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Spiezia L, Campello E, Tormene D, Simioni P. Venous Thromboembolism in Children: The Rivaroxaban Experience. Semin Thromb Hemost 2024; 50:866-872. [PMID: 38181816 DOI: 10.1055/s-0043-1778106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
The incidence of venous thromboembolism (VTE) in the pediatric population has increased more than 10-fold in the last 20 years, as a consequence of the advancement of resuscitation and surgical techniques and the global increase in life expectancy of children suffering from chronic pathologies. Monitoring anticoagulant therapy to achieve outcomes within the target range in childhood VTE, parenteral administration of medications, and frequent blood tests in children are often cumbersome. Availability of safe and effective oral agents with pediatric data to support use would be of clear benefit. A physiologically based pharmacokinetic model was developed to estimate the appropriate dosing schedule for rivaroxaban in children. This incorporated growth/maturation and variability in anthropometrics (e.g., body height, weight, and body mass index), anatomy (e.g., organ weight), physiology (e.g., blood flow rates), metabolism and excretion. Rivaroxaban use in pediatric population underwent a complete investigational program, consisting mainly of one phase I pharmacokinetics/pharmacodynamics trial, three phase II trials, one phase III trial. The phase III trial enrolled 500 patients from birth to <18 years and documented the efficacy and safety of rivaroxaban regimens at dose equivalent to the adult 20 mg dose for the prevention of fatal or symptomatic nonfatal recurrent VTE and major bleeding versus heparin or vitamin K antagonists. Results were similar to those in rivaroxaban studies in adults. The efficacy and safety of rivaroxaban in children reported in the EINSTEIN JUNIOR trial provide further support to previous trials in adults (EINSTEIN Program), which demonstrate a favorable profile for the use of rivaroxaban for the management of VTE in challenging patient populations. Other clinical evidence contributing to the use of rivaroxaban among different risk groups in pediatric VTE population confirms the consistency with principal trial. Our review aims to describe the rationale for using rivaroxaban oral suspension in clinical practice and to summarize its multiple indications in each vascular bed (e.g., cerebral venous thrombosis, symptomatic or asymptomatic central venous catheter-associated thrombosis), etiology, and patients setting.
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Affiliation(s)
- Luca Spiezia
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University School of Medicine, Padova, Italy
| | - Elena Campello
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University School of Medicine, Padova, Italy
| | - Daniela Tormene
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University School of Medicine, Padova, Italy
| | - Paolo Simioni
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University School of Medicine, Padova, Italy
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VanderPluym C, Kobayashi R. Leveling the playing field: The role of level-based dosing in pediatric anticoagulation management. Pediatr Blood Cancer 2024; 71:e31136. [PMID: 38967607 DOI: 10.1002/pbc.31136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 05/21/2024] [Indexed: 07/06/2024]
Affiliation(s)
- Christina VanderPluym
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan Kobayashi
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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3
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Alqahtani S, Gibbs KD, Montanez NA, Krause KJ, van Ommen CH, Srivaths LV. Direct oral anticoagulant therapy in adolescent venous thromboembolism: A systematic review. Pediatr Blood Cancer 2024; 71:e31131. [PMID: 38899913 DOI: 10.1002/pbc.31131] [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: 12/29/2023] [Revised: 04/18/2024] [Accepted: 05/19/2024] [Indexed: 06/21/2024]
Abstract
Adolescent venous thromboembolism (VTE) has unique challenges in management, complications, and compliance to anticoagulants. Direct oral anticoagulants (DOACs) have been approved for pediatric VTE management, with an increasing use especially in adolescents. Primary objective is to evaluate the safety and efficacy of DOAC therapy in adolescent VTE. Secondary objectives include adverse events, bleeding events, and overall mortality. A SR protocol was registered in PROSPERO 2022 (CRD42022363928). Databases were searched from inception to September 22, 2022. Studies with children aged 10-18 years, VTE diagnosis, DOAC therapy, randomized control trials (RCTs), cohort, and relevant study types were included. Studies including prophylaxis, non-DOAC therapy, arterial thrombosis, age outliers, non-relevant study types were excluded. Findings are reported in accordance to PRISMA 2020. Nine reports from five studies, published between 2016 and 2022, were included. Rivaroxaban was the most common DOAC. VTE recurrence was 0.02% in the rivaroxaban phase III trial and one patient in the dabigatran phase IIb/III trial. Complete/partial thrombus resolution (CR/PR) was 76.6% in the rivaroxaban phase III trial, and 83.9% in the dabigatran phase IIb/III trial. CR/PR was found to be 68.4% in Dhaliwal et al. study and 83.3% in Hassan et al. study. Major bleeding occurred in one patient. Headache and gastrointestinal symptoms were commonly seen. All-cause mortality occurred in a patient due to cancer progression. DOAC therapy in adolescent VTE had CR/PR in two-thirds of the patients, with low incidence of VTE recurrence and major bleeding. As there are only two randomized controlled trial (RCTs), future adolescents' studies are required to validate our results.
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Affiliation(s)
- Shaikha Alqahtani
- Department of Pediatrics, Pediatric Hematology and Oncology, The University of Texas MD Anderson Cancer Center, Children's Cancer Hospital, Houston, Texas, USA
| | | | - Natalie A Montanez
- Gulf States Hemophilia and Thrombophilia Center, Division of Hematology, Department of Pediatrics, McGovern Medical School and University of Texas Health Science Center, Houston, Texas, USA
| | - Kate J Krause
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - C Heleen van Ommen
- International Pediatric Thrombosis Network, Department Pediatric Hematology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Lakshmi V Srivaths
- Department of Pediatrics, Pediatric Hematology and Oncology, The University of Texas MD Anderson Cancer Center, Children's Cancer Hospital, Houston, Texas, USA
- Gulf States Hemophilia and Thrombophilia Center, Division of Hematology, Department of Pediatrics, McGovern Medical School and University of Texas Health Science Center, Houston, Texas, USA
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Hu H, Chen H, Li L, Zhai X, Liang P, Tang J. Endovascular management of pediatric pial arteriovenous fistulas with hereditary GDF2 mutation: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2024; 8:CASE24182. [PMID: 39186822 PMCID: PMC11373696 DOI: 10.3171/case24182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 06/11/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND Intracranial pial arteriovenous fistulas (PAVFs) are uncommon neurovascular anomalies that primarily affect the pediatric population. PAVFs are often linked to hereditary hemorrhagic telangiectasia, yet the specific genetic mutations remain unidentified. While endovascular embolization is the preferred treatment for PAVFs, complications like hydrocephalus and sinus thrombosis pose challenges in management. OBSERVATIONS The authors present a rare case of PAVF in a 6-month-old male neonate with a hereditary GDF2 mutation, where the fistula was supplied by the posterior inferior cerebellar artery and drained directly into the sigmoid sinus. The PAVF was effectively treated with endovascular embolization using coils and Onyx. Furthermore, the authors describe the successful use of rivaroxaban in managing subsequent sinus thrombosis after the embolization of PAVFs. Additionally, the authors review treatment strategies and complications following fistula disconnection. LESSONS Endovascular embolization is the primary treatment choice for the majority of pediatric PAVFs, while a hereditary GDF2 mutation is considered a potential contributing factor to the formation of these malformations in children. Rivaroxaban has shown promise as an effective therapeutic option for pediatric sinus thrombosis, supported by its established safety profile. https://thejns.org/doi/10.3171/CASE24182.
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Affiliation(s)
- Hui Hu
- Department of Neurosurgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Hao Chen
- Department of Neurosurgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Lusheng Li
- Department of Neurosurgery, Children's Hospital of Chongqing Medical University, Chongqing, China
- National Research Center for Child Health and Disorders, Chongqing, China
- Chongqing Key Laboratory of Translational Medical Research in Cognitive Development, Learning, and Memory Disorders, Chongqing, China
| | - Xuan Zhai
- Department of Neurosurgery, Children's Hospital of Chongqing Medical University, Chongqing, China
- National Research Center for Child Health and Disorders, Chongqing, China
- Chongqing Key Laboratory of Translational Medical Research in Cognitive Development, Learning, and Memory Disorders, Chongqing, China
| | - Ping Liang
- Department of Neurosurgery, Children's Hospital of Chongqing Medical University, Chongqing, China
- National Research Center for Child Health and Disorders, Chongqing, China
- Chongqing Key Laboratory of Translational Medical Research in Cognitive Development, Learning, and Memory Disorders, Chongqing, China
| | - Jun Tang
- Department of Neurosurgery, Children's Hospital of Chongqing Medical University, Chongqing, China
- National Research Center for Child Health and Disorders, Chongqing, China
- Chongqing Key Laboratory of Translational Medical Research in Cognitive Development, Learning, and Memory Disorders, Chongqing, China
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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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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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Gupta J, Garhwal P, Sharma V, Choudhary R, Sehra RN, Devpura K. Rivaroxaban in a Child with Inherited Thrombophilia and Stroke - New Kid on the Block. Indian J Pediatr 2024:10.1007/s12098-024-05191-1. [PMID: 38907863 DOI: 10.1007/s12098-024-05191-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 06/05/2024] [Indexed: 06/24/2024]
Affiliation(s)
- Juhi Gupta
- Department of Pediatrics, SMS Medical College, Jaipur, Rajasthan, India
| | - Pooja Garhwal
- Department of Pediatrics, SMS Medical College, Jaipur, Rajasthan, India
| | - Vishnu Sharma
- Department of Medicine, SMS Medical College, Jaipur, Rajasthan, India
| | - Richa Choudhary
- Department of Pediatrics, SMS Medical College, Jaipur, Rajasthan, India.
| | - R N Sehra
- Department of Pediatrics, SMS Medical College, Jaipur, Rajasthan, India
| | - Kusum Devpura
- Department of Pediatrics, SMS Medical College, Jaipur, Rajasthan, India
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Gao H, Chen M, Huang Y, Liu H, Lin Y, Chen M. Efficacy and safety of antithrombotic therapy for preventing and treating pediatric thromboembolic disease: a systematic review. Sci Rep 2024; 14:13378. [PMID: 38862574 PMCID: PMC11166992 DOI: 10.1038/s41598-024-64334-8] [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: 11/02/2023] [Accepted: 06/07/2024] [Indexed: 06/13/2024] Open
Abstract
This review used traditional and network meta-analyses (NMA) to conduct a comprehensive study of antithrombotic therapies in children with thromboembolic disease. We searched the PubMed, Embase, Cochrane Library, Web of Science and ClinicalTrials.gov databases from their inception to 26 February, 2023. And we finally included 16 randomized controlled trials. In the prevention of thromboembolic events (TEs), the use of anticoagulants had a low risk of TEs (relative risk (RR) 0.73, 95% CI 0.56 to 0.94) and a high risk of minor bleeding (RR 1.43, 95% CI 1.09 to 1.86) compared with no anticoagulants. In the treatment of TEs, direct oral anticoagulants (DOACs) were not inferior to standard anticoagulation in terms of efficacy and safety outcomes. In NMA, rivaroxaban and apixaban showed the lowest risk for TEs and major or clinically relevant nonmajor bleeding. According to the overall assessment of efficacy and safety, dabigatran may be the best choice for children with thromboembolic disease. The results of our study will provide references and suggestions for clinical drug selection.
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Affiliation(s)
- Hongjin Gao
- Department of Pharmacy, Fujian Provincial Hospital, Fuzhou, 350001, China
| | - Mingyu Chen
- School of Pharmacy, Fujian Medical University, Fuzhou, 350004, China
| | - Youqi Huang
- School of Pharmacy, Fujian Medical University, Fuzhou, 350004, China
| | - Huiting Liu
- School of Pharmacy, Fujian Medical University, Fuzhou, 350004, China
| | - Yuze Lin
- School of Pharmacy, Fujian Medical University, Fuzhou, 350004, China
| | - Min Chen
- Shengli Clinical College of Fujian Medical University, Fujian Provincial Hospital, No.134 Dongjie St., Fuzhou, 350001, China.
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Plante V, Basu M, Gettings JV, Luchette M, LaRovere KL. Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know. Semin Neurol 2024; 44:362-388. [PMID: 38788765 DOI: 10.1055/s-0044-1787047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.
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Affiliation(s)
- Virginie Plante
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Meera Basu
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Matthew Luchette
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
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10
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Weimar C, Beyer-Westendorf J, Bohmann FO, Hahn G, Halimeh S, Holzhauer S, Kalka C, Knoflach M, Koennecke HC, Masuhr F, Mono ML, Nowak-Göttl U, Scherret E, Schlamann M, Linnemann B. New recommendations on cerebral venous and dural sinus thrombosis from the German consensus-based (S2k) guideline. Neurol Res Pract 2024; 6:23. [PMID: 38637841 PMCID: PMC11027218 DOI: 10.1186/s42466-024-00320-9] [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: 03/15/2024] [Accepted: 03/20/2024] [Indexed: 04/20/2024] Open
Abstract
Over the last years, new evidence has accumulated on multiple aspects of diagnosis and management of cerebral venous and dural sinus thrombosis (CVT) including identification of new risk factors, studies on interventional treatment as well as treatment with direct oral anticoagulants. Based on the GRADE questions of the European Stroke Organization guideline on this topic, the new German guideline on CVT is a consensus between expert representatives of Austria, Germany and Switzerland. New recommendations include:• CVT occurring in the first weeks after SARS-CoV-2 vaccination with vector vaccines may be associated with severe thrombocytopenia, indicating the presence of a prothrombotic immunogenic cause (Vaccine-induced immune thrombotic thrombocytopenia; VITT).• D-dimer testing to rule out CVT cannot be recommended and should therefore not be routinely performed.• Thrombophilia screening is not generally recommended in patients with CVT. It should be considered in young patients, in spontaneous CVT, in recurrent thrombosis and/or in case of a positive family history of venous thromboembolism, and if a change in therapy results from a positive finding.• Patients with CVT should preferably be treated with low molecular weight heparine (LMWH) instead of unfractionated heparine in the acute phase.• On an individual basis, endovascular recanalization in a neurointerventional center may be considered for patients who deteriorate under adequate anticoagulation.• Despite the overall low level of evidence, surgical decompression should be performed in patients with CVT, parenchymal lesions (congestive edema and/or hemorrhage) and impending incarceration to prevent death.• Following the acute phase, oral anticoagulation with direct oral anticoagulants instead of vitamin K antagonists should be given for 3 to 12 months to enhance recanalization and prevent recurrent CVT as well as extracerebral venous thrombosis.• Women with previous CVT in connection with the use of combined hormonal contraceptives or pregnancy shall refrain from continuing or restarting contraception with oestrogen-progestagen combinations due to an increased risk of recurrence if anticoagulation is no longer used.• Women with previous CVT and without contraindications should receive LMWH prophylaxis during pregnancy and for at least 6 weeks post partum.Although the level of evidence supporting these recommendations is mostly low, evidence from deep venous thrombosis as well as current clinical experience can justify the new recommendations.This article is an abridged translation of the German guideline, which is available online.
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Affiliation(s)
- C Weimar
- BDH Klinik Elzach und Institut für Medizinische Informatik, Biometrie und Epidemiologie, Universitätsklinikum Essen, Essen, Germany.
| | - J Beyer-Westendorf
- Department of Medicine I; Division "Thrombosis & Hemostasis ", Dresden University Hospital "Carl Gustav Caris; Technical University Dresden, Dresden, Germany
| | - F O Bohmann
- Department of Neurology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
| | - G Hahn
- Department of Pediatric Radiology, University Children`s Hospital Basel UKBB, Basel, Switzerland
| | - S Halimeh
- Universitätsklinikum Essen, gerinnungszentrum rhein-ruhr, Duisburg, Germany
| | - S Holzhauer
- Klinik für Pädiatrie mit Schwerpunkt Onkologie und Hämatologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - C Kalka
- Vascular Institute Central Switzerland, Aarau, Switzerland and University of Cologne, Cologne, Germany
| | - M Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - H-C Koennecke
- Klinik für Neurologie, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - F Masuhr
- Abteilung für Neurologie, Bundeswehrkrankenhaus Berlin, Berlin, Germany
| | - M-L Mono
- Abteilung für Neurologie, Stadtspital Triemli, Zürich, Switzerland
| | - U Nowak-Göttl
- Gerinnungszentrum UKSH (Campus Kiel und Lübeck), Institut für Klinische Chemie, Kiel, Germany
| | - E Scherret
- Klinik für Neurologie der Charité - , Universitätsmedizin Berlin, Berlin, Germany
| | - M Schlamann
- Sektion Neuroradiologie, Institut für Diagnostische und Interventionelle Radiologie, Klinikum der Universität zu Köln, Cologne, Germany
| | - B Linnemann
- Klinik für Kardiologie III - Angiologie, Universitätsmedizin Mainz, Mainz, Germany
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11
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Ordieres-Ortega L, Moragón-Ledesma S, Demelo-Rodríguez P. Cerebral venous thrombosis. Rev Clin Esp 2024; 224:237-244. [PMID: 38428733 DOI: 10.1016/j.rceng.2024.02.015] [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: 03/03/2024]
Abstract
Cerebral venous thrombosis is part of the so-called thrombosis in unusual sites. It is defined as an occlusion in the cerebral venous territory. Its incidence is progressively increasing, especially in developing countries. It is more frequently observed in young women, with hormonal factors such as pregnancy or hormonal contraception being significant risk factors in the development of this condition. The clinical presentation will depend fundamentally on the topography of the thrombosis, with a confirmatory diagnosis based mainly on imaging tests. The treatment generally consists of anticoagulation, and other options may be considered depending on the severity of the case. Overall, the prognosis is better than that of other intracranial vascular disorders. This review describes the current evidence available regarding cerebral venous thrombosis.
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Affiliation(s)
- L Ordieres-Ortega
- Unidad de Enfermedad Tromboembólica Venosa, Medicina Interna, Hospital General Universitario Gregorio Marañón, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - S Moragón-Ledesma
- Unidad de Enfermedad Tromboembólica Venosa, Medicina Interna, Hospital General Universitario Gregorio Marañón, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - P Demelo-Rodríguez
- Unidad de Enfermedad Tromboembólica Venosa, Medicina Interna, Hospital General Universitario Gregorio Marañón, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Spain; Facultad de Medicina, Universidad CEU San Pablo, Spain.
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12
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Netha A, Mazhar S, Azhar A, Moeez A, Choradia A, Mohtashim A, Anees U, Ejaz U, Tariq MU, Jawad S. Effectiveness of rivaroxaban in preventing cerebral venous thromboembolism: a systematic review and meta-analysis. Ann Med Surg (Lond) 2024; 86:2098-2104. [PMID: 38576935 PMCID: PMC10990339 DOI: 10.1097/ms9.0000000000001689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/27/2023] [Indexed: 04/06/2024] Open
Abstract
Background Cerebral venous thromboembolism (CVT) poses a significant risk of venous infarction and haemorrhage, which can lead to neurological deficits and, in severe cases, even death. The optimal treatment regimen for patients with CVT remains unclear. Methods MEDLINE, Embase, Google Scholar, Web of Science (WoS), and Cochrane Central databases were searched for randomized controlled trials (RCTs) and observational studies assessing the efficacy and safety of rivaroxaban in patients with CVT. All-site venous thromboembolism (VTE), risk of clinically relevant non-major bleeding, incidence of partial recanalization, complete recanalization and major haemorrhage were among outcomes of interest. Mantel-Haenszel weighted random-effects model was used to calculate relative risks (RRs) with 95% CIs. Results The analysis included 1 RCT and 3 observational studies containing 211 patients. Compared to vitamin K antagonists (VKAs), rivaroxaban did not significantly decrease the all-site VTE [RR 0.31 (95% CI 0.01, 8.43); P=0.49, I2=0%]. Compared with VKAs, patients on rivaroxaban did not show a significantly reduced risk of recurrent cerebral venous thrombosis. In terms of incidence of partial recanalization, there was no discernible difference between rivaroxaban and VKAs [RR 0.90 (95% CI 0.66, 1.22); P=0.49, I2=0%]. There was no discernible difference in incidence of complete recanalization [RR 0.98 (95% CI 0.32, 3.03); P=0.97, I2=28%] and incidence of major haemorrhage [RR 0.19 (95% CI 0.01, 4.54); P=0.30]. Conclusion Rivaroxaban was found to have similar efficacy to VKAs. Due to its lower risk of severe bleeding and no need for INR monitoring, rivaroxaban may be a preferable treatment option for CVT.
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Affiliation(s)
- Aadarsh Netha
- Department of Medicine, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Tamilnadu, India
| | - Saad Mazhar
- Department of Medicine, King Edward Medical University
| | - Aima Azhar
- Department of Medicine, Fatima Jinnah Medical University
| | - Abdul Moeez
- Department of Medicine, Services Institute of Medical Sciences
| | - Aakash Choradia
- Department of Medicine, Tribhuwan University, Kathmandu, Nepal
| | - Ali Mohtashim
- Department of Medicine, Allama Iqbal Medical College, Lahore
| | - Usama Anees
- Department of Medicine, Quaid-e-Azam Medical College, Bahawalpur
| | - Umer Ejaz
- Department of Medicine, Rawalpindi Medical College, Rawalpindi
| | | | - Sayed Jawad
- Department of Medicine, Kabul University of Medical Sciences, Kabul, Afghanistan
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13
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Berrueco Moreno R. [Thrombosis in children: Treatment peculiarities and novelties]. Med Clin (Barc) 2024; 162:280-282. [PMID: 38302396 DOI: 10.1016/j.medcli.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 02/03/2024]
Affiliation(s)
- Rubén Berrueco Moreno
- Hematología Pediátrica, Hospital Sant Joan de Déu Barcelona, Universitat de Barcelona, Barcelona, España; Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Esplugues de Llobregat, Barcelona, España; Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, España.
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14
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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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15
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Ranjan R, Ken‐Dror G, Sharma P. Direct oral anticoagulants compared to warfarin in long-term management of cerebral venous thrombosis: A comprehensive meta-analysis. Health Sci Rep 2024; 7:e1869. [PMID: 38317672 PMCID: PMC10839163 DOI: 10.1002/hsr2.1869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/09/2024] [Accepted: 01/18/2024] [Indexed: 02/07/2024] Open
Abstract
Objectives We compared the safety and efficacy of direct oral anticoagulants (DOACs) with those of warfarin in the long-term (≥6 months) treatment of cerebral venous thrombosis (CVT). Methods We searched electronic databases up to November 2023 to compare the use of DOACs and warfarin in CVT management. Modified Rankin scores (mRS), new intracranial hemorrhage, all-cause mortality, recurrence and nonrecanalisation events were used to assess outcome. RevMan v5.4 software and the Cochran-Mantel-Haenszel method were utilized to analyse data. Results A total of 25 studies involving 2301 patients were identified as having treated CVT with either DOACs or warfarin. Good long-term mRS scores 0-2 (risk ratio [RR] = 1.01, 95% CI = 0.98-1.03; p = 0.61), new intracranial hemorrhage (RR = 1.00, 95% CI = 0.48-2.08; p = 0.99), all-cause mortality (RR = 1.00, 95% CI = 0.50-1.98; p = 0.99), nonrecanalisation (RR = 0.95, 95% CI = 0.77-1.18; p = 0.65) and recurrence venous thrombosis events (RR = 0.63, 95% CI = 0.33-1.22; p = 0.17) were similar between the two treatment arms. Subgroup analysis found recurrence of venous thrombosis was lower in the rivaroxaban group compared to warfarin (2.2% vs. 8.5%, RR = 0.33, 95% CI = 0.11-0.98; p = 0.05). Conclusion DOACs and warfarin provide comparable long-term safety and efficacy profiles. DOACs may be preferred over warfarin due to their ease of clinical management.
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Affiliation(s)
- Redoy Ranjan
- Department of Cardiac SurgeryBangabandhu Sheikh Mujib Medical UniversityDhakaBangladesh
- Institute of Cardiovascular ResearchRoyal Holloway University of London (ICR2UL)Greater LondonUK
| | - Gie Ken‐Dror
- Institute of Cardiovascular ResearchRoyal Holloway University of London (ICR2UL)Greater LondonUK
| | - Pankaj Sharma
- Institute of Cardiovascular ResearchRoyal Holloway University of London (ICR2UL)Greater LondonUK
- Department of Clinical NeurologyImperial College London Healthcare NHS TrustLondonUK
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16
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Bhat RV, Young G, Sharathkumar AA. How I treat pediatric venous thromboembolism in the DOAC era. Blood 2024; 143:389-403. [PMID: 37390311 PMCID: PMC10862368 DOI: 10.1182/blood.2022018966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 07/02/2023] Open
Abstract
ABSTRACT The direct oral anticoagulants (DOACs) rivaroxaban and dabigatran are newly licensed for the treatment and prevention of venous thromboembolism (VTE) in children and mark a renaissance in pediatric anticoagulation management. They provide a convenient option over standard-of-care anticoagulants (heparins, fondaparinux, and vitamin K antagonists) because of their oral route of administration, child-friendly formulations, and significant reduction in monitoring. However, limitations related to therapeutic monitoring when needed and the lack of approved reversal agents for DOACs in children raise some safety concerns. There is accumulating experience of safety and efficacy of DOACs in adults for a broad scope of indications; however, the cumulative experience of using DOACs in pediatrics, specifically for those with coexisting chronic illnesses, is sparse. Consequently, clinicians must often rely on their experience for treating VTE and extrapolate from data in adults while using DOACs in children. In this article, the authors share their experience of managing 4 scenarios that hematologists are likely to encounter in their day-to-day practice. Topics addressed include (1) appropriateness of indication; (2) use for special populations of children; (3) considerations for laboratory monitoring; (4) transition between anticoagulants; (5) major drug interactions; (6) perioperative management; and (7) anticoagulation reversal.
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Affiliation(s)
- Rukhmi V. Bhat
- Center for Cancer and Blood Disorders, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Guy Young
- Cancer and Blood Disorders Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Anjali A. Sharathkumar
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
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17
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Borhani-Haghighi A, Hooshmandi E. Cerebral venous thrombosis: a practical review. Postgrad Med J 2024; 100:68-83. [PMID: 37978050 DOI: 10.1093/postmj/qgad103] [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: 07/18/2023] [Revised: 09/27/2023] [Accepted: 09/29/2023] [Indexed: 11/19/2023]
Abstract
The evolution of the Coronavirus Disease-2019 pandemic and its vaccination raised more attention to cerebral venous thrombosis (CVT). Although CVT is less prevalent than arterial stroke, it results in larger years of life lost. CVT is more common in women and young patients. Predisposing factors are categorized as transient factors such as pregnancy, puerperium, oral contraceptive pills, trauma, and dehydration; and permanent factors such as neoplastic, vasculitic, thrombophilic, hematologic conditions, infectious causes such as severe acute respiratory syndrome coronavirus-2 infection and HIV. The most common manifestations are headache, seizures, focal neurologic deficits, altered level of consciousness, and cranial nerve palsies. The most common syndromes are stroke-like, raised-intracranial-pressure (ICP), isolated-headache, and encephalopathy, which may have overlaps. Diagnosis is mostly based on computed tomography, magnetic resonance imaging, and their respective venous sequences, supported by blood results abnormalities such as D-dimer elevation. Treatment includes the prevention of propagation of current thrombus with anticoagulation (heparin, or low molecular weight heparinoids and then warfarin, or direct oral anticoagulants), decreasing ICP (even by decompressive craniotomy), and treatment of specific underlying diseases.
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Affiliation(s)
- Afshin Borhani-Haghighi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz 7193635899, Iran
- Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia
| | - Etrat Hooshmandi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz 7193635899, Iran
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18
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Chen X, Guo L, Lin M. Efficacy and Safety of Direct Oral Anticoagulants in Cerebral Venous Thrombosis: Meta-Analysis of Randomized Clinical Trials. Clin Appl Thromb Hemost 2024; 30:10760296241256360. [PMID: 38772568 PMCID: PMC11110516 DOI: 10.1177/10760296241256360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 05/05/2024] [Indexed: 05/23/2024] Open
Abstract
Current guidelines recommend the standard-of-care anticoagulation (vitamin K antagonists or low-molecular-weight heparin) in patients with cerebral venous thrombosis (CVT). Herein, we performed a meta-analysis of randomized clinical trials (RCTs) to assess the efficacy and safety of direct oral anticoagulants (DOACs) compared with the current standard of care in patients with CVT. We systematically searched the PubMed and Embase databases up to December 2023 to identify clinical trials on the effect of DOACs in patients with CVT. A Mantel-Haenszel fixed effects model was applied, and the effect measures were expressed as the absolute risk differences (RDs) and 95% confidence intervals (CIs). A total of 4 RCTs involving 270 participants were included. In the pooled analysis, DOACs and standard of care had low incidence rates of recurrent VTE and all-cause death, and similar rates of any recanalization (78.2% vs 83.2%; RD = -4%, 95%CI:-14% to 5%) and complete recanalization (60.9% vs 69.4%; RD = -7%, 95%CI:-24% to 10%). Compared with the standard of care, DOACs had non-significant reductions in the rates of major bleeding (1.2% vs 2.4%; RD = -1%, 95%CI: -6% to 3%), intracranial hemorrhage (1.9% vs 3.6%; RD = -2%, 95%CI:-7% to 3%), clinically relevant non-major bleeding (3.8% vs 7.4%; RD = -4%, 95%CI:-9% to 2%), and any bleeding (17.3% vs 21.4%; RD = -4%, 95%CI:-16% to 8%) in patients with CVT. DOACs and standard of care showed similar efficacy and safety profiles for the treatment of CVT. DOACs might be safe and a convenient alternative to vitamin K antagonists for thromboprophylaxis in patients with CVT.
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Affiliation(s)
- Xi Chen
- Department of Cardiology, Sanming First Affiliated Hospital of Fujian Medical University, SanMing, China
| | - Linjuan Guo
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Meiming Lin
- Department of Cardiology, Sanming First Affiliated Hospital of Fujian Medical University, SanMing, China
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19
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Ranjan R, Ken-Dror G, Sharma P. Pathophysiology, diagnosis and management of cerebral venous thrombosis: A comprehensive review. Medicine (Baltimore) 2023; 102:e36366. [PMID: 38050259 PMCID: PMC10695550 DOI: 10.1097/md.0000000000036366] [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: 10/11/2023] [Accepted: 11/08/2023] [Indexed: 12/06/2023] Open
Abstract
Cerebral venous thrombosis is a rare cause of stroke in young mostly female adults which is frequently overlooked due to its variable clinical and radiological presentation. This review summarizes current knowledge on it risk factors, management and outcome in adults and highlights areas for future research. Females are 3 times more commonly affected and are significantly younger than males. The presenting symptoms can range from headache to loss of consciousness. However, the often-nebulous nature of symptoms can make the diagnosis challenging. Magnetic resonance imaging with venography is often the diagnostic imaging of choice. While unfractionated or low molecular-weight heparin is the mainstay of treatment, endovascular intervention with thrombolysis or thrombectomy and decompressive craniectomy may be required depending on clinical status. Nevertheless, approximately 80% of patients have a good recovery but mortality rates of -5% to 10% are not uncommon. Diagnosing cerebral venous thrombosis can be challenging but with vigilance and expert care patients have the best chance of a good clinical outcome.
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Affiliation(s)
- Redoy Ranjan
- Department of Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
- Institute of Cardiovascular Research, Royal Holloway University of London (ICR2UL), Egham Hill, Greater London, United Kingdom
| | - Gie Ken-Dror
- Institute of Cardiovascular Research, Royal Holloway University of London (ICR2UL), Egham Hill, Greater London, United Kingdom
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway University of London (ICR2UL), Egham Hill, Greater London, United Kingdom
- Department of Clinical Neurology, Imperial College London Healthcare NHS Trust, London, United Kingdom
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20
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Chung MG, Pabst L. Acute management of childhood stroke. Curr Opin Pediatr 2023; 35:648-655. [PMID: 37800414 DOI: 10.1097/mop.0000000000001295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
PURPOSE OF REVIEW The purpose of this paper is to review recent updates in the acute management of childhood arterial ischemic stroke, including reperfusion therapies and neuroprotective measures. RECENT FINDINGS With the emergence of pediatric stroke centers in recent years, processes facilitating rapid diagnosis and treatment have resulted in improved implementation of early targeted neuroprotective measures as well as the increased use of reperfusion therapies in childhood arterial ischemic stroke. Retrospective data has demonstrated that alteplase is safe in carefully selected children with arterial ischemic stroke in the first 4.5 h from symptom onset, though data regarding its efficacy in children are still lacking. There is also increasing data that suggests that thrombectomy in children with large vessel occlusion improves functional outcomes. Recent adult studies, including the use of Tenecteplase as an alteplase alternative and expansion of late thrombectomy to include patients with large ischemic cores, also are reviewed along with limitations to application of the adult data to pediatric care. SUMMARY There have been significant advances in the hyperacute care of children with ischemic stroke and early diagnosis and targeted management are of the upmost importance in improving long-term outcomes.
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Affiliation(s)
- Melissa G Chung
- Nationwide Children's Hospital, Department of Pediatrics, Divisions of Critical Care Medicine and Pediatric Neurology
| | - Lisa Pabst
- Department of Pediatrics, Division of Neurology, University of Utah, Salt Lake City, Utah, USA
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21
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Ranjan R, Ken-Dror G, Aziz MA, Amin R, Shahidullah M, Sharma P. Cerebral Venous Thrombosis Among Bangladeshi Population: A Systematic Review. Cureus 2023; 15:e49470. [PMID: 38152776 PMCID: PMC10751619 DOI: 10.7759/cureus.49470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 12/29/2023] Open
Abstract
Cerebral venous thrombosis (CVT) is a rare cause of stroke which remains unsung among Bangladeshi physicians and the general population. Our objective was to provide a comprehensive review of published data on Bangladeshi CVT patients. We searched all-electronic databases for Bangladeshi studies on CVT until November 2023, including literature in all languages. This study reviews the age of onset, gender distribution, radiological characteristics, and outcomes of Bangladeshi CVT patients. We included 13 studies (two observational and 11 case reports) that evaluated 102 CVT patients and found that women suffered CVT significantly higher than men (59.8% vs 40.2%; P =0.04), respectively. The overall age of the study population was 36.6±6.8, and men were significantly older than women (45.4±12.3 vs. 32.4±8.3; P<0.001). The most commonly affected sites were the superior sagittal sinus and transverse sinus thrombosis. Rivaroxaban was primarily used for long-term anticoagulation after initial low molecular weight heparin therapy. Furthermore, most studies observed an excellent clinical outcome with completed recanalisation on early follow-up angiography in three studies. In Bangladesh, women 1.5 times more commonly suffer from CVT and 13 years earlier than men. Although this review found that prompt diagnosis and anticoagulation therapy provides good clinical outcome, we recommended further studies to evaluate the long-term outcome, especially the safety and efficacy of oral anticoagulants, with recanalisation and recurrence rate.
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Affiliation(s)
- Redoy Ranjan
- Biological Sciences, Royal Holloway University of London, London, GBR
- Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Gie Ken-Dror
- Biological Sciences, Royal Holloway University of London, London, GBR
| | - Md Atikul Aziz
- Physical Medicine & Rehabilitation, National Institute of Neurosciences & Hospital (NINS), Dhaka, BGD
| | - Rasul Amin
- Cardiology, Bangabandhu Sheikh Mujib Medical University Hospital, Dhaka, BGD
| | - Md Shahidullah
- Neurology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Pankaj Sharma
- Biological Sciences, Royal Holloway University of London, London, GBR
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22
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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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23
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Cohen O, Barg AA, Nowak-Göttl U, Amado-Fernández C, Mazzolai L, Tiberio G, Schellong S, Skride A, Morales MDV, Monreal M, Kenet G. Venous thromboembolism characteristics, treatment and outcomes in young adults: findings from the Registro Informatizado de Enfermedad TromboEmbólica registry. J Thromb Haemost 2023; 21:2811-2823. [PMID: 37406932 DOI: 10.1016/j.jtha.2023.06.031] [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: 02/22/2023] [Revised: 06/13/2023] [Accepted: 06/25/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is rare in patients aged <21 years. Young adults aged 18 to 21 years are frequently included in adult VTE studies, whereas pediatric VTE studies include patients aged up to either 18 or 21 years. The clinical characteristics of young adult patients with VTE have not been well defined. OBJECTIVES We aimed to highlight any unique characteristics or treatment considerations that may apply to young adult patients with VTE. METHODS Data from the prospective, international Registro Informatizado de Enfermedad TromboEmbólica registry were used. Patients were stratified into subcohorts according to age. The clinical characteristics, risk factors, management, and outcomes of young adult patients with VTE were compared with those of adolescents aged 12 to 18 years and adults aged >21 years. RESULTS Of 104 253 Registro Informatizado de Enfermedad TromboEmbólica patients enrolled until August 2022, 234 were adolescents and 884 were young adults. Less cases of pulmonary embolism were reported in adolescents (P < .001). Estrogen use was a common risk factor, more prevalent in adolescents and young adults (P < .001), whereas active cancer and immobilization were uncommon in both. Most patients were initially treated with low-molecular-weight heparin. VTE recurrence, major bleeding, and all-cause mortality rates were comparably low among adolescents and young adults. None of the patients aged <21 years died from VTE recurrence. CONCLUSION Young adults have some distinctive VTE risk factors. While VTE presentation may be similar among young adults and older patients, the outcomes of patients aged <21 years are more favorable.
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Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel; Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Assaf A Barg
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel; Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ulrike Nowak-Göttl
- Institute of Clinical Chemistry, Thrombosis and Haemostasis Treatment Centre, University Hospital, Kiel-Lübeck, Germany
| | | | - Lucia Mazzolai
- Department of Angiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Gregorio Tiberio
- Department of Internal Medicine, Hospital Virgen del Camino, Pamplona, Navarra, Spain
| | - Sebastian Schellong
- Department of Medical Clinic, Municipal Hospital of Dresden Friedrichstadt, Dresden, Germany
| | - Andris Skride
- Department of Cardiology, Pauls Stradiņš Clinical University Hospital, Riga Stradiņš University, Riga, Latvia
| | | | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, Universidad Católica San Antonio de Murcia (UCAM), El Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERS), Madrid, Spain
| | - Gili Kenet
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel; Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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24
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Giossi R, Menichelli D, D'Amico F, Idotta L, Cirino M, Scardoni L, Furlanetto C, Maggi M, Bernocchi O, Bosca F, Girlando L, Pignatelli P, Pani A, Pastori D, Tozzo A, Scaglione F, Fornasari D. Efficacy and safety of direct oral anticoagulants in the pediatric population: a systematic review and a meta-analysis. J Thromb Haemost 2023; 21:2784-2796. [PMID: 37481075 DOI: 10.1016/j.jtha.2023.07.011] [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: 01/31/2023] [Revised: 07/04/2023] [Accepted: 07/11/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) represent a cornerstone of adult venous thromboembolism (VTE) treatment. Recently, randomized controlled trials (RCTs) investigating DOACs in pediatrics have been performed. OBJECTIVES To evaluate the efficacy and safety of DOACs in the pediatric population. METHODS We systematically searched MEDLINE (PubMed), EMBASE, and ClinicalTrials.gov from initiation up to August 20, 2022, for RCTs comparing DOACs to standard of care (SOC) in patients aged <18 years according to PRISMA guidelines (PROSPERO registration CRD42022353870). The primary analysis was performed according to the anticoagulation intensity and clinical setting (ie, prophylaxis in cardiac disease or treatment in VTE). Efficacy outcomes were all-cause mortality and VTE. Safety outcomes were major bleeding (MB), clinically relevant non-MB, any bleeding, serious adverse events, and discontinuation due to adverse events (AEs). RESULTS Seven RCTs were included in the systematic review and 6 in the meta-analysis (3 prophylaxis in cardiac disease and 3 treatment in VTE). DOACs showed a significant reduction of VTE recurrence for treatment (odds ratio [OR] = 0.42; 95% CI, 0.19-0.94) and a nonsignificant reduction in VTE occurrence in prophylaxis (OR = 0.22; 95% CI, 0.03-1.55). No differences were observed for any bleeding, serious AEs, and MB in prophylaxis. Nonsignificant trends were observed for clinically relevant non-MB, MB in treatment, and discontinuation due to AE in prophylaxis. We found a significant increase in discontinuation due to AE in treatment. CONCLUSIONS DOAC treatment seems to reduce VTE compared with SOC without major safety issues in the pediatric population, whereas DOAC prophylaxis seems at least comparable to SOC.
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Affiliation(s)
- Riccardo Giossi
- Chemical-Clinical Analyses Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Danilo Menichelli
- Department of General Surgery and Surgical Speciality, Sapienza University of Rome, Rome, Italy
| | - Federico D'Amico
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Laura Idotta
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Mario Cirino
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Laura Scardoni
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Costanza Furlanetto
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Matteo Maggi
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Ottavia Bernocchi
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Federica Bosca
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Luca Girlando
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Pasquale Pignatelli
- Department of Clinical, Internal, Anesthesiological, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Arianna Pani
- Department of Oncology and Hemato-Oncology, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Daniele Pastori
- Department of Clinical, Internal, Anesthesiological, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy.
| | - Alessandra Tozzo
- Maternal and Infantile Department of Pediatrics, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Scaglione
- Chemical-Clinical Analyses Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Oncology and Hemato-Oncology, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Diego Fornasari
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
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Monagle P, Male C, Raffini L. The value of the old and the new. Blood Adv 2023; 7:3683-3685. [PMID: 36939386 PMCID: PMC10368678 DOI: 10.1182/bloodadvances.2023009723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/28/2023] [Indexed: 03/21/2023] Open
Affiliation(s)
- Paul Monagle
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Haematology Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Christoph Male
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Leslie Raffini
- Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
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26
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Levy-Mendelovich S, Cohen O, Klang E, Kenet G. 50 Years of Pediatric Hemostasis: Knowledge, Diagnosis, and Treatment. Semin Thromb Hemost 2023; 49:217-224. [PMID: 36174607 DOI: 10.1055/s-0042-1756704] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Studies from the past 50 years have contributed to the expanding knowledge regarding developmental hemostasis. This is a dynamic process that begins in the fetal phase and is characterized by physiological variations in platelet counts and function, and concentrations of most coagulation factors and the native coagulation inhibitors in early life, as compared with adulthood. The developmental hemostasis studies since the 1980 to 1990s established the laboratory reference values for coagulation factors. It was only a decade or two later, that thromboelastography (TEG) or (rotational thromboelastometry [ROTEM]) as well as thrombin generation studies, provided special pediatric reference values along with the ability to evaluate clot formation and lysis. In addition, global whole blood-based clotting assays provided point of care guidance for proper transfusion support to children hospitalized in intensive care units or undergoing surgery. Although uncommon, thrombosis in children and neonates is gaining increasing recognition, typically as a secondary complication in sick children. Bleeding in children, and particularly intracerebral hemorrhage in newborns, still represent a therapeutic challenge. Notably, our review will outline the advancements in understanding developmental hemostasis and its manifestations, with respect to the pathophysiology of thrombosis and bleeding complications in young children. The changes of transfusion policy and approach to thrombophilia testing during the last decade will be mentioned. Subsequently, a brief summary of the data on anticoagulant treatments in pediatric patients will be presented. Finally, we will point out the 10 most cited articles in the field of pediatric and neonatal hemostasis.
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Affiliation(s)
- Sarina Levy-Mendelovich
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Omri Cohen
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Klang
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel
| | - Gili Kenet
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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27
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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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28
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Liu S, Bai M, Zhao Y. Cerebral venous thrombosis in patients with Sjögren's syndrome: A case report and literature review. Heliyon 2023; 9:e15246. [PMID: 37089298 PMCID: PMC10119761 DOI: 10.1016/j.heliyon.2023.e15246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/11/2022] [Accepted: 03/30/2023] [Indexed: 04/07/2023] Open
Abstract
Although cerebral venous thrombosis (CVT) is known to be induced by autoimmune diseases such as systemic lupus erythematosus and antiphospholipid syndrome, CVT caused by Sjögren's syndrome (SS) is scarcely reported in the medical literature. Since the first report of SS-induced CVT in 1994, only five cases have been reported, and the clinicopathological features of the disease are not well documented. We herein present a case report of a 41-year-old woman who was diagnosed with SS-induced CVT and perform a literature review of six cases of SS-induced CVT with a discussion of the pathogenesis, features of clinic symptoms, treatment, and prognosis of SS-associated CVT. We aim to improve the understanding of SS-induced CVT among clinicians and reduce the incidence of missed clinical diagnoses.
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29
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Mills K, Hill C, King M, Pauley JL, Cober MP, Fenn NE, Omecene NE, Smith T, Sierra CM. Just DOAC: Use of direct-acting oral anticoagulants in pediatrics. Am J Health Syst Pharm 2023; 80:412-422. [PMID: 36610740 DOI: 10.1093/ajhp/zxac387] [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: 12/23/2022] [Indexed: 01/09/2023] Open
Abstract
PURPOSE The aim of this article is to provide an overview of the current literature for direct-acting oral anticoagulant (DOAC) use in pediatric patients and summarize ongoing trials. SUMMARY In treatment of venous thromboembolism (VTE) in pediatric patients, evidence supports use of both dabigatran and rivaroxaban. Dabigatran has been shown to be noninferior to standard of care (SOC) in terms of efficacy, with similar bleeding rates. Similarly, treatment with rivaroxaban in children with acute VTE resulted in a low recurrence risk and reduced thrombotic burden, without increased risk of bleeding, compared to SOC. Treatment of pediatric cerebral venous thrombosis as well as central venous catheter-related VTE with rivaroxaban appeared to be both safe and efficacious and similar to that with SOC. Dabigatran also has a favorable safety profile for prevention of VTE, and rivaroxaban has a favorable safety profile for VTE prevention in children with congenital heart disease. Many studies with several different DOACs are ongoing to evaluate both safety and efficacy in unique patient populations, as well as VTE prevention. CONCLUSION The literature regarding pediatric VTE treatment and prophylaxis is growing, but the need for evidence-based pediatric guidelines remains. Additional long-term, postauthorization studies are warranted to further elucidate safety and efficacy in clinical scenarios excluded in clinical trials. Additional data on safety, efficacy, and dosing strategies for reversal agents are also necessary, especially as the use of DOACs becomes more common in the pediatric population.
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Affiliation(s)
| | - Carolyn Hill
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Morgan King
- Cleveland Clinic Fairview Hospital, Cleveland, OH, USA
| | | | - M Petrea Cober
- College of Pharmacy, Akron Children's Hospital/Northeast Ohio Medical University, Akron, OH, USA
| | - Norman E Fenn
- PennState Health Hershey Children's Hospital, Hershey, PA, USA
| | - Nicole E Omecene
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | - Tara Smith
- HCA Florida West Healthcare, Pensacola, FL, USA
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30
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Roth H, Ränsch R, Kossorotoff M, Chahine A, Tirel O, Brossier D, Wroblewski I, Orliaguet G, Chabrier S, Mortamet G. Post traumatic cerebral sinovenous thrombosis in children: A retrospective and multicenter study. Eur J Paediatr Neurol 2023; 43:12-15. [PMID: 36746017 DOI: 10.1016/j.ejpn.2023.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 12/26/2022] [Accepted: 01/17/2023] [Indexed: 01/26/2023]
Abstract
CONTEXT Cerebral sinovenous thrombosis (CSVT) is a rare but life-threatening condition in the pediatric population and there is no pediatric guidelines regarding anticoagulation for post traumatic CSVT. OBJECTIVE This study aims to describe a cohort of children with post traumatic CSVT and the use of anticoagulant therapy in this population. METHODS A multicenter retrospective study. Patients admitted with post traumatic CSVT in the six participating Pediatric Intensive Care Unit were included. RESULTS Overall, 29 patients (median age 8.2 years [IQR 4.8-14.6], n = 22 (76%) males) were included in the study (Table 1). CSVT was observed within the first 24 h after admission for a half of the patients (n = 14, 50%). Anticoagulation was initiated in 18 patients (62%). No patient received thrombolytic therapy or endovascular treatment. The presence of epidural hematoma was associated with the absence of anticoagulation (n = 0 versus n = 10, p = 0.003). One patient (3%) died of extracranial injury (not related with adverse event of anticoagulation) and in survivors, median Pediatric Overall Performance Category Outcome (POPC) score at discharge from PICU was 2 [IQR 2-4] (i.e., mild disability). Regarding the outcomes of patients, we found no association according to the anticoagulation status (p = 1). Overall, 23 patients (79%) had a follow-up cerebral imaging with a median delay of 42 days [IQR 6-63] after admission. CSVT was still seen in 9 patients (31%). We found no difference regarding the persistence of CSVT between patients according to the anticoagulation status (p = 0.36). The median duration of anticoagulant treatment was 58 days [IQR 44-91] and one patient (3%) experienced adverse event related to anticoagulation. CONCLUSION There were minimal adverse events in patients with post traumatic CSVT treated with therapeutic anticoagulation. However, the effect of anticoagulation on outcomes needs to be confirmed in further studies.
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Affiliation(s)
- Helena Roth
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, 38000, Grenoble, France.
| | - Roman Ränsch
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, 38000, Grenoble, France.
| | - Manoelle Kossorotoff
- French Centre for Paediatric Stroke, Pediatric Neurology Department, Necker-Enfants Maladies University Hospital, Assistance Publique Hôpitaux de Paris, 75015, Paris, France.
| | - Adela Chahine
- Pediatric Intensive Care Unit, Toulouse University Hospital, 31000, Toulouse, France.
| | - Olivier Tirel
- Pediatric Intensive Care Unit, Rennes University Hospital, 35000, Rennes, France.
| | - David Brossier
- Pediatric Intensive Care Unit, Caen University Hospital, 14000, Caen, France; Université Caen Normandie, Medical School, Caen, F-14000, France.
| | - Isabelle Wroblewski
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, 38000, Grenoble, France.
| | - Gilles Orliaguet
- Department of Pediatric Anaesthesia and Intensive Care, Necker University Hospital, AP-HP, Centre - Université Paris Cité, France; EA 7323 Université de Paris "Pharmacologie et évaluation des Thérapeutiques Chez L'enfant et La Femme Enceinte", Paris, France.
| | - Stéphane Chabrier
- French Centre for Paediatric Stroke, Pediatric Physical and Rehabilitation Medicine Department, Saint-Etienne University Hospital, 42000, Saint-Etienne, France.
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, 38000, Grenoble, France; Univ. Grenoble-Alpes, 38000, Grenoble, France.
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31
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Netteland DF, Sandset EC, Mejlænder-Evjensvold M, Aarhus M, Jeppesen E, Aguiar de Sousa D, Helseth E, Brommeland T. Cerebral venous sinus thrombosis in traumatic brain injury: A systematic review of its complications, effect on mortality, diagnostic and therapeutic management, and follow-up. Front Neurol 2023; 13:1079579. [PMID: 36698879 PMCID: PMC9869151 DOI: 10.3389/fneur.2022.1079579] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/30/2022] [Indexed: 01/11/2023] Open
Abstract
Objective Cerebral venous sinus thrombosis (CVST) is increasingly being recognized in the setting of traumatic brain injury (TBI), but its effect on TBI patients and its management remains uncertain. Here, we systematically review the currently available evidence on the complications, effect on mortality and the diagnostic and therapeutic management and follow-up of CVST in the setting of TBI. Methods Key clinical questions were posed and used to define the scope of the review within the following topics of complications; effect on mortality; diagnostics; therapeutics; recanalization and follow-up of CVST in TBI. We searched relevant databases using a structured search strategy. We screened identified records according to eligibility criteria and for information regarding the posed key clinical questions within the defined topics of the review. Results From 679 identified records, 21 studies met the eligibility criteria and were included, all of which were observational in nature. Data was deemed insufficiently homogenous to perform meta-analysis and was narratively synthesized. Reported rates of venous infarctions ranged between 7 and 38%. One large registry study reported increased in-hospital mortality in CVSP and TBI compared to a control group with TBI alone in adjusted analyses. Another two studies found midline CVST to be associated with increased risk of mortality in adjusted analyses. Direct data to inform the optimum diagnostic and therapeutic management of the condition was limited, but some data on the safety, and effect of anticoagulation treatment of CVST in TBI was identified. Systematic data on recanalization rates to guide follow-up was also limited, and reported complete recanalization rates ranged between 41 and 86%. In the context of the identified data, we discuss the diagnostic and therapeutic management and follow-up of the condition. Conclusion Currently, the available evidence is insufficient for evidence-based treatment of CVST in the setting of TBI. However, there are clear indications in the presently available literature that CVST in TBI is associated with complications and increased mortality, and this indicates that management options for the condition must be considered. Further studies are needed to confirm the effects of CVST on TBI patients and to provide evidence to support management decisions. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier: PROSPERO [CRD42021247833].
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Affiliation(s)
- Dag Ferner Netteland
- Department of Neurosurgery, Oslo University Hospital Ullevål, Oslo, Norway,Faculty of Medicine, University of Oslo, Oslo, Norway,*Correspondence: Dag Ferner Netteland ✉
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital Ullevål, Oslo, Norway,Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
| | | | - Mads Aarhus
- Department of Neurosurgery, Oslo University Hospital Ullevål, Oslo, Norway
| | | | - Diana Aguiar de Sousa
- Department of Neurosciences (Neurology), Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Eirik Helseth
- Department of Neurosurgery, Oslo University Hospital Ullevål, Oslo, Norway,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tor Brommeland
- Department of Neurosurgery, Oslo University Hospital Ullevål, Oslo, Norway
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32
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Hassan E, Motwani J. Real world experience of efficacy and safety of rivaroxaban in paediatric venous thromboembolism. Thromb Res 2023; 221:92-96. [PMID: 36495716 DOI: 10.1016/j.thromres.2022.11.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 11/25/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Paediatric clinical practice for treatment of venous thromboembolism (VTE) is based on extrapolation from adult trials with minimal data on anticoagulation efficacy and safety in children. Based on EINSTEIN-Jr clinical trial data, rivaroxaban was approved to treat VTE and prevent its recurrence in children of all ages. AIM To report the safety and efficacy of rivaroxaban use in paediatric VTE and to present real-world data, specifically about very young children. METHODS We conducted a retrospective observational study at Birmingham Children's Hospital. Data were collected from patients <16 years old who received rivaroxaban after its licensure in the period between March 2021 and June 2022. RESULTS Rivaroxaban was used for treatment of acute VTE in 64 patients. Thrombosis was CVC-related in 26 patients, unprovoked in 3, while the rest had one or more risk factors for VTE. Safety and efficacy of rivaroxaban were assessed in 52 patients after excluding patients who were on current rivaroxaban treatment and those who were lost to follow up or stopped rivaroxaban due to intolerance. No bleeding events were reported, and recurrence of thrombosis occurred in only 3.6 %. About 35 % had normalised re-imaging, 40.3 % improved, 9.6 % were unchanged and 11.5 % stopped rivaroxaban without re-imaging. Rivaroxaban was used for secondary VTE prophylaxis in 6 patients in our cohort with no recurrence of thrombosis or bleeding reports. CONCLUSIONS Our real-world experience confirmed that rivaroxaban was well tolerated, effective and safe. Further real-world data and observational studies are essential to investigate the use of rivaroxaban among different risk groups.
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Affiliation(s)
- Eman Hassan
- Department of Paediatric Haematology, Birmingham Children's Hospital, United Kingdom; Department of Paediatrics, Haematology and Oncology Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - Jayashree Motwani
- Department of Paediatric Haematology, Birmingham Children's Hospital, United Kingdom.
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Cerebral Sinovenous Thrombosis in Infants and Children: A Practical Approach to Management. Semin Pediatr Neurol 2022; 44:100993. [PMID: 36456034 DOI: 10.1016/j.spen.2022.100993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/27/2022] [Accepted: 08/29/2022] [Indexed: 11/23/2022]
Abstract
Cerebral sinovenous thrombosis (CSVT) is a rare, yet potentially devastating disorder, associated with acute complications and long-term neurologic sequelae. Consensus-based international pediatric CSVT treatment guidelines emphasize early clinical-radiologic recognition and prompt consideration for anticoagulation therapy. However, lack of clinical trials has precluded evidence-based patient selection, anticoagulant choice, optimal monitoring parameters and treatment duration. Consequently, uncertainties and controversies persist regarding anticoagulation practices in pediatric CSVT. This review focuses on commonly encountered issues that continue to pose questions and raise debates regarding anticoagulation therapy among pediatric neurologists and hematologists.
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34
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Acute Hospital Management of Pediatric Stroke. Semin Pediatr Neurol 2022; 43:100990. [PMID: 36344020 DOI: 10.1016/j.spen.2022.100990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/13/2022] [Accepted: 08/14/2022] [Indexed: 11/24/2022]
Abstract
The field of pediatric stroke has historically been hampered by limited evidence and small patient cohorts. However the landscape of childhood stroke is rapidly changing due in part to increasing awareness of the importance of pediatric stroke and the emergence of dedicated pediatric stroke centers, care pathways, and alert systems. Acute pediatric stroke management hinges on timely diagnosis confirmed by neuroimaging, appropriate consideration of recanalization therapies, implementation of neuroprotective measures, and attention to secondary prevention. Because pediatric stroke is highly heterogenous in etiology, management strategies must be individualized. Determining a child's underlying stroke etiology is essential to appropriately tailoring hyperacute stroke management and determining best approach to secondary prevention. Herein, we review the methods of recognition, diagnosis, management, current knowledge gaps and promising research for pediatric stroke.
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Naik A, Smith E, Dharnipragada R, Catapano JS, Cramer SW, Johnson R, Khanam R, Hassaneen W, Lawton MT, Arnold PM. Endovascular and Medical Management of Cerebral Venous Thrombosis: A Systematic Review and Network Meta-Analysis. World Neurosurg 2022; 165:e197-e205. [PMID: 35688371 DOI: 10.1016/j.wneu.2022.05.142] [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: 04/17/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Management of cerebral venous thrombosis (CVT) involves minimizing expansion of the thrombus and promoting the recanalization of the venous sinus. While current guidelines include indications of endovascular management and anticoagulation with heparin and warfarin, the use of direct-acting oral anticoagulants (DOACs) has increased. In this study, we aim to conduct a network meta-analysis comparing these 3 therapeutic options: standard anticoagulation, DOACs, and endovascular treatments (EVTs). METHODS Seventeen of 2265 studies identified from 4 publication databases met inclusion criteria for this network meta-analysis. Outcomes analyzed included modified Rankin Scale score, complications, mortality, and 6-month recanalization rates using a frequentist network meta-analysis approach. For each outcome, the preferential order of each intervention was ranked hierarchically based on P-score calculations used for frequentist network meta-analyses. RESULTS Modified Rankin Scale outcomes were not significantly different based on the type of treatment modality (i.e., standard anticoagulation, DOACs, or EVT). Evaluation of complications demonstrated that patients treated with EVT were significantly more likely to experience a worse outcome than individuals treated with standard anticoagulation (odds ratio [OR] = 1.83, P = 0.04). Other comparisons did not demonstrate a significant difference in adverse events. For all-cause mortality outcomes, EVT demonstrated significantly greater odds of mortality than standard anticoagulation (OR = 1.89, P = 0.02). Mortality between DOACs and standard anticoagulation was not significantly different. When comparing 6-month recanalization rates, DOACs and EVT were significantly more effective than standard anticoagulation (OR = 1.93, OR = 2.2, P < 0.05). EVT followed by DOACs was preferred over standard anticoagulation for 6-month recanalization rates. CONCLUSIONS This network meta-analysis evaluates the outcomes in CVT treatment, comparing standard anticoagulation, DOACs, and EVT, with evidence that DOACs have similar outcomes to standard anticoagulation in the treatment of CVT. EVT resulted in an increased risk of overall mortality but improved 6-month recanalization rates.
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Affiliation(s)
- Anant Naik
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, Illinois
| | - Emily Smith
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, Illinois
| | - Rajiv Dharnipragada
- University of Minnesota Medical School, University of Minnesota Twin-Cities, Minneapolis, Minnesota
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Samuel W Cramer
- Department of Neurosurgery, University of Minnesota Twin-Cities, Minneapolis, Minnesota
| | - Ryan Johnson
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Rukhsaar Khanam
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, Illinois
| | - Wael Hassaneen
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, Illinois; Department of Neurosurgery, Carle Foundation Hospital, Urbana, Illinois
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Paul M Arnold
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, Illinois; Department of Neurosurgery, Carle Foundation Hospital, Urbana, Illinois.
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Takasaki K, Hehir D, Raffini L, Samelson-Jones BJ, Shih E, Dain AS. Andexanet alfa for reversal of rivaroxaban in a child with intracranial hemorrhage. Pediatr Blood Cancer 2022; 69:e29484. [PMID: 34811876 PMCID: PMC9038625 DOI: 10.1002/pbc.29484] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/08/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Kaoru Takasaki
- Divisions of Hematology and Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David Hehir
- Divisions of Cardiology and Cardiac Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leslie Raffini
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Benjamin J Samelson-Jones
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Philadelphia, Pennsylvania, USA
| | - Evelyn Shih
- Divisions of Hematology and Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aleksandra Sarah Dain
- Divisions of Hematology and Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Moraes AADA, Conforto AB. Cerebral venous thrombosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:53-59. [PMID: 35976298 PMCID: PMC9491445 DOI: 10.1590/0004-282x-anp-2022-s108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/29/2022] [Indexed: 05/15/2023]
Abstract
Cerebral venous sinus thrombosis (CVT) consists of partial or complete occlusion of a sinus or a cerebral vein. CVT represents 0.5-1% of all strokes and is more frequent in young women. This review discusses particular aspects of CVT diagnosis and management: decompressive craniectomy (DC), anticoagulation with direct oral anticoagulants (DOACs), CVT after coronavirus-disease 19 (COVID-19) and Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT).
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Affiliation(s)
| | - Adriana Bastos Conforto
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brazil
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38
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Riat R, Gomez K. Addendum to guidelines on the investigation and management of venous thrombosis at unusual sites (Br. J. Haematol. 2012;159:28-38): Use of Direct Oral Anticoagulants. Br J Haematol 2022; 198:46-49. [PMID: 35389508 DOI: 10.1111/bjh.18189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/22/2022] [Accepted: 03/25/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Renu Riat
- Haematology Department, Buckinghamshire NHS Trust, Amersham, UK
| | - Keith Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
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Sánchez van Kammen M, Male C, Connor P, Monagle P, Coutinho JM, Lensing AWA. Anticoagulant Treatment for Pediatric Infection-Related Cerebral Venous Thrombosis. Pediatr Neurol 2022; 128:20-24. [PMID: 35032886 DOI: 10.1016/j.pediatrneurol.2021.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND We aimed to describe the clinical presentation, risk of bleeding and recurrent thrombosis, and perioperative anticoagulant management of children with cerebral venous thrombosis (CVT) and an associated head or neck infection. METHODS In this subgroup analysis of the EINSTEIN-Jr study, we included children with CVT and an associated head or neck infection who received therapeutic anticoagulants with either low-molecular-weight heparin (with or without subsequent vitamin K antagonists) or rivaroxaban for a period of 3 months. Analyses are descriptive. RESULTS Of 74 included children, 59 (80%) had otomastoiditis, 21 (28%) a central nervous system infection, 18 (24%) sinusitis, and 9 (12%) another upper respiratory tract infection; 29 (39%) had infection of multiple regions of the head or neck. All 74 children received antibiotics and therapeutic anticoagulants; 41 (55%) underwent surgery, of whom 34 were diagnosed with CVT preoperatively. Anticoagulation was started before surgery in 12 children and interrupted 0-1 days prior to surgery. Anticoagulation was (re)started in all 34 children at a median of 1 day (interquartile range: 0-1) postoperatively, in therapeutic doses in 94%. Overall, one child (1%, 95% confidence interval: 0-7) had recurrent thrombosis, and one (1%, 95% confidence interval: 0-7) had major bleeding; neither was associated with surgery. At 3 months, no children had died, 3 (4%) had persistent focal neurologic deficits, and 2 (3%) had impaired vision. CONCLUSIONS Children with CVT and an associated head or neck infection administered therapeutic anticoagulants generally had low risks of bleeding and thrombotic complications, including those who had surgical interventions with delay or interruption of anticoagulation.
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Affiliation(s)
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Philip Connor
- Department of Paediatric Haematology/Oncology, Noah's Ark Children's Hospital for Wales, Cardiff, United Kingdom
| | - Paul Monagle
- Kids Cancer Centre, Sydney Children's Hospital Randwick, NSW, Department of Clinical Haematology, Royal Children's Hospital, Haematology Research Murdoch Children's Research Institute, Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
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Direct oral anticoagulants for use in paediatrics. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:207-214. [PMID: 35033222 DOI: 10.1016/s2352-4642(21)00343-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/28/2021] [Accepted: 10/28/2021] [Indexed: 12/12/2022]
Abstract
With the increasing incidence of thromboembolism in children and improvement in management for patients with medically complex diseases, expanded availability of safe and effective anticoagulant medications is needed. Traditionally, the most common anticoagulants used for the treatment or prevention of venous thromboembolism or embolic stroke in children were either unfractionated heparin or the low-molecular-weight heparins. These medications require either intravenous access or daily subcutaneous injections, in addition to multiple venepunctures to monitor drug concentrations. Direct oral anticoagulants provide an alternative, and potentially safer, choice for children, as they are available in oral formulations and do not require drug monitoring. With the approval of the direct factor Xa inhibitor, rivaroxaban (by the European Medicines Agency and Health Canada), and the direct thrombin inhibitor, dabigatran (by the European Medicines Agency and US Food and Drug Administration), the field of paediatric anticoagulation is changing. In this Review, we provide an overview of the four direct oral anticoagulants approved in adults for the treatment and prevention of thrombosis and the completed and ongoing paediatric trials.
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41
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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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Whitworth H, Raffini L. Practical Considerations for Use of Direct Oral Anticoagulants in Children. Front Pediatr 2022; 10:860369. [PMID: 35433559 PMCID: PMC9010784 DOI: 10.3389/fped.2022.860369] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Direct oral anticoagulants (DOACs) provide an attractive alternative for the management and prevention of thrombosis in pediatric patients. With multiple ongoing and published pediatric trials and recent regulatory approval of dabigatran and rivaroxaban, the landscape of pediatric anticoagulation is rapidly changing. However, as pediatricians gain experience with these drugs, it is important to be mindful of pediatric-specific considerations that may limit the use of DOACs in certain children and adolescents. While there is increasing adult data and experience, there is a paucity of real-world evidence to guide the use of these drugs in children who would not have met clinical trial inclusion criteria. In this mini review, we summarize pediatric specific data, areas for future research, and practical considerations for the use of DOACs in children and adolescents.
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Affiliation(s)
- Hilary Whitworth
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Leslie Raffini
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
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44
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Islabão AG, Trindade VC, da Mota LMH, Andrade DCO, Silva CA. Managing Antiphospholipid Syndrome in Children and Adolescents: Current and Future Prospects. Paediatr Drugs 2022; 24:13-27. [PMID: 34904182 PMCID: PMC8667978 DOI: 10.1007/s40272-021-00484-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 11/28/2022]
Abstract
Pediatric antiphospholipid syndrome (APS) is a rare acquired multisystem autoimmune thromboinflammatory condition characterized by thrombotic and non-thrombotic clinical manifestations. APS in children and adolescents typically presents with large-vessel thrombosis, thrombotic microangiopathy, and, rarely, obstetric morbidity. Non-thrombotic clinical manifestations are frequently seen in pediatric APS and may be present even before the vascular thrombotic events occur. We review insights into the pathogenesis of APS and discuss potential targets for therapy. The identification of multiple immunologic abnormalities in patients with APS reveals molecular targets for current or future treatment. Management strategies, especially for APS in adolescents, require screening for additional prothrombotic risk factors and consideration of counseling regarding contraceptive strategies, lifestyle recommendations, treatment adherence, and mental health issues associated with this autoimmune thrombophilia. The main goal of therapy in pediatric APS is the prevention of thrombosis. The management of acute thrombosis events in children and adolescents is the same as for primary APS, which involves isolated occurrences, and secondary APS, which is seen in association with another autoimmune disease, e.g., systemic lupus erythematosus. A pediatric hematologist should be consulted so other differential thrombophilic conditions can be eliminated. Therapy includes unfractionated heparin or low-molecular-weight heparin followed by vitamin K antagonists. Treatment of catastrophic APS involves triple therapy (anticoagulation, intravenous corticosteroid pulse therapy, and plasma exchange) and may include intravenous immunoglobulin for children and adolescents with this condition. New drugs such as eculizumab and sirolimus seem to be promising drugs for APS.
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Affiliation(s)
- Aline Garcia Islabão
- Pediatric Rheumatology Unit, Hospital da Criança de Brasília Jose Alencar, Brasília, DF Brazil ,Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade de Brasília, Brasília, DF Brazil
| | - Vitor Cavalcanti Trindade
- Faculdade de Medicina, Children and Adolescent Institute, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647-Cerqueira César, São Paulo, SP 05403-000 Brazil
| | - Licia Maria Henrique da Mota
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade de Brasília, Brasília, DF Brazil ,Rheumatology Unit, Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil
| | | | - Clovis Artur Silva
- Faculdade de Medicina, Children and Adolescent Institute, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647-Cerqueira César, São Paulo, SP, 05403-000, Brazil. .,Rheumatology Division, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.
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Male C, Monagle P, Albisetti M, Brandão LR, Young G. Direct Oral Anticoagulants: Overcoming the Challenges of Managing Venous Thromboembolism in Children. J Pediatr 2022; 240:14-23. [PMID: 34687696 DOI: 10.1016/j.jpeds.2021.09.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Christoph Male
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria.
| | - Paul Monagle
- Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia; Australia and Kids Cancer Centre, Sydney Children's Hospital, Sydney, Australia
| | - Manuela Albisetti
- Division of Hematology, University Children's Hospital of Zurich, Zurich, Switzerland
| | - Leonardo R Brandão
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Guy Young
- Children's Hospital Los Angeles, University of Southern California, Keck School of Medicine, Los Angeles, CA
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46
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Nepal G, Kharel S, Bhagat R, Ka Shing Y, Ariel Coghlan M, Poudyal P, Ojha R, Sunder Shrestha G. Safety and efficacy of Direct Oral Anticoagulants in cerebral venous thrombosis: A meta-analysis. Acta Neurol Scand 2022; 145:10-23. [PMID: 34287841 DOI: 10.1111/ane.13506] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/25/2021] [Accepted: 07/11/2021] [Indexed: 12/14/2022]
Abstract
Cerebral venous thrombosis (CVT) is caused by partial or complete occlusion of the major cerebral venous sinuses or the smaller feeding cortical veins which predispose to the risk of venous infarction and hemorrhage. Current guidelines recommend treating CVT with either low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) followed by an oral vitamin K antagonist (VKA) for 3-12 months. Direct oral anticoagulants (DOACs) have already established benefit over warfarin as a long-term treatment of symptomatic venous thromboembolic disorder like deep vein thrombosis (DVT), and pulmonary embolism (PE) given its equal efficacy and better safety profile. The benefit of DOACs over warfarin as a long-term anticoagulation for CVT has likewise been extensively studied, yet it has not been approved as first-line therapy in the current practice. We therefore performed a systematic review and meta-analysis of relevant studies to generate robust evidence regarding the safety and efficacy of DOACs in CVT. This meta-analysis demonstrates that the use of DOACs in CVT has similar efficacy and safety compared to VKAs with better recanalization rate.
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Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine Maharajgunj Medical CampusTribhuvan University Institute of Medicine Maharajgunj, Kathmandu Nepal
| | - Sanjeev Kharel
- Department of Internal Medicine Maharajgunj Medical CampusTribhuvan University Institute of Medicine Maharajgunj, Kathmandu Nepal
| | - Riwaj Bhagat
- Department of Neurology University of Louisville School of Medicine Louisville KY USA
| | - Yow Ka Shing
- Department of Internal Medicine National University Hospital Singapore Singapore
| | - Megan Ariel Coghlan
- Department of Neurology University of Louisville School of Medicine Louisville KY USA
| | - Prasanta Poudyal
- Department of Otorhinolaryngology Tribhuvan University Teaching Hospital Maharajgunj Kathmandu Nepal
| | - Rajeev Ojha
- Department of Neurology Tribhuvan University Teaching Hospital Maharajgunj Kathmandu Nepal
| | - Gentle Sunder Shrestha
- Department of Anesthesiology Tribhuvan University Teaching Hospital Maharajgunj Kathmandu Nepal
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Al-Ghafry M, Sharathkumar A. Direct oral anticoagulants in pediatric venous thromboembolism: Review of approved products rivaroxaban and dabigatran. Front Pediatr 2022; 10:1005098. [PMID: 36313874 PMCID: PMC9606656 DOI: 10.3389/fped.2022.1005098] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022] Open
Abstract
Venous thromboembolism is a major hospital acquired complication in the pediatric population over the last two-decades, with a 130% increase in the past decade. Direct oral anticoagulants (DOACs) are a newer class of anticoagulant medication for the treatment and prophylaxis of VTEs that provide the primary advantages of an oral route of administration without a requirement to adjust dosing to achieve a therapeutic level. It is anticipated that these medications will quickly replace parenteral anticoagulants and clinicians should familiarize themselves with DOACs. In this article, we provide an overview of the pharmacological properties of DOACs, with a specific focus on rivaroxaban and dabigatran, which have been approved for use in pediatric patients. Each drug's characteristics are discussed along with data from their respective clinical trials.
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Affiliation(s)
- Maha Al-Ghafry
- Division of Pediatric Hematology and Oncology, Royal Hospital, Muscat, Oman
| | - Anjali Sharathkumar
- Division of Pediatric Hematology and Oncology Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, United States
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48
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Samji N, Bhatt MD, Kulkarni K. Challenges in Management of VTE in Children With Cancer: Risk Factors and Treatment Options. Front Pediatr 2022; 10:855162. [PMID: 35463883 PMCID: PMC9021605 DOI: 10.3389/fped.2022.855162] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/11/2022] [Indexed: 01/19/2023] Open
Abstract
Venous thromboembolism (VTE) occurs in 2.1 to up to 50% of children with cancer and contributes to long term morbidity as well as early mortality in this population. Pediatric patients with malignancy are predisposed to VTE due to the prothrombotic nature of cancer and its associated coagulopathies as well as chemotherapeutic agents, use of central venous catheters, surgery, radiotherapy, and concomitant thrombophilia. Management of thrombosis in this population is challenging due to concomitant thrombocytopenia, associated bleeding risks, concurrent co-morbidities, and toxicities of therapy. The aim of this paper is to highlight clinically relevant issues and management dilemmas using clinical vignettes. We review the clinical significance of asymptomatic and symptomatic thrombosis, examine the various options for asparaginase-associated thrombosis, address the role and controversies of direct oral anticoagulants, and describe our approach to managing anticoagulation therapy in the context of chemotherapy-induced thrombocytopenia.
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Affiliation(s)
- Nasrin Samji
- Department of Pediatrics, Division of Hematology Oncology, McMaster University, Hamilton, ON, Canada
| | - Mihir D Bhatt
- Department of Pediatrics, Division of Hematology Oncology, McMaster University, Hamilton, ON, Canada
| | - Ketan Kulkarni
- Department of Pediatrics, Division of Hematology Oncology, Dalhousie University and Izaak Walton Killam (IWK) Health Centre, Halifax, NS, Canada
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Biss TT, Chalmers EA. Addendum to British Society for Haematology guideline on the investigation, management and prevention of venous thrombosis in children (Br. J. Haematol. 2011; 154: 196-207). Br J Haematol 2021; 194:996-998. [PMID: 34462907 DOI: 10.1111/bjh.17794] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Tina T Biss
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Affiliation(s)
- Allan H Ropper
- From the Department of Neurology, Brigham and Women's Hospital, Boston
| | - Joshua P Klein
- From the Department of Neurology, Brigham and Women's Hospital, Boston
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