1
|
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.
Collapse
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
| |
Collapse
|
2
|
Coutinho JM, van de Munckhof A, Aguiar de Sousa D, Poli S, Aaron S, Arauz A, Conforto AB, Krzywicka K, Hiltunen S, Lindgren E, Sánchez van Kammen M, Shu L, Bakchoul T, Belder R, van den Berg R, Boumans E, Cannegieter S, Cano-Nigenda V, Field TS, Fragata I, Heldner MR, Hernández-Pérez M, Klok FA, Leker RR, Lucas-Neto L, Molad J, Nguyen TN, Saaltink DJ, Saposnik G, Sharma P, Stam J, Thijs V, van der Vaart M, Werring DJ, Wong Ramos D, Yaghi S, Yeşilot N, Tatlisumak T, Putaala J, Jood K, Arnold M, Ferro JM. Reducing the global burden of cerebral venous thrombosis: An international research agenda. Int J Stroke 2024:17474930241242266. [PMID: 38494462 DOI: 10.1177/17474930241242266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
BACKGROUND Due to the rarity of cerebral venous thrombosis (CVT), performing high-quality scientific research in this field is challenging. Providing answers to unresolved research questions will improve prevention, diagnosis, and treatment, and ultimately translate to a better outcome of patients with CVT. We present an international research agenda, in which the most important research questions in the field of CVT are prioritized. AIMS This research agenda has three distinct goals: (1) to provide inspiration and focus to research on CVT for the coming years, (2) to reinforce international collaboration, and (3) to facilitate the acquisition of research funding. SUMMARY OF REVIEW This international research agenda is the result of a research summit organized by the International Cerebral Venous Thrombosis Consortium in Amsterdam, the Netherlands, in June 2023. The summit brought together 45 participants from 15 countries including clinical researchers from various disciplines, patients who previously suffered from CVT, and delegates from industry and non-profit funding organizations. The research agenda is categorized into six pre-specified themes: (1) epidemiology and clinical features, (2) life after CVT, (3) neuroimaging and diagnosis, (4) pathophysiology, (5) medical treatment, and (6) endovascular treatment. For each theme, we present two to four research questions, followed by a brief substantiation per question. The research questions were prioritized by the participants of the summit through consensus discussion. CONCLUSIONS This international research agenda provides an overview of the most burning research questions on CVT. Answering these questions will advance our understanding and management of CVT, which will ultimately lead to improved outcomes for CVT patients worldwide.
Collapse
Affiliation(s)
- Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Diana Aguiar de Sousa
- Stroke Center, Centro Hospitalar Universitário Lisboa Central, Institute of Anatomy, Faculdade de Medicina, Universidade de Lisboa, and L Lopes Lab, Instituto de Medicina Molecular JLA, Lisbon, Portugal
| | - Sven Poli
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | | | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Adriana B Conforto
- LIM-44, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Sini Hiltunen
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Liqi Shu
- Brown University, Providence, RI, USA
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
| | - Rosalie Belder
- Netherlands Thrombosis Foundation, Voorschoten, The Netherlands
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | | | - Suzanne Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vanessa Cano-Nigenda
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Isabel Fragata
- Stroke Center, Centro Hospitalar Universitário Lisboa Central, Institute of Anatomy, Faculdade de Medicina, Universidade de Lisboa, and L Lopes Lab, Instituto de Medicina Molecular JLA, Lisbon, Portugal
- NOVA Medical School, Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Mirjam R Heldner
- Inselspital Bern, University Hospital and University of Bern, Bern, Switzerland
| | | | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Ronen R Leker
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Lia Lucas-Neto
- North Lisbon University Hospital Center and Lisbon Medical School, Lisbon, Portugal
| | | | | | | | - Gustavo Saposnik
- Stroke Outcomes & Decision Neuroscience Research Unit, University of Toronto, Toronto, ON, Canada
| | - Pankaj Sharma
- Royal Holloway University of London, London, United Kingdom
| | - Jan Stam
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | | | - David J Werring
- UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Diana Wong Ramos
- Portugal AVC-União de Sobreviventes, Familiares e Amigos, Portugal
| | | | - Nilüfer Yeşilot
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Jukka Putaala
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Marcel Arnold
- Inselspital Bern, University Hospital and University of Bern, Bern, Switzerland
| | - José M Ferro
- Hospital da Luz, University of Lisbon, Lisbon, Portugal
| |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Gordon H, Burisch J, Ellul P, Karmiris K, Katsanos K, Allocca M, Bamias G, Barreiro-de Acosta M, Braithwaite T, Greuter T, Harwood C, Juillerat P, Lobaton T, Müller-Ladner U, Noor N, Pellino G, Savarino E, Schramm C, Soriano A, Michael Stein J, Uzzan M, van Rheenen PF, Vavricka SR, Vecchi M, Zuily S, Kucharzik T. ECCO Guidelines on Extraintestinal Manifestations in Inflammatory Bowel Disease. J Crohns Colitis 2024; 18:1-37. [PMID: 37351850 DOI: 10.1093/ecco-jcc/jjad108] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, London, Centre for Immunobiology, Blizard Institute, Faculty of Medicine, Barts & The London Medical School, Queen Mary University of London, UK
| | - Johan Burisch
- Gastrounit, medical division, Hvidovre Hospital, University of Copenhagen, Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, Division of Internal Medicine, University and Medical School of Ioannina, Ioannina, Greece
| | - Mariangela Allocca
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Giorgos Bamias
- GI Unit, 3rd Academic Department of Internal Medicine, National and Kapodistrian University of Athens, Sotiria Hospital, Athens, Greece
| | - Manuel Barreiro-de Acosta
- University Hospital Santiago De Compostela CHUS, Department of Gastroenterology - IBD Unit, Santiago De Compostela, Spain
| | - Tasanee Braithwaite
- School of Immunology and Microbiology, King's College London, The Medical Eye Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Thomas Greuter
- Division of Gastroenterology and Hepatology, GZO - Zurich Regional Health Center, Wetzikon, Division of Gastroenterology and Hepatology, University Hospital Lausanne - CHUV, Lausanne, Switzerland; Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Catherine Harwood
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Department of Dermatology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Pascal Juillerat
- Gastroenterology, Clinic for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland; Crohn and Colitis Center, Gastro-entérologie Beaulieu SA, Lausanne, Switzerland
| | - Triana Lobaton
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent; Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Campus Kerckhoff, Justus Liebig University Giessen, Bad Nauheim, Germany
| | - Nurulamin Noor
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gianluca Pellino
- Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain; Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Christoph Schramm
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Hamburg Center for Translational Immunology (HCTI), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandra Soriano
- Gastroenterology Division and IBD Center, Internal Medicine Department, Azienda Unità Sanitaria Locale - IRCCS, 42122 Reggio Emilia, Italy
| | - Jürgen Michael Stein
- Interdisciplinary Crohn Colitis Centre Rhein-Main, Frankfurt/Main, Department of Gastroenterology and Clinical Nutrition, DGD Clinics Sachsenhausen, Frankfurt/Main, Germany
| | - Mathieu Uzzan
- Department of Gastroenterology, Hôpital Henri Mondor, APHP, Créteil, France
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Stephan R Vavricka
- Department of Gastroenterology and Hepatology, University Hospital, Zurich, Switzerland
| | - Maurizio Vecchi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Stephane Zuily
- Vascular Medicine Division and French Referral Center for Rare Auto-Immune Diseases, Université de Lorraine, INSERM, DCAC and CHRU-Nancy, Nancy, France
| | - Torsten Kucharzik
- Department of Gastroenterology, Lüneburg Hospital, University of Münster, Lüneburg, Germany
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Aslan T, Oztura I. A rare cerebral venous thrombosis under NOAC: thrombosis of the vein of Galen. Acta Neurol Belg 2023; 123:2427-2429. [PMID: 37016267 DOI: 10.1007/s13760-023-02258-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 03/25/2023] [Indexed: 04/06/2023]
Affiliation(s)
- Taha Aslan
- Department of Neurology, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey.
| | - Ibrahim Oztura
- Department of Neurology, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| |
Collapse
|
10
|
Zhou H, Wu M, Yu S, Xia H, Yu W, Huang K, Chen Y. Comparison of the efficacy and safety between rivaroxaban and dabigatran in the treatment of acute portal vein thrombosis in cirrhosis. BMC Gastroenterol 2023; 23:329. [PMID: 37749527 PMCID: PMC10521568 DOI: 10.1186/s12876-023-02960-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/15/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND New oral anticoagulants (NOACs) have been becoming prevalent in recent years and are increasingly used in the treatment of port vein thrombosis. The difference of the efficacy and safety between rivaroxaban and dabigatran remains unclear in the treatment of cirrhotic patients with acute portal vein thrombosis (PVT). METHODS This retrospective study included all consecutive cirrhotic patients with acute portal vein thrombosis in our institute from January 2020 to December 2021. The patients received oral anticoagulation with rivaroxaban or dabigatran. The demographic, clinical, and imaging data of patients were collected. The diagnosis of acute PVT was confirmed by imaging examinations. The severity of liver cirrhosis was assessed using Child-Pugh score and Model for End-Stage Liver Disease (MELD) score. Outcomes included recanalization (complete, partial, and persistent occlusion), liver function, bleedings, and survival. The log-rank test was used to compare Kaplan-Meier distributions of time-to-event outcomes. The Cox proportional hazards model was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS A total of 94 patients were included, 52 patients (55%) received rivaroxaban and 42 (45%) with dabigatran. The complete and partial recanalization of PVT was observed in 41 patients. There was no significant difference in complete recanalization, partial recanalization, and persistent occlusion between the two groups. With multivariate analysis, D-dimer (HR 1.165, 95% CI 1.036-1.311, p = 0.011) was independent predictors of complete recanalization. The Child-Pugh score (p = 0.001) was significantly improved in both two groups after anticoagulation, respectively. However, there was no difference between the two groups. The probability of survival was 94%, 95% in the rivaroxaban and dabigatran groups (log-rank p = 0.830). Major bleedings were reported in 3 patients (6%) in rivaroxaban group and 1 patient (2%) in dabigatran group (p = 0.646). Six patients (12%) in rivaroxaban group experienced minor bleeding, and five (12%) from dabigatran group (p = 0.691). CONCLUSIONS The efficacy and safety were comparable between rivaroxaban and dabigatran in the treatment of cirrhotic patients with acute portal vein thrombosis. And D-dimer can contribute to the prediction of PVT recanalization in cirrhotic patients.
Collapse
Affiliation(s)
- Haonan Zhou
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| | - Mingdong Wu
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| | - Shixiong Yu
- Department of General Surgery, The First Affiliated Hospital of Chongqing Medical and Pharmaceutical College, Chongqing, 400060 People’s Republic of China
| | - Han Xia
- Department of Cardiothoracic Surgery, Second Clinical Hospital, Army Medical University, Chongqing, 400000 People’s Republic of China
| | - Wu Yu
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| | - Kai Huang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| | - Yikuan Chen
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| |
Collapse
|
11
|
van de Munckhof A, Sánchez van Kammen M, Krzywicka K, Aaron S, Aguiar de Sousa D, Antochi F, Arauz A, Barboza MA, Conforto AB, Dentali F, Galdames Contreras D, Ji X, Jood K, Heldner MR, Hernández-Pérez M, Kam W, Kleinig TJ, Kristoffersen ES, Leker RR, Lemmens R, Poli S, Yeşilot N, Wasay M, Wu TY, Arnold M, Lucas-Neto L, Middeldorp S, Putaala J, Tatlisumak T, Ferro JM, Coutinho JM. Direct oral anticoagulants for the treatment of cerebral venous thrombosis - a protocol of an international phase IV study. Front Neurol 2023; 14:1251581. [PMID: 37780701 PMCID: PMC10539579 DOI: 10.3389/fneur.2023.1251581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction Current guidelines recommend that patients with cerebral venous thrombosis (CVT) should be treated with vitamin K antagonists (VKAs) for 3-12 months. Direct oral anticoagulants (DOACs), however, are increasingly used in clinical practice. An exploratory randomized controlled trial including 120 patients with CVT suggested that the efficacy and safety profile of dabigatran (a DOAC) is similar to VKAs for the treatment of CVT, but large-scale prospective studies from a real-world setting are lacking. Methods DOAC-CVT is an international, prospective, observational cohort study comparing DOACs to VKAs for the prevention of recurrent venous thrombotic events after acute CVT. Patients are eligible if they are 18 years or older, have a radiologically confirmed CVT, and have started oral anticoagulant treatment (DOAC or VKA) within 30 days of CVT diagnosis. Patients with an absolute contra-indication for DOACs, such as pregnancy or severe renal insufficiency, are excluded from the study. We aim to recruit at least 500 patients within a three-year recruitment period. The primary endpoint is a composite of recurrent venous thrombosis and major bleeding at 6 months of follow-up. We will calculate an adjusted odds ratio for the primary endpoint using propensity score inverse probability treatment weighting. Discussion DOAC-CVT will provide real-world data on the comparative efficacy and safety of DOACs versus VKAs for the treatment of CVT. Clinical trial registration ClinicalTrials.gov, NCT04660747.
Collapse
Affiliation(s)
- Anita van de Munckhof
- Department of Neurology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Sanjith Aaron
- Department of Neurology, Christian Medical College, Vellore, India
| | - Diana Aguiar de Sousa
- Department of Neurology, Stroke Center, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Florina Antochi
- Department of Neurology, Spitalul Universitar de Urgenţă Bucureşti, Bucharest, Romania
| | - Antonio Arauz
- Department of Neurology, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Miguel A. Barboza
- Department of Neurology, Rafael Angel Calderon Guardia Hospital, San José, Costa Rica
| | - Adriana B. Conforto
- Department of Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Xunming Ji
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Mirjam R. Heldner
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | | | - Wayneho Kam
- Department of Neurology, Duke University Hospital, Durham, NC, United States
| | - Timothy J. Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | - Ronen R. Leker
- Department of Neurology, Hadassah – Hebrew University Medical Center, Jerusalem, Israel
| | | | - Sven Poli
- Department of Neurology, Tübingen University Hospital, Tübingen, Germany
| | - Nilüfer Yeşilot
- Department of Neurology, Istanbul Tip Fakültesi, Istanbul, Turkey
| | - Mohammad Wasay
- Department of Neurology, Aga Khan University, Karachi, Pakistan
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Lia Lucas-Neto
- Department of Neuroradiology, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - José M. Ferro
- Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Jonathan M. Coutinho
- Department of Neurology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
12
|
Piano M, Romi A, Cervo A, Gatti A, Macera A, Pero G, Motto C, Agostoni EC, Lozupone E. Endovascular Treatment of Cerebral Vein Thrombosis: Safety and Effectiveness in the Thrombectomy Era. Diagnostics (Basel) 2023; 13:2248. [PMID: 37443641 DOI: 10.3390/diagnostics13132248] [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: 06/11/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Cerebral venous thrombosis (CVT) is a rare cause of stroke that tends to affect young people. Endovascular treatment (EVT) has not yet shown to be beneficial in CVT and is therefore actually only indicated as rescue therapy in severe and refractory cases for medical treatment. Clinical, neuroimaging, procedural and follow-up data were evaluated in order to define the safety and efficacy of EVT in the management of CVT between January 2016 and December 2022. Safety was assessed on the basis of recording adverse events. Functional outcomes (NIHSS, mRS) and neuroimaging were recorded at onset, at discharge and at a 6-month follow-up. Efficacy was assessed evaluating the recanalization rate at the end of the procedure. Twenty-one patients (17 female, 4 male, range 16-84 years) with CVT underwent EVT. Overall morbidity and mortality were both at 4.7%. Median NIHSS at the onset and at the discharge were, respectively, 10 and 2. Successful recanalization was achieved in 21/23 procedures (91.3%). Imaging follow-up (FUP) showed stable recanalization in all but one patient with successful recanalization. In 18/21 patients, a good clinical independence (mRS 0-2) was recorded at 6 months. Our study adds evidence on the safety and efficacy of endovascular techniques in the treatment of CVT.
Collapse
Affiliation(s)
- Mariangela Piano
- Department of Neuroradiology, Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore, 3, 20162 Milano, Italy
| | - Andrea Romi
- Neuroradiology Unit, IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Amedeo Cervo
- Department of Neuroradiology, Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore, 3, 20162 Milano, Italy
| | - Antonella Gatti
- Neurology and Stroke Unit, Department of Neuroscience, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milano, Italy
| | - Antonio Macera
- Department of Neuroradiology, Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore, 3, 20162 Milano, Italy
| | - Guglielmo Pero
- Department of Neuroradiology, Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore, 3, 20162 Milano, Italy
| | - Cristina Motto
- Neurology and Stroke Unit, Department of Neuroscience, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milano, Italy
| | - Elio Clemente Agostoni
- Neurology and Stroke Unit, Department of Neuroscience, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milano, Italy
| | - Emilio Lozupone
- Department of Neuroradiology, Vito-Fazzi Hospital, 73100 Lecce, Italy
| |
Collapse
|
13
|
Galeano-Valle F, Oblitas CM, González-San-Narciso C, Esteban-San-Narciso B, Lafuente-Gómez G, Demelo-Rodríguez P. Cerebral venous thrombosis in adults: a case series of 35 patients from a tertiary hospital. Rev Clin Esp 2023:S2254-8874(23)00075-9. [PMID: 37343816 DOI: 10.1016/j.rceng.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
OBJECTIVE To describe the baseline characteristics, clinical presentation, imaging tests and outcomes and identify potential prognostic factors in a cohort of patients diagnosed with cerebral venous thrombosis (CVT). PATIENTS AND METHODS Retrospective, single-center, observational study that included adult patients diagnosed with CVT from January 2016 to December 2020. The variables were reviewed through electronic medical records. RESULTS A total of 35 patients were included and the median age at diagnosis was 50.3 (+/- 17.8) years, the majority being women (74.4%). Almost 95% of the patients presented at least one risk factor for the development of CVT. Heparins were used for the acute phase in 97.1%; among them, 75% were low molecular weight heparins. The compound event (death, intensive care unit admission, National Institute of Health Stroke Scale at discharge >3, CVT recurrence, major bleeding, or the presence of complications) within the first two weeks occurred in 28.6% (10 patients). During the mean follow-up of 3.3 years, 14.3% died (among them, only one patient´s death was caused by CVT), one patient had major bleeding and no patient presented recurrence of CVT. CONCLUSIONS In our cohort, CVT affected more frequently young women with at least one risk factor for the development of CVT. The presence of edema on CT and corticosteroid treatment were associated with poor short-term prognosis. A good long-term prognosis was observed in terms of mortality, recurrence, and bleeding.
Collapse
Affiliation(s)
- Francisco Galeano-Valle
- Unidad de Enfermedad Tromboembólica Venosa, Medicina Interna, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Crhistian-Mario Oblitas
- Unidad de Enfermedad Tromboembólica Venosa, Medicina Interna, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain.
| | - Candela González-San-Narciso
- Unidad de Enfermedad Tromboembólica Venosa, Medicina Interna, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Gemma Lafuente-Gómez
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Pablo Demelo-Rodríguez
- Unidad de Enfermedad Tromboembólica Venosa, Medicina Interna, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| |
Collapse
|
14
|
Frol S, Šabovič M, Oblak JP. Apixaban for the Treatment of Cerebral Venous Sinus Thrombosis: A Single-Centre Experience and Systematic Review of the Literature. CNS Drugs 2023; 37:133-141. [PMID: 36646983 DOI: 10.1007/s40263-022-00981-7] [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] [Accepted: 12/05/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND OBJECTIVE Cerebral venous thrombosis (CVT) is a rare disease, and data regarding direct oral anticoagulant therapy are insufficient. Apixaban could have a safer profile than other direct oral anticoagulants. We present our case series of patients with CVT treated with apixaban and a systematic review of published real-world cases. METHODS We described our series of patients with CVT treated with apixaban and searched PubMed for similar published cases with reported complete outcome data: recanalisation rate, recurrent CVT, modified Rankin score, intracranial haemorrhage, other bleedings and mortality. RESULTS Four male patients (average age 43.5 years) with idiopathic CVT, who presented with a headache and/or seizure without neurological deficits/symptoms or cerebral infarcts/haemorrhage were treated with apixaban 5 mg twice daily for an average 28 months (18-46 months) and followed for on average 2.8 years. In two patients, a partial/complete recanalisation was achieved, there was no recurrent CVT, all patients achieved a modified Rankin score of 0, none experienced an intracranial haemorrhage, other bleedings or died. One patient, in whom anti-phospholipid syndrome was later diagnosed, had a recurrence of CVT after stopping apixaban. Our systematic review identified only 15 eligible patients (average age 39 years, 60% female). Partial/complete recanalisation was achieved in 74% of cases, there was no recurrent CVT, 95% achieved a modified Rankin score of ≤ 2, none experienced an intracranial haemorrhage, other bleedings or died. CONCLUSIONS Our cases and the review of similar published cases, albeit obtained on a smaller scale, suggest that apixaban may be a safe and effective therapy for CVT. This assumption should be tested in a large randomised study.
Collapse
Affiliation(s)
- Senta Frol
- Department of Vascular Neurology, University Clinical Centre Ljubljana, Ljubljana, Slovenia.
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
| | - Mišo Šabovič
- Department of Vascular Disorders, University Clinical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Janja Pretnar Oblak
- Department of Vascular Neurology, University Clinical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| |
Collapse
|
15
|
Pleșa FC, Jijie A, Toma GS, Ranetti AE, Manole AM, Rotaru R, Caloianu I, Anghel D, Dulămea OA. Challenges in Cerebral Venous Thrombosis Management-Case Reports and Short Literature Review. Life (Basel) 2023; 13:life13020334. [PMID: 36836691 PMCID: PMC9964720 DOI: 10.3390/life13020334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/07/2023] [Accepted: 01/23/2023] [Indexed: 01/28/2023] Open
Abstract
Cerebral venous thrombosis (CVT) is a rare type of stroke, with a complex clinical presentation that can make it a diagnostic challenge for the swift initiation of anticoagulation. When a hemorrhagic transformation is added, therapeutic management becomes even more complex. We describe a series of four cases, aged between 23 and 37 years old, with cerebral venous thrombosis. They were admitted to our clinic between 2014 and 2022. All cases presented significant challenges in either diagnostic, therapeutic or etiologic evaluation, at different stages of the disease. Late complications such as epilepsy or depression and other behavioral disorders represent long-term sequelae for the patient. Therefore, through its late complications, CVT is not only an acute disease but a chronic disorder with long-term follow-up requirements. The first case of the series is of a postpartum woman with focal neurological deficit caused by CVT with hemorrhagic transformation that presented multiple thrombotic complications and severe depression. The second case is of a man with extensive cerebral thrombosis who developed bilateral papillary edema under therapeutic anticoagulation treatment. The third case is of a woman with bilateral cavernous sinus thrombosis who later developed depressive disorder and focal seizures. The fourth case is of a pregnant woman in the first trimester presenting with a steep decline in consciousness level secondary to deep cerebral vein thrombosis requiring intensive care and subsequently developing a memory disorder. For a long period of time, due to being underdiagnosed, few things were known about CVT. Nowadays, we have all the tools to diagnose, treat, and follow up cases of CVT.
Collapse
Affiliation(s)
- Florentina Cristina Pleșa
- Department of Neurology, “Dr. Carol Davila” Central Military Emergency University Hospital, 134 Calea Plevnei, 010242 Bucharest, Romania
- Department of Preclinical Disciplines, “Titu Maiorescu” University, 031593 Bucharest, Romania
| | - Alina Jijie
- Department of Neurology, “Dr. Carol Davila” Central Military Emergency University Hospital, 134 Calea Plevnei, 010242 Bucharest, Romania
| | - Gabriela Simona Toma
- Department of Radiology, “Dr. Carol Davila” Central Military Emergency University Hospital, 010242 Bucharest, Romania
| | - Aurelian Emilian Ranetti
- Department of Neurology, “Dr. Carol Davila” Central Military Emergency University Hospital, 134 Calea Plevnei, 010242 Bucharest, Romania
- Department of Endocrinology, “Dr. Carol Davila” Central Military Emergency University Hospital, 010242 Bucharest, Romania
- Correspondence:
| | - Aida Mihaela Manole
- Department of Neurology, “Dr. Carol Davila” Central Military Emergency University Hospital, 134 Calea Plevnei, 010242 Bucharest, Romania
| | - Ruxandra Rotaru
- Department of Neurology, “Dr. Carol Davila” Central Military Emergency University Hospital, 134 Calea Plevnei, 010242 Bucharest, Romania
| | - Ionuț Caloianu
- Department of Neurology, “Dr. Carol Davila” Central Military Emergency University Hospital, 134 Calea Plevnei, 010242 Bucharest, Romania
| | - Daniela Anghel
- Department of Medico-Surgical and Prophylactic Disciplines, Faculty of Medicine, “Titu Maiorescu” University, 031593 Bucharest, Romania
- Department of Internal Medicine, Central Military Emergency University Hospital, 010242 Bucharest, Romania
| | - Octaviana Adriana Dulămea
- Neurology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Neurology Department, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| |
Collapse
|
16
|
Capecchi M, Abbattista M, De Simone P, Artoni A, Gianniello F, Bucciarelli P, Paolucci A, Martinelli I. Direct oral anticoagulants for the treatment of cerebral vein thrombosis. Thromb Res 2022; 220:153-155. [DOI: 10.1016/j.thromres.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/30/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
|
17
|
Nepal G, Kharel S, Bhagat R, Coghlan MA, Yadav JK, Goeschl S, Lamichhane R, Phuyal S, Ojha R, Shrestha GS. Safety and efficacy of endovascular thrombectomy in patients with severe cerebral venous thrombosis: A meta-analysis. J Cent Nerv Syst Dis 2022; 14:11795735221131736. [PMID: 36204279 PMCID: PMC9530583 DOI: 10.1177/11795735221131736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 09/08/2022] [Indexed: 11/06/2022] Open
Abstract
Background Cerebral venous thrombosis (CVT) is a rare thrombotic condition which is traditionally
treated with anti-coagulation therapy. Subsets of patients with severe CVT have been
treated with endovascular thrombectomy (EVT). Despite the high estimated mortality
associated with severe CVT, there has been only one randomized control trial done
regarding safety and efficacy of EVT in severe CVT compared to standard medical
management. Evidence in this area is lacking. Objective The aim of this systematic review is to analyze all existing literature and generate
robust information regarding the role of EVT in the management of patients with severe
CVT. Methods This systematic review and meta-analysis followed PRISMA guideline. PubMed, Embase,
Google Scholar, and CNKI were searched for eligible studies from 2007 to 2021. Safety
and efficacy of EVT were evaluated by meta-analyzing recanalization status, the good
functional outcome at follow-up, recurrent CVT, new hematoma. A pooled proportion with a
95% confidence interval was derived from a meta-analysis of various outcomes (CI). Results A total of 33 studies comprising 610 patients treated with EVT were included for
analysis which comprised one randomized control trial, one prospective study and 31
retrospective studies. Based on pooled data, 85% of patients had good functional
outcome, 62% had complete recanalization, 5% had all-cause mortality, and 3% had
catheter related complications. The efficacy outcomes in this analysis had a significant
heterogeneity and a subgroup analysis was also done to explain these findings. The
minimum time of follow up was 3 months and varied EVT techniques were used across the
studies. Conclusion This meta-analysis suggests EVT may be safe and efficacious in treating patients with
severe CVT. Registration Our protocol was registered with PROSPERO: International prospective register of
systematic reviews with the registration number CRD42021254760.
Collapse
Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine,
Maharajgunj Medical Campus, Tribhuvan University Institute of
Medicine, Maharajgunj, Nepal
| | - Sanjeev Kharel
- Department of Internal Medicine,
Maharajgunj Medical Campus, Tribhuvan University Institute of
Medicine, Maharajgunj, Nepal
| | - Riwaj Bhagat
- Department of Neurology, Boston University Medical Center, Boston, MA, USA
| | - Megan A Coghlan
- Department of Neurology, University of Louisville School of
Medicine, Louisville, KY, USA
| | - Jayant K Yadav
- Department of Internal Medicine,
Maharajgunj Medical Campus, Tribhuvan University Institute of
Medicine, Maharajgunj, Nepal
| | - Stella Goeschl
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Rajan Lamichhane
- Department of Internal Medicine,
Maharajgunj Medical Campus, Tribhuvan University Institute of
Medicine, Maharajgunj, Nepal
| | - Subash Phuyal
- Department of Neuroimaging and
Interventional Neuroradiology, Upendra Devkota Memorial National Institute of
Neurological and Allied Sciences, Bansbari, Nepal
| | - Rajeev Ojha
- Department of Neurology, Tribhuvan University Teaching
Hospital, Maharajgunj, Nepal
| | - Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching
Hospital, Maharajgunj, Nepal,Gentle S Shrestha, Department of Critical Care
Medicine, Tribhuvan University Teaching Hospital, Maharajgunj 44600, Kathmandu, Nepal.
| |
Collapse
|
18
|
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.
Collapse
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.
| |
Collapse
|
19
|
Yaghi S, Saldanha IJ, Misquith C, Zaidat B, Shah A, Joudi K, Persaud B, Abdul Khalek F, Shu L, de Havenon A, Mistry EA, Bakradze E, Goldstein ED, Reagan J, Theodorou A, Palaiodimou L, Furie K, Field TS, Tsivgoulis G, Mac Grory B. Direct Oral Anticoagulants Versus Vitamin K Antagonists in Cerebral Venous Thrombosis: A Systematic Review and Meta-Analysis. Stroke 2022; 53:3014-3024. [PMID: 35938419 DOI: 10.1161/strokeaha.122.039579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND High level evidence for direct oral anticoagulants (DOACs) in patients with cerebral venous thrombosis is lacking. We performed a systematic review and meta-analysis to assess the efficacy and safety of DOACs versus vitamin K antagonists in patients with cerebral venous thrombosis. METHODS This systematic review was registered in PROSPERO (CRD42021228800). We searched MEDLINE (via Ovid), EMBASE, CINAHL, and the Web of Science Core Collection between January 1, 2007 and Feb 22, 2022. Search terms included a combination of keywords and controlled vocabulary terms for cerebral venous thrombosis, vitamin K antagonists/warfarin, and DOACs. We included both randomized and nonrandomized studies that compared vitamin K antagonists and DOACs in 5 or more patients with cerebral venous thrombosis. Where studies were sufficiently similar, we performed meta-analyses for efficacy (recurrent venous thromboembolism and complete recanalization) and safety (major hemorrhage) outcomes, using relative risks (RRs). RESULTS Out of 10 665 records identified, we screened 254 as potentially eligible. Nineteen studies (16 observational studies [n=1735] and 3 randomized controlled trials [n=215]) met the inclusion criteria. All 3 randomized controlled trials had some concerns, and all 16 observational studies had at least moderate risk of bias. When compared with vitamin K antagonist treatment, DOAC had comparable risks of recurrent venous thromboembolism (relative risk [RR], 0.85 [95% CI, 0.52-1.37], I2=0%), major hemorrhage (RR, 0.70 [95% CI, 0.40-1.21], I2=0%), intracranial hemorrhage (RR, 0.58 [95% CI, 0.30-1.12]; I2=0%), death (RR, 1.14 [95% CI, 0.54-2.43], I2=1%), and complete venous recanalization (RR, 0.98 [95% CI, 0.87-1.11]; I2=0%). CONCLUSIONS This systematic review and meta-analysis suggest that in patients with cerebral venous thrombosis, DOACs, and warfarin may have comparable efficacy and safety. Given the limitations of the studies included (low number of randomized controlled trials, modest total sample size, rare outcome events), our findings should be interpreted with caution pending confirmation by ongoing randomized controlled trials and large, prospective, observational studies.
Collapse
Affiliation(s)
- Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI (S.Y., B.Z., A.S., K.J., B.P., L.S., E.D.G., K.F.)
| | - Ian J Saldanha
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, & Practice, and Department of Epidemiology, Brown University School of Public Health, Providence, RI (I.J.S.)
| | - Chelsea Misquith
- Brown University Library, Brown University, Providence, RI (C.M.)
| | - Bashar Zaidat
- Department of Neurology, Brown University, Providence, RI (S.Y., B.Z., A.S., K.J., B.P., L.S., E.D.G., K.F.)
| | - Asghar Shah
- Department of Neurology, Brown University, Providence, RI (S.Y., B.Z., A.S., K.J., B.P., L.S., E.D.G., K.F.)
| | - Kareem Joudi
- Department of Neurology, Brown University, Providence, RI (S.Y., B.Z., A.S., K.J., B.P., L.S., E.D.G., K.F.)
| | - Bianca Persaud
- Department of Neurology, Brown University, Providence, RI (S.Y., B.Z., A.S., K.J., B.P., L.S., E.D.G., K.F.)
| | - Feras Abdul Khalek
- Department of Hematology and Oncology, Luminis Health, Annapolis, MD (F.A.K.)
| | - Liqi Shu
- Department of Neurology, Brown University, Providence, RI (S.Y., B.Z., A.S., K.J., B.P., L.S., E.D.G., K.F.)
| | - Adam de Havenon
- Department of Neurology, Yale University, New Haven, CT (A.d.H.)
| | - Eva A Mistry
- University of Cincinnati, Department of Neurology and Rehabilitation Medicine (E.A.M.)
| | | | - Eric D Goldstein
- Department of Neurology, Brown University, Providence, RI (S.Y., B.Z., A.S., K.J., B.P., L.S., E.D.G., K.F.)
| | - John Reagan
- Department of Neurology, Vanderbilt University, Nashville (J.R.)
| | - Aikaterini Theodorou
- Second Department of Neurology, National and Kapodistrian University of Athens, "Attikon" University Hospital, Greece (A.T., L.P., G.T.)
| | - Lina Palaiodimou
- Second Department of Neurology, National and Kapodistrian University of Athens, "Attikon" University Hospital, Greece (A.T., L.P., G.T.)
| | - Karen Furie
- Department of Neurology, Brown University, Providence, RI (S.Y., B.Z., A.S., K.J., B.P., L.S., E.D.G., K.F.)
| | - Thalia S Field
- Department of Neurology, Vancouver University, CA (T.S.F.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, "Attikon" University Hospital, Greece (A.T., L.P., G.T.)
| | - Brian Mac Grory
- Department of Neurology, Duke University, Durham, NC (B.M.G.)
| |
Collapse
|
20
|
Dabigatran in Cerebral Sinus Vein Thrombosis and Thrombophilia. LIFE (BASEL, SWITZERLAND) 2022; 12:life12070970. [PMID: 35888060 PMCID: PMC9316430 DOI: 10.3390/life12070970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 11/16/2022]
Abstract
Background and Purpose: Thrombophilic gene alterations are a major risk factor for cerebral sinus vein thrombosis (CSVT). Up to 30% of all patients with cerebral sinus vein thrombosis (CSVT) are found to have thrombophilic defects such as prothrombin mutation (PTM) or factor V Leiden (FVL). Their repercussions on the plasma levels of dabigatran etexilate are unclear. In this prospective case–control study, we aimed to investigate whether thrombophilia in CSVT has an influence on dabigatran peak-plasma levels. Methods: We monitored 10 patients over 12 months with acute CSVT, genetic thrombophilia with off-label use of dabigatran etexilate 150 mg twice a day and measured dabigatran peak-plasma levels and radiological outcome. We also monitored patients without genetic thrombophilia with dabigatran etexilate 150 mg twice a day and compared the efficiency and dabigatran peak-plasma levels. Results: Patients with homozygote PTM had significantly lower dabigatran peak concentration compared to patients with FVL or the control group (23 ± 4.2 vs. 152.3 ± 27.5 and 159.6 ± 63.08; p-value ≤ 0.05) There was no significant difference in dabigatran etexilate plasma levels between the heterozygote PTM group compared to patients with FVL or the control group (p = 0.29). There was no correlation between dabigatran peak concentration and delayed thrombus dissolution. Conclusions: Dabigatran peak concentration was stable in patients with heterozygote FVL and heterozygote PTM, but not in homozygote PTM, compared to controls. Genetic screening for thrombophilia in patients after CSVT may be useful to make patient tailored therapeutic decisions regarding oral anticoagulation and may decrease thrombotic events.
Collapse
|
21
|
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).
Collapse
Affiliation(s)
| | - Adriana Bastos Conforto
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brazil
| |
Collapse
|
22
|
Riva N, Galea F, Buhagiar I, Gatt A, Calleja-Agius J. Efficacy and safety of the direct oral anti-coagulants in patients with cerebral vein thrombosis: A systematic review and meta-analysis. Br J Haematol 2022; 198:165-182. [PMID: 35362089 DOI: 10.1111/bjh.18177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 03/10/2022] [Accepted: 03/18/2022] [Indexed: 01/21/2023]
Abstract
Vitamin K antagonists (VKAs) are the standard oral anti-coagulant treatment for patients with cerebral venous thrombosis (CVT). However, the direct oral anti-coagulants (DOACs) started replacing VKAs also in this setting. We aimed to evaluate safety and efficacy of the DOACs for CVT treatment. We performed a systematic review and meta-analysis (PROSPERO protocol registration number CRD42020191472). The electronic databases MEDLINE, EMBASE and CENTRAL were searched from inception to January 2022. We included randomised controlled trials (RCTs) and observational studies, enrolling at least 10 adult patients with CVT treated with any DOACs. Twenty-three studies were included, for a total of 618 CVT patients treated with DOACs (treatment duration range 3-12 months). Mortality rate was 1.76% [95% confidence interval (CI) 0.70%-3.24%; I2 = 0%; 5/428 patients, 18 studies]; major bleeding 2.41% (95% CI 1.26%-3.91%; I2 = 1.5%; 12/534 patients, 21 studies); recurrent thrombosis 2.05% (95% CI 1.04%-3.37%; I2 = 0%; 10/577 patients, 21 studies); excellent neurological outcome 85.9% (95% CI 79.0%-91.7%; I2 = 63.7%; 289/340 patients, 13 studies); vessel recanalisation 89.0% (95% CI 82.9%-93.9%; I2 = 62.7%; 316/359 patients, 16 studies). No significant differences emerged by study design (RCTs vs. observational studies) or by treatment (DOACs vs. VKAs). This systematic review showed that the DOACs might represent a reasonable oral anti-coagulant treatment option for CVT patients.
Collapse
Affiliation(s)
- Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Francesca Galea
- Department of Anatomy, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Isaac Buhagiar
- Department of Anatomy, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Alex Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Jean Calleja-Agius
- Department of Anatomy, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| |
Collapse
|
23
|
Abstract
Cerebral venous thrombosis (CVT) is a rare form of stroke that often affects younger age groups, especially reproductive age group females. CVT is a potentially fatal neurological condition that can be frequently overlooked due to the vague nature of its clinical and radiological presentation. Headache is the most common presenting symptom. However, a wide range of symptoms can be present and the symptom onset can be acute, subacute, or chronic. Neuroimaging is mandatory in cases where CVT is suspected. Both magnetic resonance venography and computed tomography venography can confirm a diagnosis of CVT. Anticoagulation with low-molecular-weight heparin is the mainstay of treatment. Intracranial hemorrhage is not considered a contraindication to the use of anticoagulants in CVT. Endovascular intervention is still controversial but can be a treatment option for patients with neurological deterioration or thrombus progression, despite the use of anticoagulation or with development of new or worsening intracerebral hemorrhage. Patients with CVT have an increased risk of recurrence of CVT and other types of venous thromboembolism. This review provides an overview of the epidemiology, diagnosis, and treatment of CVT in adults. Commentary about increased presentation of CVT in patients with coronavirus disease 2019 (COVID-19), or after immunization against COVID-19, is also provided.
Collapse
|
24
|
Yaghi S, Shu L, Bakradze E, Salehi Omran S, Giles JA, Amar JY, Henninger N, Elnazeir M, Liberman AL, Moncrieffe K, Lu J, Sharma R, Cheng Y, Zubair AS, Simpkins AN, Li GT, Kung JC, Perez D, Heldner M, Scutelnic A, Seiffge D, Siepen B, Rothstein A, Khazaal O, Do D, Kasab SA, Rahman LA, Mistry EA, Kerrigan D, Lafever H, Nguyen TN, Klein P, Aparicio H, Frontera J, Kuohn L, Agarwal S, Stretz C, Kala N, El Jamal S, Chang A, Cutting S, Xiao H, de Havenon A, Muddasani V, Wu T, Wilson D, Nouh A, Asad SD, Qureshi A, Moore J, Khatri P, Aziz Y, Casteigne B, Khan M, Cheng Y, Mac Grory B, Weiss M, Ryan D, Vedovati MC, Paciaroni M, Siegler JE, Kamen S, Yu S, Leon Guerrero CR, Atallah E, De Marchis GM, Brehm A, Dittrich T, Psychogios M, Alvarado-Dyer R, Kass-Hout T, Prabhakaran S, Honda T, Liebeskind DS, Furie K. Direct Oral Anticoagulants Versus Warfarin in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT): A Multicenter International Study. Stroke 2022; 53:728-738. [PMID: 35143325 DOI: 10.1161/strokeaha.121.037541] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A small randomized controlled trial suggested that dabigatran may be as effective as warfarin in the treatment of cerebral venous thrombosis (CVT). We aimed to compare direct oral anticoagulants (DOACs) to warfarin in a real-world CVT cohort. METHODS This multicenter international retrospective study (United States, Europe, New Zealand) included consecutive patients with CVT treated with oral anticoagulation from January 2015 to December 2020. We abstracted demographics and CVT risk factors, hypercoagulable labs, baseline imaging data, and clinical and radiological outcomes from medical records. We used adjusted inverse probability of treatment weighted Cox-regression models to compare recurrent cerebral or systemic venous thrombosis, death, and major hemorrhage in patients treated with warfarin versus DOACs. We performed adjusted inverse probability of treatment weighted logistic regression to compare recanalization rates on follow-up imaging across the 2 treatments groups. RESULTS Among 1025 CVT patients across 27 centers, 845 patients met our inclusion criteria. Mean age was 44.8 years, 64.7% were women; 33.0% received DOAC only, 51.8% received warfarin only, and 15.1% received both treatments at different times. During a median follow-up of 345 (interquartile range, 140-720) days, there were 5.68 recurrent venous thrombosis, 3.77 major hemorrhages, and 1.84 deaths per 100 patient-years. Among 525 patients who met recanalization analysis inclusion criteria, 36.6% had complete, 48.2% had partial, and 15.2% had no recanalization. When compared with warfarin, DOAC treatment was associated with similar risk of recurrent venous thrombosis (aHR, 0.94 [95% CI, 0.51-1.73]; P=0.84), death (aHR, 0.78 [95% CI, 0.22-2.76]; P=0.70), and rate of partial/complete recanalization (aOR, 0.92 [95% CI, 0.48-1.73]; P=0.79), but a lower risk of major hemorrhage (aHR, 0.35 [95% CI, 0.15-0.82]; P=0.02). CONCLUSIONS In patients with CVT, treatment with DOACs was associated with similar clinical and radiographic outcomes and favorable safety profile when compared with warfarin treatment. Our findings need confirmation by large prospective or randomized studies.
Collapse
Affiliation(s)
- Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Liqi Shu
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | | | - Setareh Salehi Omran
- Department of Neurology, University of Colorado School of Medicine, Aurora (S.S.O.)
| | - James A Giles
- Department of Neurology, Washington University, Saint Louis, MO (J.A.G., J.Y.A.)
| | - Jordan Y Amar
- Department of Neurology, Washington University, Saint Louis, MO (J.A.G., J.Y.A.)
| | - Nils Henninger
- Department of Neurology, University of Massachusetts, Worcester. (N.H., M.E.).,Department of Psychiatry, University of Massachusetts, Worcester. (N.H.)
| | - Marwa Elnazeir
- Department of Neurology, University of Massachusetts, Worcester. (N.H., M.E.)
| | - Ava L Liberman
- Department of Neurology, Weill Cornell Medical Center, NY (A.L.L.)
| | | | - Jenny Lu
- Department of Neurology, Montefiore Medical Center, NY (K.M., J.L.)
| | - Richa Sharma
- Department of Neurology, Yale University, New Haven, CT (R.S., Y.C., A.S.Z., A.d.H.)
| | - Yee Cheng
- Department of Neurology, Yale University, New Haven, CT (R.S., Y.C., A.S.Z., A.d.H.)
| | - Adeel S Zubair
- Department of Neurology, Yale University, New Haven, CT (R.S., Y.C., A.S.Z., A.d.H.)
| | - Alexis N Simpkins
- Department of Neurology, University of Florida, Gainesville (A.N.S., G.T.L., J.C.K., D.P.)
| | - Grace T Li
- Department of Neurology, University of Florida, Gainesville (A.N.S., G.T.L., J.C.K., D.P.)
| | - Justin Chi Kung
- Department of Neurology, University of Florida, Gainesville (A.N.S., G.T.L., J.C.K., D.P.)
| | - Dezaray Perez
- Department of Neurology, University of Florida, Gainesville (A.N.S., G.T.L., J.C.K., D.P.)
| | - Mirjam Heldner
- Department of Neurology, Inselspital Universitätsspital, Bern, Switzerland (M.H., A.S., D.S., B.S.)
| | - Adrian Scutelnic
- Department of Neurology, Inselspital Universitätsspital, Bern, Switzerland (M.H., A.S., D.S., B.S.)
| | - David Seiffge
- Department of Neurology, Inselspital Universitätsspital, Bern, Switzerland (M.H., A.S., D.S., B.S.)
| | - Bernhard Siepen
- Department of Neurology, Inselspital Universitätsspital, Bern, Switzerland (M.H., A.S., D.S., B.S.)
| | - Aaron Rothstein
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (A.R., O.K., D.D.)
| | - Ossama Khazaal
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (A.R., O.K., D.D.)
| | - David Do
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (A.R., O.K., D.D.)
| | - Sami Al Kasab
- Department of Neurology, Medical University of South Carolina, Charleston (S.A.K., L.A.R.).,Department of Neurosurgery, Medical University of South Carolina, Charleston (S.A.K.)
| | - Line Abdul Rahman
- Department of Neurology, Medical University of South Carolina, Charleston (S.A.K., L.A.R.)
| | - Eva A Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati (E.A.M., P.K., Y.A., B.C.)
| | - Deborah Kerrigan
- Department of Neurology, Vanderbilt University, Nashville, TN (D.K., H.L.)
| | - Hayden Lafever
- Department of Neurology, Vanderbilt University, Nashville, TN (D.K., H.L.)
| | - Thanh N Nguyen
- Department of Neurology, Boston University School of Medicine, MA (T.N.N., P.K., H.A.)
| | - Piers Klein
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati (E.A.M., P.K., Y.A., B.C.).,Department of Neurology, Boston University School of Medicine, MA (T.N.N., P.K., H.A.)
| | - Hugo Aparicio
- Department of Neurology, Boston University School of Medicine, MA (T.N.N., P.K., H.A.)
| | | | - Lindsey Kuohn
- Department of Neurology, New York University, NY (J.F., L.K., S.A.)
| | - Shashank Agarwal
- Department of Neurology, New York University, NY (J.F., L.K., S.A.)
| | - Christoph Stretz
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Narendra Kala
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Sleiman El Jamal
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Alison Chang
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Shawna Cutting
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| | - Han Xiao
- Department of Biostatistics, University of California Santa Barbara (H.X.)
| | - Adam de Havenon
- Department of Neurology, Yale University, New Haven, CT (R.S., Y.C., A.S.Z., A.d.H.)
| | - Varsha Muddasani
- Department of Neurology, University of Utah, Salt Lake City (V.M.)
| | - Teddy Wu
- Department of Neurology, Christchurch hospital, New Zealand (T.W., D.W.)
| | - Duncan Wilson
- Department of Neurology, Christchurch hospital, New Zealand (T.W., D.W.)
| | - Amre Nouh
- Department of Neurology, Hartford Hospital, CT (A.N., S.D.A.)
| | | | - Abid Qureshi
- Department of Neurology, University of Kansas, Kansas City (A.Q., J.M.)
| | - Justin Moore
- Department of Neurology, University of Kansas, Kansas City (A.Q., J.M.)
| | | | - Yasmin Aziz
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati (E.A.M., P.K., Y.A., B.C.)
| | - Bryce Casteigne
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati (E.A.M., P.K., Y.A., B.C.)
| | - Muhib Khan
- Department of Neurology, Spectrum Health, Michigan State University, Grand Rapids (M.K., Y.C.)
| | - Yao Cheng
- Department of Neurology, Spectrum Health, Michigan State University, Grand Rapids (M.K., Y.C.)
| | - Brian Mac Grory
- Department of Neurology, Duke University, Durham, NC (B.M.G., M.W., D.R.)
| | - Martin Weiss
- Department of Neurology, Duke University, Durham, NC (B.M.G., M.W., D.R.)
| | - Dylan Ryan
- Department of Neurology, Duke University, Durham, NC (B.M.G., M.W., D.R.)
| | | | | | - James E Siegler
- Department of Neurology, Cooper University, Camden, NJ (J.E.S., S.K., S.Y.)
| | - Scott Kamen
- Department of Neurology, Cooper University, Camden, NJ (J.E.S., S.K., S.Y.)
| | - Siyuan Yu
- Department of Neurology, Cooper University, Camden, NJ (J.E.S., S.K., S.Y.)
| | | | - Eugenie Atallah
- Department of Neurology, George Washington University, District of Columbia (C.R.L.G., E.A.)
| | - Gian Marco De Marchis
- Department of Neurology, University Hospital Basel and University of Basel, Switzerland (G.M.D.M., T.D.)
| | - Alex Brehm
- Department of interventional and diagnostic Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel and University of Basel, Switzerland (A.B., M.P.)
| | - Tolga Dittrich
- Department of Neurology, University Hospital Basel and University of Basel, Switzerland (G.M.D.M., T.D.)
| | - Marios Psychogios
- Department of interventional and diagnostic Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel and University of Basel, Switzerland (A.B., M.P.)
| | | | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, IL (R.A.-D., T.K.-H., S.P.)
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, IL (R.A.-D., T.K.-H., S.P.)
| | - Tristan Honda
- Department of Neurology, University of California at Los Angeles (T.H., D.S.L.)
| | - David S Liebeskind
- Department of Neurology, University of California at Los Angeles (T.H., D.S.L.)
| | - Karen Furie
- Department of Neurology, Brown University, Providence, RI (S.Y., L.S., C.S., N.K., S.E.J., A.C., S.C., K.F.)
| |
Collapse
|
25
|
Jiang YY, Chen LJ, Wu XJ, Zhou GQ, Mo DC, Li XL, Liu LY, Li JL, Luo M. Efficacy and Safety Assessment of Rivaroxaban for the Treatment of Cerebral Venous Sinus Thrombosis in a Chinese Population. Clin Appl Thromb Hemost 2022; 28:10760296221144038. [PMID: 36503260 DOI: 10.1177/10760296221144038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
We aimed to investigate the efficacy and safety of rivaroxaban for acute and long-term management of cerebral venous sinus thrombosis (CVST). This study reviewed CVST-diagnosed patients admitted to the First Affiliated Hospital of Guangxi Medical University from January 2015 to December 2020. The primary outcome was a composite of recurrent thrombosis or major bleeding events. The secondary efficacy outcomes included a disease recovery time (DRT) presenting the time from admission to the endpoint as recovery (the modified Rankin scale [mRS] score [0-1]) within 30 and 90 days, and length of hospital stay (LHS). Patients treated with rivaroxaban (38) and warfarin (45) were enrolled in the final analysis. The primary outcome had no significant difference (5.3% vs 11.1%, P = .576) between the 2 groups. The secondary efficacy outcome regarding the median 30-d DRT was 17 days (95% confidence interval [CI], 14.6-19.4) in the rivaroxaban group, compared with 26.0 days (95% CI, 16.8-35.2) in the warfarin group (hazard ratio, 1.806; 95% CI, 1.051-3.103; log-rank P = .026). Two groups have a significant difference in LHS (P = .041). Patients with cerebral edema, intracerebral hemorrhage, and mild/moderate disability (admission mRS score [2-3]) treated with rivaroxaban recovered faster than those with warfarin (log-rank P < .05). Patients with cerebral edema, intracerebral hemorrhage, and mild/moderate disability treated with rivaroxaban had a shorter recovery time than those treated with warfarin within 1 month from admission, indicating that rivaroxaban a promising convenient therapy for CVST, helping them speedily restore social functions.
Collapse
Affiliation(s)
- Yi-Ying Jiang
- Department of Neurology, 117742First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Li-Jie Chen
- Department of Neurology, 117742First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiao-Ju Wu
- Department of Neurology, 117742First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Guo-Qiu Zhou
- Department of Neurology, 117742First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Dong-Can Mo
- Department of Neurology, 117742First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiao-Ling Li
- Department of Neurology, 117742First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Liu-Yu Liu
- Department of Neurology, 117742First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jian-Li Li
- Department of Neurology, 117742First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Man Luo
- Department of Neurology, 117742First Affiliated Hospital of Guangxi Medical University, Nanning, China.,Guangxi Key Laboratory of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention, Nanning, China.,Guangxi Clinical Research Center for Cardio-cerebrovascular Diseases, Nanning, China
| |
Collapse
|