Trends in incidence and epidemiologic characteristics of cerebral venous thrombosis in the United States

Incidence Trends and Risk of Recurrent Stroke of Cervical Artery Dissections in the United States Between 2005 and 2019

BACKGROUND AND OBJECTIVES

Cervical artery dissection (CeAD) is a common cause of acute ischemic stroke (AIS), especially in patients younger than 55 years, but data regarding trends and subsequent AIS risk after CeAD remain scarce. We aimed to determine national trends in CeAD admissions and examine post-CeAD risk of ischemic stroke.

METHODS

We used the National Inpatient Sample (2005-2019), National Readmission Database (2015-2019), and State Inpatient Database for New York (2011-2017) and Florida (2011-2019). Adult patients with spontaneous CeAD were identified using International Classification of Diseases, Ninth Revision, Clinical Modification and International Classification of Diseases, Tenth Revision, Clinical Modification codes. Survey-weighted annual CeAD cases were combined with US census data to estimate annual incidence. National estimates were verified with state-level data, which allows for the removal of duplicate admissions for a single patient through a unique patient identifier. Joinpoint regression was used to quantify the average annual percent change (AAPC) of CeAD incidence. AIS readmission risk after CeAD without concurrent AIS was assessed with death as a competing risk using Fine and Gray competing risk methodology.

RESULTS

From 2005 to 2019, we identified 125,102 patients (46.09% female, mean age 51.4 years) with spontaneous CeAD. CeAD incidence increased from 10.7 cases per million population in 2005 to 45.6 cases per million population in 2019, revealing an AAPC of 10.21% (95% CI 9.67%-10.76%). This substantial increase in CeAD admissions was particularly high in the older, Black, and Hispanic populations. Statewide data corroborated this upward trend with an AAPC of 8.47% (95% CI 7.97%-9.48%). Among patients with CeAD without AIS, vertebral artery dissection was the sole major predictor of subsequent ischemic stroke risk within 90 days (adjusted subdistributed hazard ratio 1.77, 95% CI 1.18-2.64, p = 0.006). Interaction and subgroup analyses were performed and demonstrated similar results.

DISCUSSION

There was an almost 5-fold increase in CeAD hospitalizations and an upward incidence trend from 2005 to 2019, particularly in racial minorities, which may be attributed to increased imaging and awareness of CeAD. Our study also revealed a small but significant risk of AIS in patients with vertebral artery dissection without concurrent ischemic stroke. These findings underscore the importance of studying acute treatment and secondary prevention strategies in patients with CeAD.

Pathophysiology and Management of Cerebral Venous Thrombosis

Cerebral venous thrombosis (CVT) is a less common type of stroke that can occur across all age groups but predominantly affects children and young adults. Diagnosis is often challenging due to the nonspecific and variable clinical presentation. The disease course is heterogeneous, with CVT-related parenchymal lesions developing in approximately 50 to 60% of cases. Despite some advancements, significant gaps persist in understanding the pathophysiology of CVT, including the mechanisms underlying brain injury. Anticoagulation is the cornerstone of CVT treatment, but strategies targeting secondary mechanisms of parenchymal damage are still lacking. Here, the current state of the field is briefly reviewed, with the aim to introduce a wide audience (neuroscientists and clinicians alike) to the disease and inform clinical practice and future research.

Cerebral Venous Sinus Thrombosis During Pregnancy and the Postpartum Period: A Review of Pathophysiological Mechanisms, Clinical Manifestations, and Treatment Approaches

Cerebral venous sinus thrombosis (CVST) is a rare neurological emergency associated with significant morbidity and mortality. CVST has been found to account for up to 57% of pregnancy-related strokes. Pregnancy and the postpartum period are associated with physiological changes that lead to a hypercoagulable state, increasing the risk for CVST. The pathophysiological mechanism for CVST involves increased venule and capillary pressure as well as intracranial pressure, which lead to clinical manifestations such as headaches, seizures, and focal neurological deficits. Diagnosis involves imaging including computed tomography, magnetic resonance imaging, venography, and in some cases, cerebral angiography. Treatment options during pregnancy and postpartum include anticoagulation with low molecular weight heparin and symptomatic management. Further research is needed to elucidate the safety and efficacy of endovascular treatment techniques in severe or refractory cases of CVST, particularly during pregnancy and puerperium. In this review, we describe the physiological changes of pregnancy, outline the pathophysiological mechanisms and clinical findings of CVST, and discuss treatment approaches specific to pregnancy and the postpartum period.

Key prognostic risk factors linked to poor functional outcomes in cerebral venous sinus thrombosis: a systematic review and meta-analysis

BACKGROUND

Cerebral venous sinus thrombosis is a rare stroke with several clinical manifestations. Several studies have identified prognostic risk factors associated with poor functional outcomes and established predictive models. This systematic review and meta-analysis assessed the overall effect size of all prognostic risk factors.

METHODS

A systematic review was conducted to explore all prognostic risk factors in studies published from the initial to June 2024 among 5 Databases included PubMed / Medline, Scopus, EBSCOhost, Web of Science, and Cochran Library. The quality of the methodology was analyzed using the Newcastle-Ottawa Scale. Data analysis was performed using the Statistical Package for Social Sciences (SPSS) version 29.

RESULTS

Sixty-four studies involving 18,958 participants with a mean age of 38.46 years and females 63.03% were included in the quantitative meta-analysis. Functional outcomes were primarily measured using the Modified Rankin Scale (mRS), with scores ≥ 2 or ≥ 3 indicating poor outcomes in 35.00% and 60.00% of studies, respectively. For general information, age (InOR = 0.98, 95% CI 0.53-1.43), intracranial hemorrhage (OR = 3.79, 95% CI 2.77-5.20), and ischemic infarction (OR = 3.18, 95% CI 2.40-4.23) were associated with poor functional outcomes. For general and neurological symptoms, headache (OR = 0.22, 95% CI 0.17-0.29), seizure (OR = 2.74, 95% CI 1.76-4.27), focal deficit (OR = 4.72, 95% CI 3.86-5.78), coma (OR = 11.60, 95% CI 6.12-21.98), and consciousness alteration (OR = 7.07, 95% CI 4.15-12.04) were outstanding factors. The blood biomarkers of NLR (log OR = 1.72, 95% CI 0.96-2.47), lymphocytes (Cohen's d = -0.63, 95 CI -0.78--0.47), and D-dimer (lnOR = 1.34, 95% CI 0.87-1.80) were the three most frequently reported factors. Parenchymal lesion (OR = 4.71, 95% CI 1.12-19.84) and deep cerebral venous thrombosis (OR = 6.30, 95% CI 2.92-13.63) in radiological images were two frequently reported factors. CVST patients with cancer (OR = 3.87, 95% CI 2.95-5.07) or high blood glucose levels (OR = 3.52, 95% CI 1.61-7.68) were associated with poor functional outcomes. In the meta-regression analysis, ischemic infarction (P = 0.032), consciousness alteration (P < 0.001), and NLR (P = 0.015) were associated with mRS prediction.

CONCLUSIONS

Pooled effect sizes revealed that ischemic infarction, headache, neurological focal deficit, lymphopenia, and cancer were significantly associated with poor functional outcomes, with low to moderate heterogeneity. Consciousness alterations/deterioration and deep cerebral venous thrombosis were also significant prognostic factors, albeit with substantial heterogeneity. The meta-regression analysis showed that the effect sizes of consciousness alterations/deterioration and NLR increased with worsening mRS scores. Other notable risk factors included age, intracranial hemorrhage, seizures, coma, D-dimer, parenchymal lesions, and hyperglycemia. This systematic review provides a comprehensive overview of the prognostic risk factors for poor functional outcomes in patients undergoing CVST, which can guide clinical decision-making and future research.

TRIAL REGISTRATION

This systematic review and meta-analysis has been registered with INPLASY (International Platform of Registered Systematic Review and Meta-analysis Protocols), and the registration number is INPLASY202480072. The registration period is 14 August 2024.

Update on management of cerebral venous thrombosis

PURPOSE OF REVIEW

This review intends to systematize the diagnostic and treatment approach to cerebral venous thrombosis (CVT), highlighting key studies that have been recently published.

RECENT FINDINGS

In light of the recent pandemic, new risk factors for CVT have emerged. Contrast-enhanced MRI and susceptibility-weighted imaging have been shown to offer increased sensitivity for detecting cortical vein thrombosis.Dabigatran seems to be as effective and well tolerated as warfarin for long-term anticoagulation. Partial venous recanalization often occurs in patients treated with anticoagulation only, as early as 8 days after treatment onset. For patients with CVT and impending brain herniation, two-thirds of those who undergo decompressive craniectomy survive, with one-third being functionally independent 6 months after diagnosis.

SUMMARY

CVT is an unusual type of cerebrovascular disease that mostly affects women of fertile age. Risk factors should be identified and addressed. Diagnosis relies on confirmation of venous sinus and/or vein thrombosis, usually by CT venography or MRI. Anticoagulation is the cornerstone of treatment. Despite the lack of high-quality evidence, endovascular treatment is often considered in severe cases. Special populations require tailored approaches. About 80% achieve mRS 0-1, but residual symptoms often affect quality of life and the ability to return to work.

Recurrent syncope after hysteroscopy finally diagnosed as cerebral venous sinus thrombosis: a case report

Cerebral venous sinus thrombosis (CVST) is a rare cerebrovascular condition that causes obstruction of venous blood flow or cerebrospinal fluid circulation, leading to intracranial hypertension symptoms such as syncope and vomiting. Transurethral Resection of the Prostate (TURP) syndrome, a complication of hysteroscopic surgery, can also present with cerebral edema and symptoms similar to CVST, making differentiation challenging. Cases of unexplained recurrent syncope posthysteroscopy diagnosed as CVST have not been previously reported. We present a case of a 33-year-old woman who underwent hysteroscopy for abnormal uterine bleeding. Five hours postoperation, she experienced syncope, which resolved spontaneously. Ten hours later, she had recurrent syncope, nausea, and vomiting. Head computed tomography suggested cerebral edema, potentially indicating TURP syndrome. However, the brief surgery and minimal fluid imbalance (200 mL) made TURP syndrome unlikely. Further investigation with cranial magnetic resonance venography revealed multiple venous sinus thromboses, explaining the recurrent syncope linked to minimal fluid volume expansion postsurgery. Subsequent screening identified hyperhomocysteinemia as a contributing factor. Treatment with anticoagulants, folic acid, and vitamin B6 led to a favorable outcome. This case involves recurrent syncope after hysteroscopy secondary to CVST. If symptoms such as recurrent syncope, nausea, and vomiting, indicating increased intracranial pressure, arise posthysteroscopy and cannot be attributed to typical TURP syndrome, primary intracranial vascular conditions like CVST should be considered, as even a minor increase in blood volume can exacerbate these intracranial pressure symptoms.

Predictors of early intracerebral hemorrhage in patients with cerebral sinus venous thrombosis: Systematic review and meta-analysis

OBJECTIVES

Patients with cerebral venous thrombosis (CVT) may present with early intracerebral hemorrhage (EICH). The objective of this study was to identify predictors for EICH in CVT patients via a systematic review and meta-analysis of observational studies. Additionally, we aimed to evaluate the clinical outcomes associated with the presence of EICH in these patients.

METHODS

Literature search on PubMed, EMBASE and Cochrane Library databases from inception up to 1 February 2024 was conducted. Five studies with predictors of EICH were included in qualitative synthesis and meta-analysis.

RESULTS

Pooled analysis demonstrated a statistically significant association between female gender and EICH (odd ratios (OR) = 1.51, 95 % confidence interval (CI) = 1.23-1.85, p < 0.01). The ICH patients had higher likelihood of seizures (OR = 3.07, 95 % CI = 1.69-5.58, p < 0.01), focal neurological deficits (OR = 4.07, 95 % CI = 2.57-6.44, p < 0.01), and decreased level of consciousness (OR = 3.89, 95 % CI = 2.53-5.87, p < 0.01). Superior Sagittal Sinus thrombosis was associated with higher likelihood of EICH (OR: 1.49, 95 % CI 1.05-2.13, P = 0.03). No statistically significant association was demonstrated between presence of EICH and pregnancy, presence of hematological diseases or thrombophilia, or other site of venous thrombosis (deep venous system, or multiple sinuses involvement). Furthermore, patients who exhibited early EICH were notably less likely to attain a favorable functional outcome (mRS 0-2) (OR: 0.28; 95 % CI 0.16-0.49; p < 0.001).

CONCLUSION

This meta-analysis demonstrates that among CVT patients, female patients with new onset seizures, focal neurological deficits and decreased level of consciousness are more likely to present with EICH.

Cerebral venous thrombosis in elderly patients

BACKGROUND AND PURPOSE

We aimed to report the characteristics of cerebral venous thrombosis (CVT) in elderly people (aged ≥65 years).

METHODS

This multicenter retrospective cohort included elderly patients hospitalized for a first CVT in nine Paris-Ile-de-France hospitals between 2011 and 2021. The estimated incidence was compared to CVT recorded by the French health insurance data system. Lariboisière Hospital's CVT registry allowed comparisons of our elderly cohort with individuals younger than 65 years.

RESULTS

One hundred fourteen patients were included in this study (mean age = 74.2 years, range = 65-93, 61% female). The CVT annual incidence in Ile-de-France was 5.9-7.1 per million elderly individuals versus 8.5 per million nationwide. Headaches and focal deficits were the most common initial clinical features (50% and 51%, respectively), followed by seizures and confusion (40% and 27%). Treatment included anticoagulation (93%) and, rarely, endovascular procedure (2%) or craniectomy (1%). Compared with adult patients aged <65 years (younger adults), elderly patients presented fewer headaches (50% vs. 96%, p < 0.01) and intracranial hypertension (7% vs. 22%, p < 0.01) but more seizures and focal deficits (40% vs. 27% and 51% vs. 38%, respectively, p < 0.01). Underlying cancer, hemopathy, and locoregional infections were more frequent in elderly patients than among younger adults (p < 0.01). The prognosis of patients from our elderly cohort was poorer than that of younger adults; 8% died in the acute phase, and 73% had a favorable outcome at 1 year (vs. 1.7% and 87%, respectively, p < 0.01).

CONCLUSIONS

CVT in elderly patients has a specific clinical presentation, epidemiology, and risk factors such as cancer or hemopathy, justifying specialized management.

The changing face of cerebral venous sinus thrombosis-emerging new causes and treatments

Cerebral venous sinus thrombosis (CVST) is an uncommon site of venous thromboembolism. CVST more commonly affects younger people and women, in stark contrast to other forms of venous thrombosis in which incidence increases with age and overall affects men. Traditional risk factors for the development of CVST include endogenous and exogenous estrogen (combined oral contraceptives and pregnancy and the puerperium), thrombophilias, and rare hematologic disorders. New and emerging risk factors include obesity, polycystic ovary syndrome, COVID-19 infection, and vaccine-induced thrombocytopenia and thrombosis and vaccine-induced thrombocytopenia and thrombosis-like disorders. Management centers around anticoagulation, management of the underlying cause, and consideration of invasive measures including endovascular thrombolysis and/or thrombectomy and craniectomy for severe cases. This review discusses the emerging risk factors and their identification, evidence for treatment including the use of direct oral anticoagulants, and the role of invasive management options.

Anticoagulation Status and Outcome in Cerebral Venous Thrombosis: A Single-Center Retrospective Study from South India

BACKGROUND AND OBJECTIVES

Early initiation and maintenance of anticoagulation appears to be the mainstay of treatment of cerebral venous thrombosis (CVT), but the evidence supporting the intensity and duration of anticoagulation is limited.

METHODS

We retrospectively collected data of patients admitted with CVT over a 5-year period, who had a minimum of 6 months of clinical follow-up and three or more prothrombin time international normalized ratio (INR) values spread over 6 months. Data collected included demographic, clinical, and radiologic parameters, anticoagulation status during the follow-up, complications, and clinical status at the last follow-up.

RESULTS

We identified 204 patients, and the mean age was 34.4 ± 11.1 years. The majority had a provoked etiology (194, 95.1%) for CVT. After initial anticoagulation with unfractionated heparin, all patients transitioned to acenocoumarol or warfarin and this was maintained for a mean duration of 16.02 ± 11.2 months. Time in therapeutic range of INR 2-3 was only 5.1 ± 11.8 percent days and time spent in an INR of 1-1.5 was 68.7 ± 31.8 percent days. The average INR over 6 months was 1.37 ± 0.33. Duration of follow-up was 18.9 ± 13.25 months, and a good outcome was noted in 183 (89.7%) patients. Complications were seen in 29 (14.2%) patients. Multivariate analysis showed only the CVT grading scale score to be an independent predictor of good outcome.

CONCLUSIONS

Maintenance of an intensive level of anticoagulation may not be required in patients with CVT and may be particularly true when a transient and treatable risk factor is the provoking etiology.

Efficacy and safety of direct oral anticoagulants versus warfarin in the treatment of cerebral venous sinus thrombosis

BACKGROUND

Given the evolving application and promising outcomes of direct oral anticoagulants (DOACs) in various thromboembolic conditions, we aimed to compare the efficacy and safety of DOACs with warfarin in the post-acute treatment of cerebral venous sinus thrombosis (CVST) using clinical and radiological parameters.

METHODS

A total of 140 CVST patients were enrolled, with 95 receiving warfarin and 45 receiving DOACs as post-acute treatment. Clinical and imaging parameters of the patients in follow-up visits were investigated, including the last modified Rankin Scale (mRS), venous thromboembolic events, CVST recurrence, mortality rate, recanalization status, and hemorrhagic events, to compare the efficacy and safety of treatment between the two groups.

RESULTS

At baseline, patients' assessments using two prognostic scores, ISCVT-RS and IN-REvASC, revealed that there was no statistically significant difference in the distribution of prognostic risk categories between the warfarin and DOACs groups. Following acute therapy, patients in the warfarin and DOACs groups were followed up for the median of 359 and 325 days, respectively. Analysis to compare the efficacy of warfarin and DOACs revealed no significant difference in last mRS scores, CVST recurrence rate, venous thromboembolic events, and recanalization status between the two groups. Additionally, there was no statistically significant difference in the risk of hemorrhagic events between warfarin and DOACs groups.

CONCLUSION

Our findings show that DOACs have comparable safety and efficacy in the post-acute treatment of CVST patients; however, large-scale randomized controlled trials are required to validate our findings.

Inpatient Outcomes of Cerebral Venous Thrombosis in Patients With Malignancy Throughout the United States

BACKGROUND AND PURPOSE

Cerebral venous thrombosis (CVT) is associated with a high degree of morbidity and mortality. Our objective is to elucidate characteristics, treatments, and outcomes of patients with cancer and CVT (CA-CVT).

METHODS

The 2016-2019 National Inpatient Sample (NIS) database was queried for patients with a primary diagnosis of CVT. Patients with a currently active diagnosis of malignancy (CA-CVT) were then identified. Demographics and comorbidities were compared between CA-CVT and CVT patients. Subgroup analyses explored patients with hematopoietic cancer and non-hematopoietic cancers. Stroke severity and treatment were explored. Inpatient outcomes studied were discharge disposition, length of stay, and mortality.

RESULTS

Between 2016 and 2019, 6,140 patients had a primary diagnosis code of CVT, and 370 (6.0%) patients had a coexisting malignancy. The most common malignancy was hematopoietic (n=195, 52.7%), followed by central nervous system (n=40, 10.8%), respiratory (n=40, 10.8%), and breast (n=40, 10.8%). These patients tended to be older than non-CA-CVT and were more likely to have coexisting comorbidities. CA-CVT patients had higher severity scores on the International Study of Cerebral Vein and Dural Sinus Thrombosis Risk Score (ISCVT-RS) and increased complications. In a propensity-score matched cohort, there were no differences in inpatient outcomes.

CONCLUSION

Malignancy occurs in 6% of patients presenting with CVT and should be considered a potential comorbidity in instances where clear causes of hypercoagulabilty have not been identified. Malignancy was linked to higher mortality rates. Nonetheless, after adjusting for the severity of CVT, the outcomes for inpatients with cancer-associated CVT were comparable to those without cancer, indicating that the increased mortality associated with malignancy is probably due to more severe CVT conditions.

Characteristics and outcomes of cerebral venous thrombosis associated with COVID-19

INTRODUCTION

Previous reports and meta-analyses derived from small case series reported a mortality rate of up to 40% in patients with coronavirus disease 2019 associated cerebral venous thrombosis (COVID-CVT). We assessed the clinical characteristics and outcomes in an international cohort of patients with COVID-CVT.

PATIENTS AND METHODS

This was a registry study of consecutive COVID-CVT patients diagnosed between March 2020 and March 2023. Data collected by the International Cerebral Venous Thrombosis Consortium from patients with CVT diagnosed between 2017 and 2018 served as a comparison. Outcome analyses were adjusted for age and sex.

RESULTS

We included 70 patients with COVID-CVT from 23 hospitals in 15 countries and 206 controls from 14 hospitals in 13 countries. The proportion of women was smaller in the COVID-CVT group (50% vs 68%, p < 0.01). A higher proportion of COVID-CVT patients presented with altered mental state (44% vs 25%, p < 0.01), the median thrombus load was higher in COVID-CVT patients (3 [IQR 2-4] vs 2 [1-3], p < 0.01) and the length of hospital stay was longer compared to controls (11 days [IQR 7-20] vs 8 [4-15], p = 0.02). In-hospital mortality did not differ (5/67 [7%, 95% CI 3-16] vs 7/206 [3%, 2-7], aOR 2.6 [95% CI 0.7-9]), nor did the frequency of functional independence after 6 months (modified Rankin Scale 0-2; 45/58 [78%, 95% CI 65-86] vs 161/185 [87%, 81-91], aOR 0.5 [95% CI 0.2-1.02]).

CONCLUSION

In contrast to previous studies, the in-hospital mortality rate and functional outcomes during follow-up did not differ between COVID-CVT patients and the pre-COVID-19 controls.

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

BACKGROUND

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

AIMS

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

SUMMARY OF REVIEW

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

CONCLUSIONS

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

External validation of the SI2NCAL2C score for outcomes following cerebral venous thrombosis

OBJECTIVES

Prognostication for cerebral venous thrombosis (CVT) remains difficult. We sought to validate the SI2NCAL2C score in an international cohort.

MATERIALS AND METHODS

The SI2NCAL2C score was originally developed to predict poor outcome (modified Rankin Scale (mRS) 3-6) at 6 months, and mortality at 30 days and 1 year using data from the International CVT Consortium. The SI2NCAL2C score uses 9 variables: the absence of any female-sex-specific risk factors, intracerebral hemorrhage, central nervous system infection, focal neurological deficits, coma, age, lower level of hemoglobin, higher level of glucose, and cancer. The ACTION-CVT study was an international retrospective study that enrolled consecutive patients across 27 centers. The poor outcome score was validated using 90-day mRS due to lack of follow-up at the 6-month time-point in the ACTION-CVT cohort. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC) and calibration plots. Missing data were imputed using the additive regression and predictive mean matching methods. Bootstrapping was performed with 1000 iterations.

RESULTS

Mortality data were available for 950 patients and poor outcome data were available for 587 of 1,025 patients enrolled in ACTION-CVT. Compared to the International CVT Consortium, the ACTION-CVT cohort was older, less often female, and with milder clinical presentation. Mortality was 2.5% by 30 days and 6.0% by one year. At 90-days, 16.7% had a poor outcome. The SI2NCAL2C score had an AUC of 0.74 [95% CI 0.69-0.79] for 90-day poor outcome, 0.72 [0.60-0.82] for mortality by 30 days, and 0.82 [0.76-0.88] for mortality by one year.

CONCLUSIONS

The SI2NCAL2C score had acceptable to good performance in an international external validation cohort. The SI2NCAL2C score warrants additional validation studies in diverse populations and clinical implementation studies.

Trends in cerebral venous thrombosis before and during the COVID-19 pandemic: Analysis of the National Inpatient Sample

OBJECTIVES

We sought to provide updated incidence and trend data for cerebral venous thrombosis (CVT) in the United States from 2016-2020, examine the impact of the COVID-19 pandemic on CVT, and identify predictors of in-hospital mortality.

MATERIALS AND METHODS

Validated ICD-10 codes were used to identify discharges with CVT in the National Inpatient Sample (NIS). Sample weights were applied to generate nationally representative estimates, and census data were used to compute incidence rates. The first wave of the COVID-19 pandemic was defined as January-May 2020. Trend analysis was completed using Joinpoint regression.

RESULTS

From 2016 to 2020, the incidence of CVT increased from 24.34 per 1,000,000 population per year (MPY) to 33.63 per MPY (Annual Percentage Change (APC) 8.6 %; p < 0.001). All-cause in-hospital mortality was 4.9 % [95 % CI 4.5-5.4]. On multivariable analysis, use of thrombectomy, increased age, atrial fibrillation, stroke diagnosis, infection, presence of prothrombotic hematologic conditions, lowest quartile of income, intracranial hemorrhage, and male sex were associated with in-hospital mortality. CVT incidence was similar comparing the first 5 months of 2020 and 2019 (31.37 vs 32.04; p = 0.322) with no difference in median NIHSS (2 [IQR 1-10] vs. 2 [1-9]; p = 0.959) or mortality (4.2 % vs. 5.6 %; p = 0.176).

CONCLUSIONS

CVT incidence increased in the US from 2016 to 2020 while mortality did not change. Increased age, prothrombotic state, stroke diagnosis, infection, atrial fibrillation, male sex, lowest quartile of income, intracranial hemorrhage, and use of thrombectomy were associated with in-hospital mortality following CVT. During the first wave of the COVID-19 pandemic, CVT volumes and mortality were similar to the prior year.

Multicenter registry study of cerebral venous thrombosis in china (RETAIN-CH): Rationale and design

BACKGROUND AND RATIONALE

Cerebral venous thrombosis (CVT) is a rare cerebrovascular disorder that mainly affects young and middle-aged adults. Epidemiological data on the incidence, risk factors, diagnosis, treatment, and prognosis of CVT are lacking in China. In addition, there is a lack of evidence from large, multicenter, real-world studies on the efficacy and safety of endovascular.

AIM

To understand the incidence, diagnosis and treatment status of CVT in China and to estimate the effectiveness and safety of endovascular treatment in the real-world.

METHODS

A multicenter, retrospective observational cohort study will be conducted on CVT patient records from 104 hospitals, between January 1, 2018 and June 30, 2022, identified using a 2-stage cluster sampling design based on per capita gross domestic product. Each enrolled participant is required to complete a further follow-up, which includes the current situation and the assessment at 3 and 12 months after discharge.

STUDY OUTCOMES

The outcomes of this study will include the current status of the incidence, pathogenesis, etiology, clinical symptoms, diagnosis, and treatment of CVT in China, as well as the effectiveness and safety of endovascular treatment in the real-world.

DISCUSSION

Results from this study will provide evidence on the incidence, specific risk factors, symptomatic and imaging features, and clinical outcomes of CVT in China as well as indicate whether endovascular treatment is superior to medical management alone for patients with acute CVT in the real-world.

TRIAL REGISTRATION

http://www.

CLINICALTRIALS

gov.

IDENTIFIER

NCT05448248.

Subtypes of Venous Thromboembolism in Inflammatory Bowel Disease: A Nationwide Assessment

Background

Data detailing the risk of Venous Thromboembolism (VTE) subtypes among individuals with Inflammatory bowel disease (IBD) remain limited.Aims: We looked to assess the odds of VTE subtypes among hospitalized individuals with IBD as compared to those without IBD.

Materials & Methods

Using the Nationwide Inpatient Sample database, we applied a multivariable regression analysis to compare the odds of primary VTE-related hospitalizations among individuals with and without IBD from 2016 to 2020, including deep venous thrombosis (DVT), pulmonary embolism (PE), portal vein thrombosis (PVT), Budd Chiari syndrome (BCS), renal vein thrombosis (RVT), and cerebral venous sinus thrombosis (CVST).

Results

Overall, there were 15,565 primary VTE-related hospitalizations among individuals with IBD, as compared to 1,449,164 among individuals without IBD. Having IBD increased the odds for DVT (aOR = 1.34, 95%CI: 1.25-1.43), PVT (aOR = 3.16, 95%CI: 2.65-3.76), and CVST (aOR=1.45, 95%CI: 1.05-2.00), without significant increase in the odds of a PE, BCS, or RVT. Further, individuals with ulcerative colitis (UC) were at a higher risk for the majority of VTE-subtypes as compared to those with Crohn's disease (CD). Among individuals with a VTE-related hospitalization, the presence of IBD was not associated with increased mortality (aOR = 0.77, 95%CI: 0.40-1.50), but was associated with an increased length of stay (CD - 4.8 days, UC - 5.3 days, without IBD - 4.3 days, p<0.01).

Conclusions

Clinicians should retain a high index of suspicion when evaluating VTE-related symptoms among individuals with IBD, as the presence of IBD confers a higher risk of DVT, PVT and CVST related-hospitalizations, and longer stays as compared to individuals without IBD.

Global Safety Assessment of Adverse Events of Special Interest Following 2 Years of Use and 772 Million Administered Doses of mRNA-1273

Background

Large-scale use of mRNA COVID-19 vaccines during the pandemic was associated with enhanced safety monitoring to ensure accurate and timely review of safety. We reviewed the mRNA-1273 (original strain) safety profile following 2 years of use (>772 million administered doses), primarily focusing on predefined safety topics (ie, adverse events of special interest [AESIs]) proposed in advance of COVID-19 vaccine use.

Methods

Cumulative mRNA-1273 safety data were included from spontaneous adverse event (AE) cases reported to Moderna's global safety database between 18 December 2020 and 17 December 2022. Reporting rates of AESIs were calculated per 1 million doses of mRNA-1273 administered. Observed-to-expected (OE) ratios were computed by comparing observed rates of AESIs with the background/expected rate for these events to evaluate potential associations with mRNA-1273.

Results

There were 658 759 identified case reports associated with 2 517 669 AEs. Most AEs were nonserious (83.4%; 2 098 954/2 517 669). Overall 0.7% (17 751/2 517 669) were fatal. AESIs represented 13.7% of all AEs (344 921/2 517 669), with reporting rates for most AESIs below the expected background incidence. Exceptions included anaphylaxis (OE ratio 3 days after vaccination, 2.09; 95% CI, 1.93-2.25) and, among individuals aged 12 to 40 years, myocarditis (OE ratio 7 days after any dose, 3.89 [3.50-4.32]; among men after dose 2, 8.57 [6.88-10.68]) and pericarditis (OE ratio 7 days after vaccination, 3.47; 2.89-4.16).

Conclusions

This safety analysis of mRNA-1273 identified evidence of increased risk for anaphylaxis, myocarditis, and pericarditis but not for other AESIs identified for enhanced monitoring ahead of COVID-19 vaccine use.

Prognosis after cerebral venous thrombosis: Mortality during initial admission and at 30 days and one year after discharge in a large Canadian population-based cohort

BACKGROUND

Prognosis following cerebral venous thrombosis (CVT) is more favorable than other stroke types, but longer-term literature is limited, and trends over time are under-explored.

OBJECTIVE

Using administrative data, we examined factors associated with mortality in the inpatient setting, at 30 days and at one year following hospital discharge among a large consecutive cohort of Canadian patients with CVT.

DESIGN/METHODS

CVT patients from British Columbia (BC), Canada from 2000 to 2017 were identified using ICD diagnosis codes from the BC subset of the Canadian Institute for Health Information's Discharge Abstract Database. Logistic regression was used to investigate factors associated with inpatient mortality and survival analysis with Cox regression was used to explore factors associated with mortality at 30 days and one year.

RESULTS

Of 554 incident CVT patients identified, 508 (92 %) survived their index admission. Older age (OR 1.04, 95 % CI 1.03-1.06, p < 0.01) and the presence of seizures (OR 2.31, 95 % CI 1.08-4.94, p = 0.03) or intracranial bleeding (OR 2.28, 95 % CI 1.08-4.85, p = 0.03) were associated with increased odds of inpatient mortality. Mortality after hospital discharge was 3.0 % at 30 days and 9.4 % at one year. Older age (HR 1.05, 95 % CI 1.02-1.08, p < 0.01 at 30 days; HR 1.05, 95 % CI 1.04-1.07, p < 0.01 at 1 year) and having recent or active malignancy (HR 4.17, 95 % CI 1.51-11.52, p < 0.01 at 30 days; HR 4.60, 95 % CI 2.60-8.11, p < 0.01 at 1 year) were significantly associated with higher risks of mortality at 30 days and one year after discharge. There were decreases in inpatient mortality over the study period, but this was offset by higher mortality within 30 days after discharge in the later study epochs.

CONCLUSIONS

Among patients discharged with a diagnosis of CVT, one-year mortality was high at 9.4 %. Older age and a history of cancer were associated with higher mortality after discharge.

Clinicoradiological Features and Long-term Cognitive and Functional Outcome in Patients with Deep Cerebral Venous Thrombosis

Background

Deep cerebral venous thrombosis (DCVT) can have long-term functional and cognitive sequelae. Although literature exists on cognitive impairment after arterial stroke, cognitive sequelae after cerebral venous thrombosis (CVT) are much less studied.

Methods

Clinical records of 29 patients diagnosed with DCVT were reviewed. The Modified Telephonic Interview for Cognitive Status (TICS-M) was adapted and validated in the regional language (Kannada) and applied to 18 patients with DCVT, at a mean follow-up duration of 5.32 years. Screening for depression was done via telephonic Patient Health Questionnaire-9 (PHQ-9)-Kannada version, and functional status was screened by applying the modified Rankin Scale (mRS).

Results

DCVT had a mortality rate of 10.34% due to acute complications. mRS scores of 0-1 were achieved at follow-up in all patients who survived. Receiver operating characteristic (ROC) analysis revealed a cutoff of ≤44.5 (maximum score of 49) for the diagnosis of cognitive impairment via TICS-M (Kannada version) in DCVT patients. Evidence of cognitive dysfunction was seen in eight patients (42.10%), and three patients (16.66%) had evidence of depression.

Conclusions

Survivors of acute DCVT can potentially have long-term cognitive sequelae. Screening for cognitive dysfunction, depression, and functional status can be effectively done using telephonically applied scales that are adapted to the local language. Neuropsychological evaluation and early cognitive rehabilitation can be initiated for patients in whom deficits are identified on cognitive screening.

Post cerebral venous thrombosis headache - Prevalence, mechanisms and risk factors

INTRODUCTION

Headache after cerebral venous thrombosis (post-CVT headache [PCH]) is a common complaint during follow-up. Risk factors and their pathophysiology are not well known. We studied PCH prevalence in CVT patients, its pathophysiology, and possible risk factors.

MATERIALS AND METHODS

We performed a retrospective observational study of patients admitted to a tertiary hospital between 2006 and 2019 with CVT and at least one follow-up appointment. We diagnosed PCH when patients reported headaches during the follow-up visit. Recanalization was retrospectively assessed by two neuroradiologists using the first available follow-up MRI/ MRV, and the PRIORITy-CVT study classification.

RESULTS

Of 131 patients, sixty (60/131, 45.8 %) reported PCH at the 3-month follow-up. Of these PCH, 9 had previous migraine (9/60, 5.0 %) and 13 previous tension-type headaches (13/60, 21.6 %), before CVT. Forty-four (44/60, 73.3 %) PCH patients had de novo headache: 21 (21/60, 35.0 %) de novo tension-type headaches; 6 (6/60, 10.0 %) de novo migraine; 6 [(6/60, 10.0 %) secondary headache disorders: 3 due to dural arteriovenous fistula, 2 due to intracranial hypertension, and 1 recurrent CVT], and 11 other headache types. Most patients had at least partial recanalization, with no difference in PCH frequency amongst recanalization subgroups (p = 0.598). Premorbid depression (p = 0.009, OR 7.9, 95 % CI 1.6-31.4) increased the odds ratio of PCH, while superior sagittal sinus thrombosis (p = 0.005, OR 0.15, 95 % CI 0.03-0.56) decreased it.

DISCUSSION

Our study shows that PCH is a common finding after CVT and elucidates potential risk factors. PCH is common in patients with previous or de novo primary headache. In PCH patients without previous headache, secondary causes of headache, namely related to CVT complications, should be excluded. PCH is also increased in patients with premorbid depression. There was no statistically significant difference in PCH amongst the PRIORITy-CVT recanalization subgroups, but most patients had at least partial recanalization.

Epidemiology, pathogenesis, and management of Coronavirus disease 2019-associated stroke

The Coronavirus disease 2019 (COVID-19) epidemic has triggered a huge impact on healthcare, socioeconomics, and other aspects of the world over the past three years. An increasing number of studies have identified a complex relationship between COVID-19 and stroke, although active measures are being implemented to prevent disease transmission. Severe COVID-19 may be associated with an increased risk of stroke and increase the rates of disability and mortality, posing a serious challenge to acute stroke diagnosis, treatment, and care. This review aims to provide an update on the influence of COVID-19 itself or vaccines on stroke, including arterial stroke (ischemic stroke and hemorrhagic stroke) and venous stroke (cerebral venous thrombosis). Additionally, the neurovascular mechanisms involved in SARS-CoV-2 infection and the clinical characteristics of stroke in the COVID-19 setting are presented. Evidence on vaccinations, potential therapeutic approaches, and effective strategies for stroke management has been highlighted.

Blood Coagulation and Thrombotic Disorders following SARS-CoV-2 Infection and COVID-19 Vaccination

Although abundant data confirm the efficacy and safety profile of the developed vaccines against COVID-19, there are still some concerns regarding vaccination in high-risk populations. This is especially valid for patients susceptible to thrombotic or bleeding events and hesitant people due to the fear of thrombotic incidents following vaccination. This narrative review focuses on various inherited and acquired thrombotic and coagulation disorders and the possible pathophysiologic mechanisms interacting with the coagulation system during immunization in view of the currently available safety data regarding COVID-19 vaccines. Inherited blood coagulation disorders and inherited thrombotic disorders in the light of COVID-19, as well as blood coagulation and thrombotic disorders and bleeding complications following COVID-19 vaccines, along with the possible pathogenesis hypotheses, therapeutic interventions, and imaging for diagnosing are discussed in detail. Lastly, the lack of causality between the bleeding and thrombotic events and COVID-19 vaccines is debated, but still emphasizes the importance of vaccination against COVID-19, outweighing the minimal risk of potential rare adverse events associated with coagulation.

Risk and Prognosis of Cancer in Patients With Cerebral Venous Thrombosis Compared With the Danish General Population

BACKGROUND

Whether cerebral venous thrombosis (CVT) is a marker of cancer in clinical practice remains unknown. Little is known about the prognosis of cancer detected subsequent to CVT.

METHODS

We used Danish nationwide registries (1996-2019) to identify patients with a first-time primary inpatient diagnosis of CVT without a history of cancer (N=811, 65% women, median age 42 years). We assessed the risk of an incident cancer diagnosis using standardized incidence ratios (SIRs). This measure contrasts the number of observed cancers among patients with CVT to the number of expected cancers where patients with CVT have the same cancer risk as the general population. We used Kaplan-Meier survival analysis and Cox regression to compare the survival of patients with both cancer and CVT with the survival of patients with cancer but without CVT, matched on cancer site, sex, age, and year of cancer diagnosis.

RESULTS

Observing 43 incident cancer cases during follow-up, the overall SIR was unity (SIR, 1.04 [95% CI, 0.75-1.40]). However, the risk was ≈7-fold the expected level in the first 3 months following CVT diagnosis (SIR, 7.00 [95% CI, 3.02-13.80]) and ≈2-fold the expected level from 3 to 12 months following CVT diagnosis (SIR, 2.21 [95% CI, 0.89-4.56]). By 12 months following CVT diagnosis, the risk resembled the expected level (SIR, 0.76 [95% CI, 0.50-1.09]). Survival among cancer patients with prior CVT versus cancer patients without prior CVT was 91% versus 87% after 6 months and 65% versus 70% after 5 years. The adjusted hazard ratio of death was 0.78 (95% CI, 0.44-1.38).

CONCLUSIONS

Patients with CVT were not at overall increased risk of a cancer diagnosis, except in the first 3 months after diagnosis during which period the risk was elevated ≈7-fold. The estimate from this early period, however, was based on only a few cancer diagnoses. Unlike other forms of venous thrombosis, a prior diagnosis of CVT did not negatively impact cancer survival.

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

Introduction

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

Methods

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

Discussion

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

Clinical trial registration

ClinicalTrials.gov, NCT04660747.

Cerebrovascular Disease in COVID-19

Not in the history of transmissible illnesses has there been an infection as strongly associated with acute cerebrovascular disease as the novel human coronavirus SARS-CoV-2. While the risk of stroke has known associations with other viral infections, such as influenza and human immunodeficiency virus, the risk of ischemic and hemorrhagic stroke related to SARS-CoV-2 is unprecedented. Furthermore, the coronavirus disease 2019 (COVID-19) pandemic has so profoundly impacted psychosocial behaviors and modern medical care that we have witnessed shifts in epidemiology and have adapted our treatment practices to reduce transmission, address delayed diagnoses, and mitigate gaps in healthcare. In this narrative review, we summarize the history and impact of the COVID-19 pandemic on cerebrovascular disease, and lessons learned regarding the management of patients as we endure this period of human history.

Obstetric and Gynecologic Disorders and the Nervous System

OBJECTIVE

This article discusses obstetric and gynecologic associations with common neurologic disorders.

LATEST DEVELOPMENTS

Neurologic complications of obstetric and gynecologic disorders can arise throughout the lifespan. Caution should be exercised when prescribing fingolimod and natalizumab to patients with multiple sclerosis who are of childbearing potential because of the risk of disease rebound when they are discontinued. OnabotulinumtoxinA is considered safe in pregnancy and lactation based on long-term observational data. Hypertensive disorders of pregnancy are associated with higher subsequent cerebrovascular risk, likely via multiple mechanisms.

ESSENTIAL POINTS

Neurologic disorders may present in a variety of obstetric and gynecologic contexts, with meaningful implications for recognition and treatment. These interactions must be considered when treating women with neurologic conditions.

Diagnosis and Treatment of Cerebral Venous Thrombosis

OBJECTIVE

Cerebral venous thrombosis (CVT), thrombosis of the dural sinus, cerebral veins, or both, is a rare cerebrovascular disease. Although mortality rates after CVT have declined over time, this condition can result in devastating neurologic outcomes. This article reviews the latest literature regarding CVT epidemiology, details new factors associated with the development of CVT, and describes advances in CVT treatment. It also contains a discussion of future directions in the field, including novel diagnostic imaging modalities, and potential strategies to reduce the risks associated with CVT.

LATEST DEVELOPMENTS

The incidence of CVT may be as high as 2 per 100,000 adults per year. It remains a difficult condition to diagnose given its variable clinical manifestations and the necessity of neuroimaging for confirmation. The COVID-19 pandemic has revealed a novel CVT trigger, vaccine-induced immune thrombotic thrombocytopenia (VITT), as well as an association between COVID-19 infection and CVT. Although VITT is a very rare event, timely diagnosis and treatment of CVT due to VITT likely improves patient outcomes. Direct oral anticoagulants are currently being used to treat CVT and emerging data suggest that these agents are as safe and effective as vitamin K antagonists. The role of endovascular therapy to treat CVT, despite a recent clinical trial, remains unproven.

ESSENTIAL POINTS

The incidence of CVT has increased, outcomes have improved, and the use of direct oral anticoagulants to treat CVT represents an important advance in the clinical care of these patients. Rates of CVT as a complication of COVID-19 vaccines using adenoviral vectors are very low (<5 per million vaccine doses administered), with the benefits of COVID-19 vaccination far outweighing the risks.

Intravenous Thrombolysis for Acute Ischemic Stroke

OBJECTIVE

This article reviews the history of IV thrombolysis, its current indications and implementation, the duality of the "time is brain" versus "tissue clock" approaches, the impact of endovascular thrombectomy on IV thrombolysis, the emergence of tenecteplase, and future research directions.

LATEST DEVELOPMENTS

The growing use of factor Xa inhibitors has increasingly caused patients with stroke to be excluded from treatment with IV thrombolysis. Important geographic, socioeconomic, sex, race, and ethnic disparities have been identified in the implementation of IV thrombolysis and need to be overcome. IV thrombolysis substantially improves outcomes when provided within the first golden hour after stroke onset in patients treated in mobile stroke units, supporting the "time is brain" concept and encouraging the possible value of more widespread implementation of the mobile stroke unit approach. At the same time, other studies have shown that IV thrombolysis can be successful in patients whose "tissue clock" is still ticking up to 9 hours after stroke onset or in patients who awaken with their stroke, as demonstrated by favorable imaging profiles. These considerations, along with the emergence of endovascular thrombectomy, have fostered examination of our care systems, including the "drip and ship" versus direct to comprehensive or endovascular thrombectomy stroke center approaches, as well as the possibility of skipping IV thrombolysis in certain patients treated with endovascular thrombectomy. Data suggesting that tenecteplase is at least noninferior to alteplase, as well as its more convenient dosing, has led to its increased use. Ongoing studies are evaluating newer thrombolytics and adding antithrombotic therapy to IV thrombolysis.

ESSENTIAL POINTS

IV thrombolysis remains the most common acute stroke treatment. Advances in acting faster to treat stroke have increased its efficacy, and advances in imaging have expanded its use. However, implementing these advances and overcoming disparities in IV thrombolysis use remain major challenges.

A Model of High-Speed Endovascular Sonothrombolysis with Vortex Ultrasound-Induced Shear Stress to Treat Cerebral Venous Sinus Thrombosis

This research aims to demonstrate a novel vortex ultrasound enabled endovascular thrombolysis method designed for treating cerebral venous sinus thrombosis (CVST). This is a topic of substantial importance since current treatment modalities for CVST still fail in as many as 20% to 40% of the cases, and the incidence of CVST has increased since the outbreak of the coronavirus disease 2019 pandemic. Compared with conventional anticoagulant or thrombolytic drugs, sonothrombolysis has the potential to remarkably shorten the required treatment time owing to the direct clot targeting with acoustic waves. However, previously reported strategies for sonothrombolysis have not demonstrated clinically meaningful outcomes (e.g., recanalization within 30 min) in treating large, completely occluded veins or arteries. Here, we demonstrated a new vortex ultrasound technique for endovascular sonothrombolysis utilizing wave-matter interaction-induced shear stress to enhance the lytic rate substantially. Our in vitro experiment showed that the lytic rate was increased by at least 64.3% compared with the nonvortex endovascular ultrasound treatment. A 3.1-g, 7.5-cm-long, completely occluded in vitro 3-dimensional model of acute CVST was fully recanalized within 8 min with a record-high lytic rate of 237.5 mg/min for acute bovine clot in vitro. Furthermore, we confirmed that the vortex ultrasound causes no vessel wall damage over ex vivo canine veins. This vortex ultrasound thrombolysis technique potentially presents a new life-saving tool for severe CVST cases that cannot be efficaciously treated using existing therapies.

Association between thromboembolic events and COVID-19 infection within 30 days: a case-control study among a large sample of adult hospitalized patients in the United States, March 2020-June 2021

The association between thromboembolic events (TE) and COVID-19 infection is not completely understood at the population level in the United States. We examined their association using a large US healthcare database. We analyzed data from the Premier Healthcare Database Special COVID-19 Release and conducted a case-control study. The study population consisted of men and non-pregnant women aged ≥ 18 years with (cases) or without (controls) an inpatient ICD-10-CM diagnosis of TE between 3/1/2020 and 6/30/2021. Using multivariable logistic regression, we assessed the association between TE occurrence and COVID-19 diagnosis, adjusting for demographic factors and comorbidities. Among 227,343 cases, 15.2% had a concurrent or prior COVID-19 diagnosis within 30 days of their index TE. Multivariable regression analysis showed a statistically significant association between a COVID-19 diagnosis and TE among cases when compared to controls (adjusted odds ratio [aOR] 1.75, 95% CI 1.72-1.78). The association was more substantial if a COVID-19 diagnosis occurred 1-30 days prior to index hospitalization (aOR 3.00, 95% CI 2.88-3.13) compared to the same encounter as the index hospitalization. Our findings suggest an increased risk of TE among persons within 30 days of being diagnosed COVID-19, highlighting the need for careful consideration of the thrombotic risk among COVID-19 patients, particularly during the first month following diagnosis.

Incidence of Cerebral Venous Thrombosis: A Population-Based Study, Systematic Review, and Meta-Analysis

BACKGROUND

Studying the baseline incidence of cerebral venous thrombosis (CVT) prior to COVID-19 and the limitations of how this has been previously reported in the literature will help improve understanding of this disease and how risks may have changed in the post-COVID era.

METHODS

We examined CVT incidence using linked administrative data in British Columbia, Canada (population 5.2 million). To contextualize our findings, we also examined CVT incidence in the published literature and searched MEDLINE and EMBASE for article titles and abstracts up to Nov 2, 2021 on CVT incidence in adults. We performed abstract screening and full-text review prior to data extraction and explored associations between CVT incidence and year of study, geographic location, and study quality with meta-analyses and meta-regression. A random-effects restricted maximum likelihood model was used. Publication bias was assessed using the Egger tests and using visual inspection of the funnel plot for symmetry.

RESULTS

There were 554 unique CVT cases (mean age 50.9 years, 55.4% women) in British Columbia from 2000 to 2017; overall annual incidence was 8.7 (95%CI' 8.0-9.4) per million. Incidence increased over time in men across the entire study period, and from 2011 to 2017 in women. We identified 22 other studies on CVT incidence before 2020 (21/23 total studies included in meta-analysis). Annual incidence overall was 12.1 (95% CI' 9.9-14.3) per million with significant between-study heterogeneity (I2 98.8%, Qp-value<0.001). There were no significant associations on meta-regression between incidence and study year, study quality score, or gross national income per capita of the study country. Visual inspection of the funnel plot and a significant Egger test (z=2.8, P<0.01) suggested possible publication bias.

CONCLUSIONS

Incidence of CVT in Canadian data increased over time but remained lower than in other population-based studies. Significant heterogeneity exists in the literature, which may be subject to publication bias.

Contemporary Incidence and Burden of Cerebral Venous Sinus Thrombosis in Children of the United States

Background:

The incidence of cerebral venous thrombosis (CVT) in children of the United States is unknown, and it is uncertain how the burden of CVT hospitalizations in children changed over the last decade.

Methods:

We conducted a retrospective cohort study using the State Inpatient Database and Kid’s inpatient database. All new CVT cases in children (0–19 years) in the New York 2006 to 2018 State Inpatient Database (n=705), and all cases of CVT in the entire US contained in the 2006 to 2019 Kid’s inpatient database (weighted n=6115) were identified using validated International Classification of Diseases (ICDs ) codes. Incident counts were combined with census data to compute incidence. Between-group differences in incidence were tested using 2-proportions Z -test, and Joinpoint regression was used to trend incidence over time.

Results:

Across the study period, 48.2% of all incident CVT cases and 44.6% of all CVT admissions nationally were in girls. Of all incident cases, 27.2% were infants and 65.8% of these infants were neonates. Average incidence across the study period was (1.1/100 000/year, SE:0.04) but incidence in infants (6.4/100 000/year) was at least 5 times the incidence in other age groups (1–4 years: 0.7/100 000/year, 15–19 years: 1.2/100 000/year). Incidence and national burden of CVT admissions was higher in girls in adolescents 15 to 19 years, but overall burden was higher in boys in other age groups. Age- and sex-standardized CVT incidence increased by 3.8% annually (95% CI, 0.2%–7.6%), while the overall burden of admissions increased by 4.9% annually (95% CI, 3.6%–6.2%).

Conclusions:

CVT incidence in New York and national burden of CVT increased significantly over the last decade.

Predictors of Recurrent Venous Thrombosis After Cerebral Venous Thrombosis: Analysis of the ACTION-CVT Study

BACKGROUND AND OBJECTIVE

Cerebral venous thrombosis (CVT) is a rare cause of stroke carrying a nearly 4% risk of recurrence after 1 year. There are limited data on predictors of recurrent venous thrombosis in patients with CVT. In this study, we aim to identify those predictors.

METHODS

This is a secondary analysis of the ACTION-CVT study which is a multicenter international study of consecutive patients hospitalized with a diagnosis of CVT over a 6-year period. Patients with cancer-associated CVT, CVT during pregnancy, or CVT in the setting of known antiphospholipid antibody syndrome were excluded per the ACTION-CVT protocol. The study outcome was recurrent venous thrombosis defined as recurrent venous thromboembolism (VTE) or de novo CVT. We compared characteristics between patients with vs without recurrent venous thrombosis during follow-up and performed adjusted Cox regression analyses to determine important predictors of recurrent venous thrombosis.

RESULTS

Nine hundred forty-seven patients were included with a mean age of 45.2 years, 63.9% were women, and 83.6% had at least 3 months of follow-up. During a median follow-up of 308 (interquartile range 120-700) days, there were 5.05 recurrent venous thromboses (37 VTE and 24 de novo CVT) per 100 patient-years. Predictors of recurrent venous thrombosis were Black race (adjusted hazard ratio [aHR] 2.13, 95% CI 1.14-3.98, p = 0.018), history of VTE (aHR 3.40, 95% CI 1.80-6.42, p < 0.001), and the presence of one or more positive antiphospholipid antibodies (aHR 3.85, 95% CI 1.97-7.50, p < 0.001). Sensitivity analyses including events only occurring on oral anticoagulation yielded similar findings.

DISCUSSION

Black race, history of VTE, and the presence of one or more antiphospholipid antibodies are associated with recurrent venous thrombosis among patients with CVT. Future studies are needed to validate our findings to better understand mechanisms and treatment strategies in patients with CVT.

Venous stroke–a stroke subtype that should not be ignored

Based on the etiology, stroke can be classified into ischemic or hemorrhagic subtypes, which ranks second among the leading causes of death. Stroke is caused not only by arterial thrombosis but also by cerebral venous thrombosis. Arterial stroke is currently the main subtype of stroke, and research on this type has gradually improved. Venous thrombosis, the particular type, accounts for 0.5–1% of all strokes. Due to the lack of a full understanding of venous thrombosis, as well as its diverse clinical manifestations and neuroimaging features, there are often delays in admission for it, and it is easy to misdiagnose. The purpose of this study was to review the pathophysiology mechanisms and clinical features of arterial and venous thrombosis and to provide guidance for further research on the pathophysiological mechanism, clinical diagnosis, and treatment of venous thrombosis. This review summarizes the pathophysiological mechanisms, etiology, epidemiology, symptomatology, diagnosis, and treatment heterogeneity of venous thrombosis and compares it with arterial stroke. The aim is to provide a reference for a comprehensive understanding of venous thrombosis and a scientific understanding of various pathophysiological mechanisms and clinical features related to venous thrombosis, which will contribute to understanding the pathogenesis of intravenous stroke and provide insight into diagnosis, treatment, and prevention.

Outcome Prediction in Cerebral Venous Thrombosis: The IN-REvASC Score

BACKGROUND

We identified risk factors, derived and validated a prognostic score for poor neurological outcome and death for use in cerebral venous thrombosis (CVT).

METHODS

We performed an international multicenter retrospective study including consecutive patients with CVT from January 2015 to December 2020. Demographic, clinical, and radiographic characteristics were collected. Univariable and multivariable logistic regressions were conducted to determine risk factors for poor outcome, mRS 3-6. A prognostic score was derived and validated.

RESULTS

A total of 1,025 patients were analyzed with median 375 days (interquartile range [IQR], 180 to 747) of follow-up. The median age was 44 (IQR, 32 to 58) and 62.7% were female. Multivariable analysis revealed the following factors were associated with poor outcome at 90- day follow-up: active cancer (odds ratio [OR], 11.20; 95% confidence interval [CI], 4.62 to 27.14; P<0.001), age (OR, 1.02 per year; 95% CI, 1.00 to 1.04; P=0.039), Black race (OR, 2.17; 95% CI, 1.10 to 4.27; P=0.025), encephalopathy or coma on presentation (OR, 2.71; 95% CI, 1.39 to 5.30; P=0.004), decreased hemoglobin (OR, 1.16 per g/dL; 95% CI, 1.03 to 1.31; P=0.014), higher NIHSS on presentation (OR, 1.07 per point; 95% CI, 1.02 to 1.11; P=0.002), and substance use (OR, 2.34; 95% CI, 1.16 to 4.71; P=0.017). The derived IN-REvASC score outperformed ISCVT-RS for the prediction of poor outcome at 90-day follow-up (area under the curve [AUC], 0.84 [95% CI, 0.79 to 0.87] vs. AUC, 0.71 [95% CI, 0.66 to 0.76], χ2 P<0.001) and mortality (AUC, 0.84 [95% CI, 0.78 to 0.90] vs. AUC, 0.72 [95% CI, 0.66 to 0.79], χ2 P=0.03).

CONCLUSIONS

Seven factors were associated with poor neurological outcome following CVT. The INREvASC score increased prognostic accuracy compared to ISCVT-RS. Determining patients at highest risk of poor outcome in CVT could help in clinical decision making and identify patients for targeted therapy in future clinical trials.

A novel severe cerebral venous thrombosis rat model based on semi-ligation combined with ferric chloride and thrombin

AIMS

An applicable cerebral venous sinus thrombosis (CVST) model is imperative for exploring its pathophysiology. We established a novel severe CVST model using semi-ligation, ferric chloride, and thrombin.

METHODS

A total of 138 male Sprague-Dawley rats were randomly divided into semi-ligation (n = 75) and non-semi-ligation (n = 63) groups. A sham group (n = 46) was also included. We compared short-term and long-term neurological and cognitive dysfunction, mortality rates, thrombus load, venous infarction volume, the blood-brain barrier permeability, brain water content, and microglia activation among the three groups.

RESULTS

Thrombi involving multiple venous sinuses appeared in all semi-ligation rats within 2 days postoperatively. Compared with the non-semi-ligation group, short-term and long-term neurological dysfunction were more severe (p < 0.05), and thrombus weight, venous infarction volumes, and microglia activation were more significant (p < 0.05) in the semi-ligation group. Further, the cognitive function of the semi-ligation group significantly decreased (p < 0.05) on postoperative day 21. Cumulative mortality rates between the semi-ligation and non-semi-ligation groups did not differ significantly.

CONCLUSION

Semi-ligation combined with ferric chloride and thrombin can produce a severe CVST model with multiple venous sinus involvement, which is suitable for short- and long-term neurological and cognitive dysfunction assessment.

Direct Oral Anticoagulants Versus Vitamin K Antagonists in Cerebral Venous Thrombosis: A Systematic Review and Meta-Analysis

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.

High Incidence and Unique Features of Cerebral Venous Sinus Thrombosis in Hospitalized Patients With COVID-19 Infection

Cerebral venous sinus thrombosis (CVST) secondary to vaccine-induced thrombotic thrombocytopenia is an extremely rare side effect of adenovirus-based COVID-19 vaccines. CVST incidence associated with COVID-19 itself has not been widely reported. We report the incidence of CVST in patients hospitalized with COVID-19 during the first year of the pandemic.

Does gender difference matter in cerebral venous thrombosis?

Female specific risk factors (FSRFs) in cerebral venous thrombosis (CVT) may have difference in clinical, imaging and outcome parameters compared to those females with additional risk factors and males. We compare the clinical, MRI and outcome between male and female patients with CVT. We also compare female patients with and without female specific risk factors. 172 patients were included from a prospectively maintained CVT registry. The diagnosis was confirmed on magnetic resonance venography (MRV). Clinical details, risk factors, MRI and MRV findings were noted. The risk factors in the females were categorized as 1) Isolated FSRF (oral contraceptive, pregnancy, puerperium), 2) FSRF in addition to other risk factor, 3) non FSRF only, and 4) no risk factor groups. Outcome at 6 months was assessed using modified Rankin Scale (mRS) as death, poor (mRS 3-5) and good (mRS ≤ 2). There were 80 (46.5%) females; 24 (30%) had FSRFs and 18 (75%) of whom also had other risk factors leaving only 6(25%) females with isolated FSRF. The frequency of other prothrombotic risk factors, and clinical and imaging findings were similar in males and females except more frequent hyperhomocysteinemia in males (59% vs 41%; P = 0.036) and altered sensorium in females (66% vs 40%; P = 0.001). 17(9.9%) patients died, 12(7%) had poor and 143(83.1%) had good outcome, which were similar in both the gender, and in the females with and without FSRF. Isolated FSRF is rare in CVT, and there is no gender difference in terms of non FSRFs, clinico-radiological severity and outcome.

Thrombotic Complications after COVID-19 Vaccination: Diagnosis and Treatment Options

Coronavirus disease 2019 (COVID-19) vaccines were developed a few months after the emergence of the pandemic. The first cases of vaccine-induced thrombotic complications after the use of adenoviral vector vaccines ChAdOx1 nCoV-19 by AstraZeneca, and Ad26.COV2.S by Johnson & Johnson/Janssen, were announced shortly after the initiation of a global vaccination program. In these cases, the occurrence of thrombotic events at unusual sites-predominantly located in the venous vascular system-in association with concomitant thrombocytopenia were observed. Since this new entity termed vaccine-induced thrombotic thrombocytopenia (VITT) shows similar pathophysiologic mechanisms as heparin-induced thrombocytopenia (HIT), including the presence of antibodies against heparin/platelet factor 4 (PF4), standard routine treatment for thrombotic events-arterial or venous-are not appropriate and may also cause severe harm in affected patients. Thrombotic complications were also rarely documented after vaccination with mRNA vaccines, but a typical VITT phenomenon has, to date, not been established for these vaccines. The aim of this review is to give a concise and feasible overview of diagnostic and therapeutic strategies in COVID-19 vaccine-induced thrombotic complications.

Global Impact of the COVID-19 Pandemic on Cerebral Venous Thrombosis and Mortality

BACKGROUND AND PURPOSE

Recent studies suggested an increased incidence of cerebral venous thrombosis (CVT) during the coronavirus disease 2019 (COVID-19) pandemic. We evaluated the volume of CVT hospitalization and in-hospital mortality during the 1st year of the COVID-19 pandemic compared to the preceding year.

METHODS

We conducted a cross-sectional retrospective study of 171 stroke centers from 49 countries. We recorded COVID-19 admission volumes, CVT hospitalization, and CVT in-hospital mortality from January 1, 2019, to May 31, 2021. CVT diagnoses were identified by International Classification of Disease-10 (ICD-10) codes or stroke databases. We additionally sought to compare the same metrics in the first 5 months of 2021 compared to the corresponding months in 2019 and 2020 (ClinicalTrials.gov Identifier: NCT04934020).

RESULTS

There were 2,313 CVT admissions across the 1-year pre-pandemic (2019) and pandemic year (2020); no differences in CVT volume or CVT mortality were observed. During the first 5 months of 2021, there was an increase in CVT volumes compared to 2019 (27.5%; 95% confidence interval [CI], 24.2 to 32.0; P<0.0001) and 2020 (41.4%; 95% CI, 37.0 to 46.0; P<0.0001). A COVID-19 diagnosis was present in 7.6% (132/1,738) of CVT hospitalizations. CVT was present in 0.04% (103/292,080) of COVID-19 hospitalizations. During the first pandemic year, CVT mortality was higher in patients who were COVID positive compared to COVID negative patients (8/53 [15.0%] vs. 41/910 [4.5%], P=0.004). There was an increase in CVT mortality during the first 5 months of pandemic years 2020 and 2021 compared to the first 5 months of the pre-pandemic year 2019 (2019 vs. 2020: 2.26% vs. 4.74%, P=0.05; 2019 vs. 2021: 2.26% vs. 4.99%, P=0.03). In the first 5 months of 2021, there were 26 cases of vaccine-induced immune thrombotic thrombocytopenia (VITT), resulting in six deaths.

CONCLUSIONS

During the 1st year of the COVID-19 pandemic, CVT hospitalization volume and CVT in-hospital mortality did not change compared to the prior year. COVID-19 diagnosis was associated with higher CVT in-hospital mortality. During the first 5 months of 2021, there was an increase in CVT hospitalization volume and increase in CVT-related mortality, partially attributable to VITT.

Background rates of five thrombosis with thrombocytopenia syndromes of special interest for COVID-19 vaccine safety surveillance: Incidence between 2017 and 2019 and patient profiles from 38.6 million people in six European countries

Background

Thrombosis with thrombocytopenia syndrome (TTS) has been reported among individuals vaccinated with adenovirus‐vectored COVID‐19 vaccines. In this study, we describe the background incidence of non‐vaccine induced TTS in six European countries.

Methods

Electronic medical records from France, the Netherlands, Italy, Germany, Spain, and the United Kingdom informed the study. Incidence rates of cerebral venous sinus thrombosis (CVST), splanchnic vein thrombosis (SVT), deep vein thrombosis (DVT), pulmonary embolism (PE), and myocardial infarction or ischemic stroke, all with concurrent thrombocytopenia, were estimated among the general population of persons in a database between 2017 and 2019. A range of additional potential adverse events of special interest for COVID‐19 vaccinations were also studied in a similar manner.

Findings

A total of 38 611 617 individuals were included. Background rates ranged from 1.0 (95% CI: 0.7–1.4) to 8.5 (7.4–9.9) per 100 000 person‐years for DVT with thrombocytopenia, from 0.5 (0.3–0.6) to 20.8 (18.9–22.8) for PE with thrombocytopenia, from 0.1 (0.0–0.1) to 2.5 (2.2–2.7) for SVT with thrombocytopenia, and from 1.0 (0.8–1.2) to 43.4 (40.7–46.3) for myocardial infarction or ischemic stroke with thrombocytopenia. CVST with thrombocytopenia was only identified in one database, with incidence rate of 0.1 (0.1–0.2) per 100 000 person‐years. The incidence of non‐vaccine induced TTS increased with age, and was typically greater among those with more comorbidities and greater medication use than the general population. It was also more often seen in men than women. A large proportion of those affected were seen to have been taking antithrombotic and anticoagulant therapies prior to their event.

Interpretation

Although rates vary across databases, non‐vaccine induced TTS has consistently been seen to be a very rare event among the general population. While still remaining very rare, rates were typically higher among older individuals, and those affected were also seen to generally be male and have more comorbidities and greater medication use than the general population.

Cerebral Venous Thrombosis in Patients With Heparin-Induced Thrombocytopenia a Systematic Review

BACKGROUND

Cerebral venous thrombosis (CVT) has recently been reported as a common thrombotic manifestation in association with vaccine-induced thrombotic thrombocytopenia, a syndrome that mimics heparin-induced thrombocytopenia (HIT) and occurs after vaccination with adenovirus-based SARS-CoV-2 vaccines. We aimed to systematically review the incidence, clinical features, and prognosis of CVT occurring in patients with HIT.

METHODS

The study protocol was registered with PROSPERO (CRD42021249652). MEDLINE, EMBASE and Cochrane CENTRAL were searched up to June 1, 2021 for HIT case series including >20 patients, or any report of HIT-related CVT. Demographic, neuroradiological, clinical, and mortality data were retrieved. Meta-analysis of proportions with random-effect modeling was used to derive rate of CVT in HIT and in-hospital mortality. Pooled estimates were compared with those for CVT without HIT and HIT without CVT, to determine differences in mortality.

RESULTS

From 19073 results, we selected 23 case series of HIT (n=1220) and 27 cases of HIT-related CVT (n=27, 71% female). CVT developed in 1.6% of 1220 patients with HIT (95% CI,1.0%-2.5%, I²=0%). Hemorrhagic brain lesions occurred in 81.8% of cases of HIT-related CVT and other concomitant thrombosis affecting other vascular territory was reported in 47.8% of cases. In-hospital mortality was 33.3%. HIT-related CVT carried a 29% absolute increase in mortality rate compared with historical CVT controls (33.3% versus 4.3%, P<0.001) and a 17.4% excess mortality compared with HIT without CVT (33.3% versus 15.9%, P=0.046).

CONCLUSIONS

CVT is a rare thrombotic manifestation in patients with HIT. HIT-related CVT has higher rates of intracerebral hemorrhage and a higher mortality risk, when compared with CVT in historical controls. The recently reported high frequency of CVT in patients with vaccine-induced thrombotic thrombocytopenia was not observed in HIT, suggesting that additional pathophysiological mechanisms besides anti-platelet factor-4 antibodies might be involved in vaccine-induced thrombotic thrombocytopenia-related CVT.

Incidence of Cerebral Venous Thrombosis Following SARS-CoV-2 Infection vs mRNA SARS-CoV-2 Vaccination in Singapore

IMPORTANCE

Reports of cerebral venous thrombosis (CVT) after messenger RNA (mRNA)-based SARS-CoV-2 vaccination has caused safety concerns, but CVT is also known to occur after SARS-CoV-2 infection. Comparing the relative incidence of CVT after infection vs vaccination may provide a better perspective of this complication.

OBJECTIVE

To compare the incidence rates and clinical characteristics of CVT following either SARS-CoV-2 infection or mRNA-based SARS-CoV-2 vaccines.

DESIGN, SETTING, AND PARTICIPANTS

Between January 23, 2020, and August 3, 2021, this observational cohort study was conducted at all public acute hospitals in Singapore, where patients hospitalized with CVT within 6 weeks of SARS-CoV-2 infection or after mRNA-based SARS-CoV-2 vaccination (BNT162b2 [Pfizer-BioNTech] or mRNA-1273 [Moderna]) were identified. Diagnosis of SARS-CoV-2 infection was based on quantitative reverse transcription-polymerase chain reaction or positive serology. National SARS-CoV-2 infection data were obtained from the National Centre for Infectious Disease, Singapore, and vaccination data were obtained from the National Immunisation Registry, Singapore.

EXPOSURES

SARS-CoV-2 infection or mRNA-based SARS-CoV-2 vaccines.

MAIN OUTCOMES AND MEASURES

Clinical characteristics, crude incidence rate (IR), and incidence rate ratio (IRR) of CVT after SARS-CoV-2 infection and after mRNA SARS-CoV-2 vaccination.

RESULTS

Among 62 447 individuals diagnosed with SARS-CoV-2 infections included in this study, 58 989 (94.5%) were male; the median (range) age was 34 (0-102) years; 6 CVT cases were identified (all were male; median [range] age was 33.5 [27-40] years). Among 3 006 662 individuals who received at least 1 dose of mRNA-based SARS-CoV-2 vaccine, 1 626 623 (54.1%) were male; the median (range) age was 50 (12-121) years; 9 CVT cases were identified (7 male individuals [77.8%]; median [range] age: 60 [46-76] years). The crude IR of CVT after SARS-CoV-2 infections was 83.3 per 100 000 person-years (95% CI, 30.6-181.2 per 100 000 person-years) and 2.59 per 100 000 person-years (95% CI, 1.19-4.92 per 100 000 person-years) after mRNA-based SARS-CoV-2 vaccination. Six (66.7%) received BNT162b2 (Pfizer-BioNTech) vaccine and 3 (33.3%) received mRNA-1273 (Moderna) vaccine. The crude IRR of CVT hospitalizations with SARS-CoV-2 infection compared with those who received mRNA SARS-CoV-2 vaccination was 32.1 (95% CI, 9.40-101; P < .001).

CONCLUSIONS AND RELEVANCE

The incidence rate of CVT after SARS-CoV-2 infection was significantly higher compared with after mRNA-based SARS-CoV-2 vaccination. CVT remained rare after mRNA-based SARS-CoV-2 vaccines, reinforcing its safety.

Incidence of venous thrombotic events and events of special interest in a retrospective cohort of commercially insured US patients

OBJECTIVE

To estimate the US incidence of thrombotic events and related rare diagnoses.

DESIGN

Claims-based retrospective cohort study of incidence.

SETTING

US commercial health insurance administrative claims database.

PARTICIPANTS

Adults 25-64 years of age between 2015 and 2019 with a minimum of 12 consecutive thrombosis-free months of continuous enrolment beginning 2014 were selected.

MAIN OUTCOMES

Age (10-year intervals) and sex stratum-specific incidence rates per 100 000 person-years were determined for venous thromboembolism (VTE), cerebral venous thrombosis (CVT) and other major venous thrombotic events, and events of special interest, including immune thrombocytopenic purpura (ITP), haemolytic-uremic syndrome (HUS) and heparin-induced thrombocytopenia (HIT).

RESULTS

Of 13 249 229 enrollees (half female/male), incidence of venous thromboembolic events (deep vein thrombosis (DVT), pulmonary embolism (PE), CVT or other major venous thrombotic conditions) was 247.89 per 100 000 person-years (95% CI: 245.96 to 249.84). Incidence of VTE was 213.79 with ICD codes alone (95% CI: 211.99 to 215.59) and 129.34 (95% CI: 127.95 to 130.75) when also requiring a filled anticoagulation prescription or an inferior vena cava (IVC) filter. Incidence was 6.37 for CVT (95% CI: 6.07 to 6.69), 26.06 for ITP (95% CI: 25.44 to 26.78), 0.94 for HUS (95% CI: 0.82 to 1.06) and 4.82 for HIT (95% CI: 4.56 to 5.10). The co-occurrence of CVT with either ITP or HIT (diagnoses within 14 days of one another) was 0.090 (95% CI: 0.06 to 0.13). Incidence tended to increase with age and was higher for women under 55. Incidence for CVT, HUS and CVT with ITP or HIT was higher for women in all age groups. Incidence of PE and CVT increased significantly over the 5-year period, while DVT rates decreased.

CONCLUSIONS

These results are the first US estimates for the incidence of thrombotic and rare events of interest in a large, commercially insured US population. Findings provide a critically important reference for determining excess morbidity associated with COVID-19 and more generally for vaccine pharmacovigilance.

Cerebral Venous Sinus Thrombosis following COVID-19 Vaccination: Analysis of 552 Worldwide Cases

To date, billions of vaccine doses have been administered to restrain the current COVID-19 pandemic worldwide. Rare side effects, including intravascular blood clots, were reported in the general population after vaccination. Among these, cerebral venous sinus thrombosis (CVST) has been considered the most serious one. To shed further light on such an event, we conducted a literature search for case descriptions of CVST in vaccinated people. Findings were analyzed with emphasis on demographic characteristics, type of vaccine, site of thrombosis, clinical and histopathological findings. From 258 potential articles published till September 2021, 41 studies were retrieved for a total of 552 patients. Of these, 492 patients (89.1%) had received AZD1222/Vaxzevria, 45 (8.2%) BNT162b2/CX-024414 Spikevax, 15 (2.7%) JNJ-78436735, and 2 (0.3%) Covishield vaccine. CVST occurred in 382 women and 170 men (mean aged 44 years), and the median timing from the shot was 9 days (range 2-45). Thrombi were predominantly seen in transverse (84%), sigmoid (66%), and/or superior sagittal (56%) sinuses. Brain injury (chiefly intracranial bleeding) occurred in 32% of cases. Of 426 patients with detailed clinical course, 63% were discharged in good clinical conditions, at times with variable neurological sequelae, whereas 37% deceased, largely due to brain injury. This narrative review confirmed CVST as a rare event after (adenoviral vector) COVID-19 vaccination, with a women/men rate ratio of 2.25. Though the pathogenesis of thrombosis is still under discussion, currently available histopathological findings likely indicate an underlying immune vasculitis.