined secondary efficacy endpoint) and in the modified Qureshi scale (additional endpoint), between baseline and the end of the treatment. RESULTS Of 120 cerebral venous thrombosis patients randomized, venous recanalization could be evaluated in 108 (55 allocated to dabigatran and 53 to warfarin, 1 patient had a missing occlusion score at baseline). No patient worsened in the score of occluded cerebral veins and sinuses, while 33 (60%) on dabigatran and 35 (67%) on warfarin improved. The mean score change from baseline in the occlusion score was similar in the two treatment groups (dabigatran -0.8, SD 0.78; warfarin -1.0, SD 0.92). In the modified Qureshi score, full recanalization was adjudicated in 24 (44%) and 19 (36%), and partial recanalization in 23 (42%) and 26 (49%) patients in the dabigatran and warfarin arms, respectively. No statistically significant treatment difference in the modified Qureshi score could be detected (p = 0.44). CONCLUSION The majority of patients with cerebral venous thrombosis, anticoagulated with either dabigatran or warfarin for six months, showed partial or complete recanalization of occluded sinuses and veins at the end of the treatment.Clinical trial registration: Trial registry name: ClinicalTrials.gov URL: https://clinicaltrials.gov Registration number: NCT02913326.
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Affiliation(s)
- José M Ferro
- Department of Neurosciences and Mental Health, Serviço de Neurologia, Hospital Santa Maria, Lisbon, Portugal.,Instituto de Medicina Molecular, Universidade de Lisboa, Lisboa, Portugal.,Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Martin Bendszus
- Neurologische Klinik, Abteilung für Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Olav Jansen
- Department of Radiology and Neuroradiology, University of Kiel, Kiel, Germany
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Adam Kobayashi
- Faculty of Health Sciences and Physical Education, Kazimierz Pulaski University of Technology and Humanities, Radom, Poland
| | - Diana Aguiar de Sousa
- Department of Neurosciences and Mental Health, Serviço de Neurologia, Hospital Santa Maria, Lisbon, Portugal.,Instituto de Medicina Molecular, Universidade de Lisboa, Lisboa, Portugal.,Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Lia L Neto
- Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Serviço de Neuroradiologia, Hospital Santa Maria/Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Corinna Miede
- HMS Analytical Software GmbH, Weimar (Lahn), Germany
| | - Jorge Caria
- Boehringer Ingelheim International, Ingelheim am Rhein, Germany
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35
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Aguiar de Sousa D, Pereira-Santos MC, Serra-Caetano A, Neto LL, Sousa AL, Gabriel D, Correia M, Gil-Gouveia R, Oliveira R, Penas S, Carvalho Dias M, Correia MA, Carvalho M, Sousa AE, Canhão P, Ferro JM. Matrix Metalloproteinase-9 Levels are Associated with Brain Lesion and Persistent Venous Occlusion in Patients with Cerebral Venous Thrombosis. Thromb Haemost 2021; 121:1476-1482. [PMID: 33759145 DOI: 10.1055/s-0041-1726094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Elucidating mechanisms of brain damage in cerebral venous thrombosis (CVT) would be instrumental to develop targeted therapies and improve prognosis prediction. Matrix metalloproteinase-9 (MMP-9), a gelatinase that degrades major components of the basal lamina, has been associated to blood-brain barrier disruption. We aimed to assess, in patients with CVT, the temporal change in serum concentrations of MMP-9 and its association with key imaging and clinical outcomes. METHODS Pathophysiology of Venous Infarction-PRediction of InfarctiOn and RecanalIzaTion in CVT (PRIORITy-CVT) was a multicenter prospective cohort study of patients with newly diagnosed CVT. Serial collection of peripheral blood samples performed on day 1, 3, and 8, and standardized magnetic resonance imaging on day 1, 8, and 90. MMP-9 was quantified using enzyme-linked immunosorbent assay in 59 patients and 22 healthy controls. Primary outcomes were parenchymal brain lesion, early evolution of brain lesion, early recanalization, and functional outcome on day 90. RESULTS CVT patients with parenchymal brain lesion had higher baseline concentrations of MMP-9 compared with controls (adjusted p = 0.001). The area under receiver operating characteristic curve value for MMP-9 for predicting brain lesion was 0.71 (95% confidence interval [CI]: 0.57-0.85, p = 0.009). Patients with venous recanalization showed early decline of circulating MMP-9 and significantly lower levels on day 8 (p = 0.021). Higher MMP-9 on day 8 was associated with persistent venous occlusion (odds ratio: 1.20 [per 20 ng/mL], 95% CI: 1.02-1.43, p = 0.030). CONCLUSION We report a novel relationship among MMP-9, parenchymal brain damage, and early venous recanalization, suggesting that circulating MMP-9 is a dynamic marker of brain tissue damage in patients with CVT.
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Affiliation(s)
- Diana Aguiar de Sousa
- Department of Neurosciences and Mental Health (Neurology), Hospital de Santa Maria/CHULN, Universidade de Lisboa, Lisbon, Portugal.,Institute of Anatomy, Faculdade de Medicina, University of Lisbon, Lisbon, Portugal.,Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | | | - Ana Serra-Caetano
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Lia Lucas Neto
- Institute of Anatomy, Faculdade de Medicina, University of Lisbon, Lisbon, Portugal.,Department of Neuroradiology, Hospital de Santa Maria - CHULN, Universidade de Lisboa, Lisbon, Portugal
| | - Ana Luísa Sousa
- Department of Neurology, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | - Denis Gabriel
- Department of Neurology, Centro Hospitalar Universitário do Porto - Hospital Santo António, Porto, Portugal
| | - Manuel Correia
- Department of Neurology, Centro Hospitalar Universitário do Porto - Hospital Santo António, Porto, Portugal
| | | | | | - Sara Penas
- Institute of Anatomy, Faculdade de Medicina, University of Lisbon, Lisbon, Portugal
| | - Mariana Carvalho Dias
- Department of Neurosciences and Mental Health (Neurology), Hospital de Santa Maria/CHULN, Universidade de Lisboa, Lisbon, Portugal
| | - Manuel A Correia
- Department of Neuroradiology, Hospital de Santa Maria - CHULN, Universidade de Lisboa, Lisbon, Portugal
| | - Marta Carvalho
- Department of Neurology, Centro Hospitalar Universitário de São João, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ana E Sousa
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Patrícia Canhão
- Department of Neurosciences and Mental Health (Neurology), Hospital de Santa Maria/CHULN, Universidade de Lisboa, Lisbon, Portugal.,Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - José M Ferro
- Department of Neurosciences and Mental Health (Neurology), Hospital de Santa Maria/CHULN, Universidade de Lisboa, Lisbon, Portugal.,Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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36
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Schuchardt FF, Demerath T, Elsheikh S, Wehrum T, Harloff A, Urbach H, Meckel S. Dural Arteriovenous Fistula Formation Secondary to Cerebral Venous Thrombosis: Longitudinal Magnetic Resonance Imaging Assessment Using 4D-Combo-MR-Venography. Thromb Haemost 2021; 121:1345-1352. [PMID: 33657624 DOI: 10.1055/s-0041-1723991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE Dural arteriovenous fistulae (DAVFs) can develop secondary to cerebral venous thrombosis (CVT). The incidence of DAVF has not yet been investigated prospectively. METHODS Between July 2012 and January 2018, combined static and dynamic 4D MR venography (4D-combo-MRV) was performed in 24 consecutive patients at diagnosis of CVT and after 6 months. 3 Tesla magnetic resonance imaging with time of flight and contrast-enhanced magnetization-prepared rapid acquisition with gradient echo were performed at baseline to evaluate the extent of thrombosis and affected vessel segments. Baseline and follow-up 4D-combo-MRV were assessed for signs of DAVF. Interrater reliability of DAVF detection and the extent of recanalization were analyzed with kappa statistics. RESULTS DAVFs were detected in 4/30 CVT patients (13.3%, 95% confidence interval [CI] 3.3-26.7). Two of 24 patients (8.3%, 95% CI: 0-20.8) had coincidental DAVF with CVT on admission. At follow-up, de novo formation of DAVF following CVT was seen in 2/24 patients (8.3%, 95% CI: 0-20.8). Both de novo DAVFs were low grade and benign fistulae (Cognard type 1, 2a), which had developed at previously thrombosed segments. Endovascular treatment was required in two high degree lesions (Cognard 2a + b) detected at baseline and in one de novo DAVF (Cognard 1) because of debilitating headache and tinnitus. Thrombus load, vessel recanalization, and frequency of cerebral lesions (hemorrhage, ischemia) were not associated with DAVF occurrence. CONCLUSION This exploratory study showed that de novo DAVF formation occurs more frequently than previously described. Although de novo DAVFs were benign, 75% of all detected DAVFs required endovascular treatment. Therefore, screening for DAVF by dynamic MRV, such as 4D-combo-MRV, seems worthwhile in CVT patients.
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Affiliation(s)
- Florian F Schuchardt
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Theo Demerath
- Department of Neuroradiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Samer Elsheikh
- Department of Neuroradiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Wehrum
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Harloff
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stephan Meckel
- Department of Neuroradiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Neuroradiology, Kepler University Hospital Linz, Neuromed Campus, Linz, Austria
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Abstract
Thrombosis of the cerebral veins and sinuses (CVT) is a distinct cerebrovascular disorder that, unlike arterial stroke, most often affects children and young adults, especially women. In this review, we will summarize recent advances on the knowledge of patients with CVT.
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Affiliation(s)
- Diana Aguiar de Sousa
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria - CHULN, University of Lisbon, Lisbon, Portugal.,Faculdade de Medicina, Universidade de, Lisboa, Portugal.,Instituto de Medicina Molecular João Lobo Antunes, Lisbon, Portugal
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Krajíčková D, Král J, Herzig R, Klzo Ľ, Krajina A, Havelka J, Šimůnek L, Vyšata O, Van Quang T, Bar M, Vališ M. Factors influencing therapy choice and clinical outcome in cerebral venous sinus thrombosis. Sci Rep 2020; 10:21633. [PMID: 33303787 PMCID: PMC7728772 DOI: 10.1038/s41598-020-78434-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 11/02/2020] [Indexed: 11/09/2022] Open
Abstract
We aimed was to assess the factors influencing therapy choice and clinical outcome after 3-4 months in patients with cerebral venous sinus thrombosis (CVST). In a retrospective, bi-centric study, the set consisted of 82 consecutive CVST patients (61 females; mean age 33.5 ± 15.7 years). Following data were collected: baseline characteristics, presence of gender-specific risk factors (GSRF), location and extent of venous sinus impairment, clinical presentation, type of treatment, recanalization, presence of parenchymal lesions, and clinical outcome after 3-4 months (assessed using the modified Rankin Scale [mRS], with excellent outcome defined as mRS 0-1). Multivariate logistic regression analysis was used for statistical evaluation. After 3-4 months, complete recovery was achieved in 41 (50%) and excellent clinical outcome in 67 (81.7%) patients. Female sex (OR 0.11; p = 0.0189) and presence of focal neurologic deficit (OR 0.16; p = 0.0165) were identified as significant independent negative predictors and, the presence of GSRF (OR 15.63; p = 0.0011) as significant independent positive predictor of excellent clinical outcome. In conclusion, in our CVST patients, the presence of GSRF was associated with excellent clinical outcome, while the female sex itself was associated with poorer clinical outcome.
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Affiliation(s)
- Dagmar Krajíčková
- Department of Neurology, Comprehensive Stroke Center, Charles University Faculty of Medicine and University Hospital, 500 05, Hradec Králové, Czech Republic
| | - Jiří Král
- Department of Neurology, University Hospital Ostrava and University of Ostrava Faculty of Medicine, 708 52, Ostrava, Czech Republic.,Department of Neurology, St. Anne's University Hospital and Medical Faculty of Masaryk University, 656 91, Brno, Czech Republic
| | - Roman Herzig
- Department of Neurology, Comprehensive Stroke Center, Charles University Faculty of Medicine and University Hospital, 500 05, Hradec Králové, Czech Republic
| | - Ľudovít Klzo
- Department of Radiology, Comprehensive Stroke Center, Charles University Faculty of Medicine and University Hospital, 500 05, Hradec Králové, Czech Republic
| | - Antonín Krajina
- Department of Radiology, Comprehensive Stroke Center, Charles University Faculty of Medicine and University Hospital, 500 05, Hradec Králové, Czech Republic
| | - Jaroslav Havelka
- Department of Radiology, University Hospital Ostrava and University of Ostrava Faculty of Medicine, 708 52, Ostrava, Czech Republic
| | - Libor Šimůnek
- Department of Neurology, Comprehensive Stroke Center, Charles University Faculty of Medicine and University Hospital, 500 05, Hradec Králové, Czech Republic
| | - Oldřich Vyšata
- Department of Neurology, Comprehensive Stroke Center, Charles University Faculty of Medicine and University Hospital, 500 05, Hradec Králové, Czech Republic
| | - Tran Van Quang
- Department of Mathematics, Faculty of Nuclear Sciences and Physical Engineering, Czech Technical University, 160 00, Prague, Czech Republic
| | - Michal Bar
- Department of Neurology, University Hospital Ostrava and University of Ostrava Faculty of Medicine, 708 52, Ostrava, Czech Republic
| | - Martin Vališ
- Department of Neurology, Comprehensive Stroke Center, Charles University Faculty of Medicine and University Hospital, 500 05, Hradec Králové, Czech Republic.
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Aguiar de Sousa D, Pereira-Santos MC, Serra-Caetano A, Lucas Neto L, Sousa AL, Gabriel D, Correia M, Gil-Gouveia R, Oliveira R, Penas S, Carvalho Dias M, Correia MA, Carvalho M, Sousa AE, Canhão P, Ferro JM. Blood biomarkers associated with inflammation predict poor prognosis in cerebral venous thrombosis:: a multicenter prospective observational study. Eur J Neurol 2020; 28:202-208. [PMID: 32918842 DOI: 10.1111/ene.14526] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/31/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Experimental studies suggest inflammation can contribute to blood barrier disruption and brain injury in cerebral venous thrombosis (CVT). We aimed to determine whether blood biomarkers of inflammation were associated with the evolution of brain lesions, persistent venous occlusion or functional outcome in patients with CVT. METHODS Pathophysiology of Venous Infarction-Prediction of Infarction and Recanalization in CVT (PRIORITy-CVT) was a multicenter prospective cohort study of patients with newly diagnosed CVT. Evaluation of neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) concentrations in peripheral blood samples was performed at admission in 62 patients. Additional quantification of interleukin (IL)-6 was performed at day 1, 3 and 8 in 35 patients and 22 healthy controls. Standardized magnetic resonance imaging was performed at day 1, 8 and 90. Primary outcomes were early evolution of brain lesion, early recanalization and functional outcome at 90 days. RESULTS Interleukin-6 levels were increased in patients with CVT with a peak at baseline. IL-6, NLR and CRP levels were not related with brain lesion outcomes or early recanalization but had a significant association with unfavourable functional outcome at 90 days (IL-6: OR = 1.28, 95% CI: 1.05-1.56, P = 0.046; NLR: OR = 1.39, 95% CI: 1.4-1.87, P = 0.014; CRP: OR = 1.756, 95% CI: 1.010-3.051, P = 0.029). Baseline IL-6 had the best discriminative capacity, with an area under the receiver operating characteristic curve to predict unfavourable functional outcome of 0.74 (P = 0.031). CONCLUSIONS Increased baseline levels of NLR, CRP and IL-6 may serve as new predictive markers of worse functional prognosis at 90 days in patients with CVT. No association was found between inflammatory markers and early evolution of brain lesion or venous recanalization.
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Affiliation(s)
- D Aguiar de Sousa
- Department, of Neurosciences and Mental Health (Neurology), Hospital Santa Maria/Centro Hospitalar Universitário Lisboa Norte, Lisbon.,Institute of Anatomy, Faculdade de Medicina, Universidade de Lisboa, Lisbon.,Instituto de Medicina Molecular João Lobo Antunes, Lisbon, Portugal
| | | | - A Serra-Caetano
- Instituto de Medicina Molecular João Lobo Antunes, Lisbon, Portugal
| | - L Lucas Neto
- Institute of Anatomy, Faculdade de Medicina, Universidade de Lisboa, Lisbon.,Department of Neuroradiology, Hospital de Santa Maria/Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - A L Sousa
- Department of Neurology, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | - D Gabriel
- Department of Neurology, Centro Hospitalar Universitário do Porto - Hospital Santo António, Porto, Portugal
| | - M Correia
- Department of Neurology, Centro Hospitalar Universitário do Porto - Hospital Santo António, Porto, Portugal
| | - R Gil-Gouveia
- Department of Neurology, Hospital da Luz, Lisbon, Portugal
| | - R Oliveira
- Department of Neurology, Hospital da Luz, Lisbon, Portugal
| | - S Penas
- Institute of Anatomy, Faculdade de Medicina, Universidade de Lisboa, Lisbon
| | - M Carvalho Dias
- Department, of Neurosciences and Mental Health (Neurology), Hospital Santa Maria/Centro Hospitalar Universitário Lisboa Norte, Lisbon
| | - M A Correia
- Department of Neuroradiology, Hospital de Santa Maria/Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - M Carvalho
- Department of Neurology, Centro Hospitalar Universitário de São João and Faculty of Medicine, University of Porto, Porto, Portugal
| | - A E Sousa
- Instituto de Medicina Molecular João Lobo Antunes, Lisbon, Portugal
| | - P Canhão
- Department, of Neurosciences and Mental Health (Neurology), Hospital Santa Maria/Centro Hospitalar Universitário Lisboa Norte, Lisbon.,Instituto de Medicina Molecular João Lobo Antunes, Lisbon, Portugal
| | - J M Ferro
- Department, of Neurosciences and Mental Health (Neurology), Hospital Santa Maria/Centro Hospitalar Universitário Lisboa Norte, Lisbon.,Instituto de Medicina Molecular João Lobo Antunes, Lisbon, Portugal
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