Hemi-spinal cord infarction due to vertebral artery dissection in congenital afibrinogenemia

Medical Management of a Mural Thrombus Inducing Repeated Ischemic Strokes in a Patient with Congenital Afibrinogenemia

OBJECTIVES

Congenital afibrinogenemia is an autosomal recessive inherited disorder that can cause thrombotic as well as hemorrhagic events. We describe a case of repeated mild ischemic strokes due to a mural thrombus in the carotid artery and our medical treatment.

CASE DESCRIPTION

A 49-year-old woman with congenital afibrinogenemia developed two minor ischemic strokes in two months. Clinical images revealed scattered fresh infarcts in the right middle cerebral artery region and mild cervical carotid artery stenosis. The risk for surgical treatment was considered to be extraordinarily high. The patient was treated with 100 mg/day of aspirin and 3 g fibrinogen infusion every two weeks. After the one-year course of medication, the mural thrombus gradually decreased, and there were no bleeding or ischemic stroke events.

CONCLUSION

This case report highlights the successful treatment of an ischemic stroke in a patient with a congenital afibrinogenemia with an antiplatelet agent and fibrinogen replacement. There are no guidelines for managing ischemic stroke in patients with congenital afibrinogenemia, and further studies are needed.

Sulcal artery syndrome: A Three-patient series and review of literature

OBJECTIVE

This study aims to describe the clinical characteristics of patients with sulcal artery syndrome, and between those with vertebral artery dissection against those without.

METHODS

We report three cases of sulcal artery syndrome without vertebral artery dissection, performed a systematic review and retrospective analysis of the characteristics of patients with sulcal artery syndrome in available literature, and compared the clinical features of those with vertebral artery dissection against those without.

RESULTS

We report 3 patients with sulcal artery syndrome, and analysed them with 17 other cases identified in literature between January 1990 till April 2020. The mean age was 47 years (range 10-80), with twice as many males as females. Pain at onset was a prominent feature (17/18, 94.4%). Preceding trauma occurred in less than half (7/18, 38.9%). Most had cervical cord infarctions (18/20, 90%), often over the high cervical cord (16/18, 88.9%). Good functional recovery (mRS 0-2) was observed in 86.7% (13/15). While vertebral artery dissection was the leading aetiology (11/20, 55.5%), about half of the cases were due to other causes. Cervical cord involvement was significantly associated with vertebral artery dissection (p = 0.026).

CONCLUSION

Sulcal artery syndrome should be suspected in patients with acute hemicord syndrome, especially in males with cervical cord involvement or pain at onset. High cervical cord involvement was strongly suggestive of underlying vertebral artery dissection. Additionally, DWI sequences are useful when evaluating acute myelopathies, and its inclusion in conventional MRI sequences is supported in prevailing literature.

Thromboembolism in patients with congenital afibrinogenaemia

Frequent arterial and venous thromboembolism in patients with congenital afibrinogenaemia (CA) is neither understood nor is a safe and effective treatment established. It was our objective to report on the clinical observations and laboratory data contributing to the understanding of the frequency, physiopathology, prognosis and treatment of CA. We observed the long-term clinical course and laboratory data in a cohort of four patients with CA and thromboembolic complications, and conducted a systematic review retrieving all available data. Four patients with CA developed recurrent and extensive arterial and venous thromboembolism (TE) from an age of 25–51 years. In two patients, a treatment strategy targeting at maintaining constantly measurable fibrinogen (Fbg) levels (≥0.5 g/l) either by regular Fbg replacement or by orthotopic liver transplantation resulted in long-term remissions. Radiological imaging documented resolved arterial thrombi after 6–12 months. In contrast, recurrent thromboembolic events were observed in two other patients with infrequent Fbg replacement. A systematic review of the literature revealed 48 reports of TE in patients with CA (median age at first event 31 years), and a favourable outcome in most patients with frequent application of Fbg, aimed at constantly measurable trough levels. Present data suggests that patients with CA are at high risk of arterial and venous thromboembolic events, probably caused by thrombin excess owing to lack of thrombin scavenging by Fbg/fibrin. Regular low-dose Fbg replacement might be a safe and effective treatment option in patients with CA and thromboembolic complications.

Note: Preliminary data of this report were presented as oral presentation at the XXV Congress of the International Society on Thrombosis and Haemostasis, June 20th to 25th, Toronto, Canada.

Supplementary Material to this article is available online at www.thrombosis-online.com.

Magnetic Resonance Imaging and Clinical Features in Acute and Subacute Myelopathies

Differential diagnosis of acute and subacute transverse myelopathy includes inflammatory, infectious, vascular, metabolic and paraneoplastic etiologies. Information on the diagnostic approach to transverse myelopathy with regard to daily clinical practice is provided. The differentiation between five lesion patterns on magnetic resonance imaging (MRI) in myelitis may be helpful: (1) longitudinal extensive transverse myelitis, (2) short segment ovoid or peripherally located, (3) "polio-like", (4) granulomatous and (5) segmental with rash. A correlation with these imaging features is supported if the clinical course and neurological symptoms are known. Although the mean interval from onset to nadir of symptoms in spinal cord infarction is 1 h, an overlap with a fulminant course of myelitis is possible, and impaired diffusion may also occur in acute inflammatory processes. As a result, laboratory testing, including aquaporin-4 antibodies and cerebrospinal fluid analysis, is crucial for the correct interpretation of imaging findings. Moreover, the discrimination of acute complete and acute partial transverse myelitis is advantageous in order to identify diverse entities, the latter often being a precursor to multiple sclerosis. Additional brain imaging is mandatory in suspected demyelinating, infectious, neoplastic and systemic autoimmune disease. A symmetrical lesion pattern restricted to individual tracts or dorsal columns indicates subacute combined degeneration of the spinal cord and, in addition to deficiency syndromes, a paraneoplastic etiology should be considered.

Spinal cord ischemia: aetiology, clinical syndromes and imaging features

INTRODUCTION

The purpose of this study was to analyse MR imaging features and lesion patterns as defined by compromised vascular territories, correlating them to different clinical syndromes and aetiological aspects.

METHODS

In a 19.8-year period, clinical records and magnetic resonance imaging (MRI) features of 55 consecutive patients suffering from spinal cord ischemia were evaluated.

RESULTS

Aetiologies of infarcts were arteriosclerosis of the aorta and vertebral arteries (23.6%), aortic surgery or interventional aneurysm repair (11%) and aortic and vertebral artery dissection (11%), and in 23.6%, aetiology remained unclear. Infarcts occurred in 38.2% at the cervical and thoracic level, respectively, and 49% of patients suffered from centromedullar syndrome caused by anterior spinal artery ischemia. MRI disclosed hyperintense pencil-like lesion pattern on T2WI in 98.2%, cord swelling in 40%, enhancement on post-contrast T1WI in 42.9% and always hyperintense signal on diffusion-weighted imaging (DWI) when acquired.

CONCLUSION

The most common clinical feature in spinal cord ischemia is a centromedullar syndrome, and in contrast to anterior spinal artery ischemia, infarcts in the posterior spinal artery territory are rare. The exclusively cervical location of the spinal sulcal artery syndrome seems to be a likely consequence of anterior spinal artery duplication which is observed preferentially here.

[Cervical cord infarction associated with unilateral vertebral artery dissection due to golf swing]

A-68-year-old man experienced nuchal pain and bilateral shoulder weakness that occurred suddenly after he performed a golf swing. He was conscious. His cranial nerves were normal, but bilateral deltoid and biceps muscle strengths weakened. Magnetic resonance image (MRI) showed no brain stem infarctions or cervical epidural hematoma. We tentatively diagnosed him with concussion of the spinal cord because of mild recovery of his bilateral upper limb weakness after several hours; he was later discharged. The next day, he suddenly developed serious tetraplegia and was admitted to the emergency department. His breathing was controlled by a respirator as he had expectoration difficulty and respiratory muscle paralysis. A lesion in the cervical cord became apparent on MRI; the right vertebral artery was not detected on magnetic resonance angiography. Cervical MRI showed the intimal flap and a lack of flow void in the right vertebral artery. These findings revealed a right vertebral artery dissection. Cervical cord infarction due to unilateral vertebral artery dissection is rarer than posterior cerebral infarction due to the same pathogenesis; however, some such cases have been reported. We consider the present case to be caused by cervical cord infarction associated with unilateral vertebral artery dissection resulting from golf swing.

Chronic subdural hematoma in a patient with congenital afibrinogenemia successfully treated with fibrinogen replacement

A 37-year-old woman with congenital afibrinogenemia presented with chronic subdural hematoma (CSDH) manifesting as severe headache, nausea, and somnolence after a minor head trauma. Brain computed tomography scans showed a right subdural hematoma associated with midline shift. Laboratory studies showed prolongation of prothrombin time, activated partial thromboplastin time, and undetectably low level of fibrinogen. Until the present episode, she had received plasma-derived fibrinogen concentrate around menstruation and pregnancy. She had also suffered from spinal cord infarction due to vertebral artery occlusion. Burr-hole evacuation and drainage of CSDH was successfully performed using fibrinogen concentrate. The development of CSDH with afibrinogenemia is very rare. Although the past repeated administrations of fibrinogen concentrate were suspected to generate CSDH, paradoxical thrombotic complications caused by upregulation of prothrombin activation, thrombin generation, and growth factors released from platelets might be related to the development of CSDH with congenital afibrinogenemia.

Cryoprecipitate: no longer the best therapeutic choice in congenital fibrinogen disorders?

Congenital abnormalities of fibrinogen are rare disorders classified as quantitative (afibrinogenemia and hypofibrinogenemia) or qualitative types (dysfibrinogenemia and hypodysfibrinogenemia). Fibrinogen is essential to haemostasis as the substrate for fibrin clot formation and also acts in primary haemostasis as a key ligand in platelet aggregation. Quantitative deficiency of fibrinogen can result in severe bleeding, or arterial and venous thromboembolism, and poor wound healing. Dysfibrinogenemia is characterized by functional abnormalities of fibrinogen, which may be asymptomatic (in 50% of cases), or cause bleeding (25%) or thrombosis (25%). Replacement of the deficient or abnormal fibrinogen with frozen plasma, cryoprecipitate, or fibrinogen concentrate has been found to be effective in practice in treating haemostatic complications of these disorders. Although cryoprecipitate is the most commonly used replacement material, pathogen-reduced fibrinogen concentrates have several advantages, most importantly a lower potential risk of viral transmission and standardized fibrinogen content allowing accurate dosing. They also avoid transfusing unwanted clotting factors, platelet microparticles and immunoglobulins, and can be administered rapidly without thawing. The use of fibrinogen concentrate to treat congenital fibrinogen disorders is strongly supported in principle and increasingly by practical experience and evidence.