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Ninan GA, Miraclin T A, Karumathil S, Prasad JD, Kumar S, Bal D, Nair A, Ahmed SA, Appaswamy Thirumal P, George B, Sivadasan A, Aaron S. Interventions in cerebrovascular emergencies among patients with Paroxysmal nocturnal haemoglobinuria - A word of caution. J Stroke Cerebrovasc Dis 2023; 32:107305. [PMID: 37677898 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107305] [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: 02/15/2023] [Revised: 06/14/2023] [Accepted: 08/10/2023] [Indexed: 09/09/2023] Open
Abstract
INTRODUCTION Paroxysmal nocturnal haemoglobinuria (PNH) is a clonal hematopoietic disorder, where there is deficiency of glycosylphosphatidylinositol (GPI) anchored proteins in the cell membrane, leading to increased complement sensitivity of red blood cells, intravascular hemolysis and vascular inflammation. Arterial and venous strokes in patients with PNH are a rarity posing significant diagnostic and therapeutic challenges. We report our experience with management of PNH patients with cerebrovascular emergencies. METHODS We report 2 patients with PNH, one who was previously diagnosed with PNH and had arterial stroke, the other had an index presentation of cerebral venous sinus thrombosis (CVT) and was subsequently diagnosed with PNH. We also present the systematic review of literature reporting similar cases, highlighting the challenges in management. RESULTS Both patients presented to our centre with cerebrovascular emergency. The first patient was a diagnosed with PNH, and presented with left hemispheric infarction caused by thrombosis of middle cerebral artery. He was thrombolysed and underwent mechanical thrombectomy, which was unsuccessful in view of repeated re - thrombosis of the vessel. The patient survived with significant disability. The second patient had severe cerebral venous sinus thrombosis with large right hemispheric hemorrhagic venous infarction. She underwent emergency decompressive hemicraniectomy complicated by massive blood loss and disseminated intravascular coagulation. She subsequently had recurrent life threatening intracranial bleed secondary to platelet transfusions, thrombocytopenia, and use of contrast agents. She progressed to develop Budd Chiari syndrome and was initiated on Eculuzimab. She became transfusion independent, however remained in minimally conscious state and succumbed to sepsis. CONCLUSIONS Management of arterial and venous strokes is complex in patients with PNH. Invasive procedures and platelet transfusions are to be avoided in acute thrombosis, till robust evidence is available establishing the safety of the same in patients with PNH. Eculuzimab is a promising option, but far from reach for patients in developing countries.
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Affiliation(s)
- George Abraham Ninan
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Angel Miraclin T
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sujith Karumathil
- Department of Clinical Haematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - John Davis Prasad
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sarath Kumar
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Deepti Bal
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Aditya Nair
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Shaikh Atif Ahmed
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Biju George
- Department of Clinical Haematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ajith Sivadasan
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sanjith Aaron
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
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Abstract
The most frequent and feared complication of paroxysmal nocturnal hemoglobinuria (PNH) is thrombosis. Recent research has demonstrated that the complement and coagulation systems are closely integrated with each influencing the activity of the other to the extent that thrombin itself has recently been shown to activate the alternative pathway of complement. This may explain some of the complexity of the thrombosis in PNH. In this review, the recent changes in our understanding of the pathophysiology of thrombosis in PNH, as well as the treatment of thrombosis, will be discussed. Mechanisms explored include platelet activation, toxicity of free hemoglobin, nitric oxide depletion, absence of other glycosylphosphatidylinositol-linked proteins such as urokinase-type plasminogen activator receptor and endothelial dysfunction. Complement inhibition with eculizumab has a dramatic effect in PNH and has a major impact in the prevention of thrombosis as well as its management in this disease.
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Tiu R, Yacoub H, Maciejewski J, Sila CA. Recurrent Ischemic Stroke in Paroxysmal Nocturnal Hemoglobinuria: Paroxysmal Nocturnal Hemoglobinuria or Missed Patent Foramen Ovale? J Stroke Cerebrovasc Dis 2009; 18:409-10. [DOI: 10.1016/j.jstrokecerebrovasdis.2008.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Revised: 12/01/2008] [Accepted: 12/16/2008] [Indexed: 11/26/2022] Open
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