Reducing the global burden of cerebral venous thrombosis: An international research agenda

BACKGROUND

Due to the rarity of cerebral venous thrombosis (CVT), performing high-quality scientific research in this field is challenging. Providing answers to unresolved research questions will improve prevention, diagnosis, and treatment, and ultimately translate to a better outcome of patients with CVT. We present an international research agenda, in which the most important research questions in the field of CVT are prioritized.

AIMS

This research agenda has three distinct goals: (1) to provide inspiration and focus to research on CVT for the coming years, (2) to reinforce international collaboration, and (3) to facilitate the acquisition of research funding.

SUMMARY OF REVIEW

This international research agenda is the result of a research summit organized by the International Cerebral Venous Thrombosis Consortium in Amsterdam, the Netherlands, in June 2023. The summit brought together 45 participants from 15 countries including clinical researchers from various disciplines, patients who previously suffered from CVT, and delegates from industry and non-profit funding organizations. The research agenda is categorized into six pre-specified themes: (1) epidemiology and clinical features, (2) life after CVT, (3) neuroimaging and diagnosis, (4) pathophysiology, (5) medical treatment, and (6) endovascular treatment. For each theme, we present two to four research questions, followed by a brief substantiation per question. The research questions were prioritized by the participants of the summit through consensus discussion.

CONCLUSIONS

This international research agenda provides an overview of the most burning research questions on CVT. Answering these questions will advance our understanding and management of CVT, which will ultimately lead to improved outcomes for CVT patients worldwide.

Direct oral anticoagulants for the treatment of cerebral venous thrombosis - a protocol of an international phase IV study

Introduction

Current guidelines recommend that patients with cerebral venous thrombosis (CVT) should be treated with vitamin K antagonists (VKAs) for 3-12 months. Direct oral anticoagulants (DOACs), however, are increasingly used in clinical practice. An exploratory randomized controlled trial including 120 patients with CVT suggested that the efficacy and safety profile of dabigatran (a DOAC) is similar to VKAs for the treatment of CVT, but large-scale prospective studies from a real-world setting are lacking.

Methods

DOAC-CVT is an international, prospective, observational cohort study comparing DOACs to VKAs for the prevention of recurrent venous thrombotic events after acute CVT. Patients are eligible if they are 18 years or older, have a radiologically confirmed CVT, and have started oral anticoagulant treatment (DOAC or VKA) within 30 days of CVT diagnosis. Patients with an absolute contra-indication for DOACs, such as pregnancy or severe renal insufficiency, are excluded from the study. We aim to recruit at least 500 patients within a three-year recruitment period. The primary endpoint is a composite of recurrent venous thrombosis and major bleeding at 6 months of follow-up. We will calculate an adjusted odds ratio for the primary endpoint using propensity score inverse probability treatment weighting.

Discussion

DOAC-CVT will provide real-world data on the comparative efficacy and safety of DOACs versus VKAs for the treatment of CVT.

Clinical trial registration

ClinicalTrials.gov, NCT04660747.

The nucleus accumbens beyond the anterior commissure: implications for psychosurgery

INTRODUCTION

The nucleus accumbens (Acc) is a basal forebrain structure integrated in the dopaminergic cerebral rewarding circuits and implicated in some neuropsychiatric disorders. It has become a target for deep brain stimulation for some of these disorders when refractory to medical treatment. However, it is controversial as to which target is the best and similar results have been achieved with the stimulation of neighboring structures such as the bed nucleus of the stria terminalis (BNST). Previous studies have established the stereotactic anatomy of the human Acc, but some difficulties remain concerning its precise posterior limit, which is assumed to be at the level of the anterior commissure (AC). It is our purpose to clarify the anatomy of this zone, given the importance of its exact identification in psychosurgery.

METHODS

A total of 16 Acc were collected by autopsy, fixed, dissected, embedded and cut in coronal 5-µm slices. The slices were stained with hematoxylin and eosin, marked with anti-D1 and anti-D2 antibodies and analyzed under a microscope.

RESULTS

The human Acc has the same cellular structure as the dorsal striatum, except in its posterior subcommissural part where voluminous neurons prevail, similar to and contiguous with the BNST.

CONCLUSIONS

The Acc is longer than previously described, with a sub- and postcommissural extension behind the AC, continuous with the BNST.

Three dimensional anatomy of the human nucleus accumbens

BACKGROUND

The Nucleus accumbens (Acc) is the main structure of the ventral striatum. It acts as a motor-limbic interface, being involved in emotional and psychomotor functions, frequently disturbed in neuropsychiatric disorders such as obsessive compulsive disorder and addiction. Most of the studies concerning the Acc were made in animals and those performed in humans are contradictory. Nevertheless, it has become a target for stereotactic deep brain stimulation for some of those diseases, when refractory to medical treatment. Previous studies performed by our group have established the localization, limits and dimensions of the human Acc and its stereotactic coordinates. Now it is our purpose to perform the Acc anatomical three-dimensional (3D) reconstruction in order to clarify its shape and topography and to render this nucleus a safer target for stereotactic procedures.

METHODS

Anatomical coronal slicing of ten Acc from human brains was performed, perpendicular to the anterior commissure-posterior commissure line and to the midline; then the Acc contours were traced and its dimensions and 3D stereotactic coordinates measured, on each slice. Finally a 3D computerized model was created.

RESULTS

The human Acc was identified as a distinct brain structure, with clear-cut limits on its posterior half. It lies parallel to the midline, descends caudally, and progresses from a globose to a flattened and dorsolateral concave shape. Its main expression is subcomissural.

CONCLUSION

This study defined more accurately the 3D anatomy of the human Acc, providing new tools for stereotactic procedures.