Arterial and venous strokes in the setting of COVID-19

Background and purposeCoronavirus disease 2019 (COVID-19) is a global pandemic that causes flu-like symptoms. There is a growing body of evidence suggesting that both the central and peripheral nervous systems can be affected by SARS-CoV-2, including stroke. We present three cases of arterial ischemic strokes and one venous infarction from a cerebral venous sinus thrombosis in the setting of COVID-19 infection who otherwise had low risk factors for stroke.MethodsWe retrospectively reviewed patients presenting to a large tertiary care academic US hospital with stroke and who tested positive for COVID-19. Medical records were reviewed for demographics, imaging results and lab findings.ResultsThere were 3 cases of arterial ischemic strokes and 1 case of venous stroke: 3 males and 1 female. The mean age was 55 (48–70) years. All arterial strokes presented with large vessel occlusions and had mechanical thrombectomy performed. Two cases presented with stroke despite being on full anticoagulation.ConclusionsIt is important to recognize the neurological manifestations of COVID-19, especially ischemic stroke, either arterial or venous in nature. Hypercoagulability and the cytokine surge are perhaps the cause of ischemic stroke in these patients. Further studies are needed to understand the role of anticoagulation in these patients.     

Cerebral venous thrombosis in COVID-19-associated coagulopathy: A case report

COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was first reported in Wuhan, China in December 2019, and is ongoing pandemic. While a majority of patients with SARS-CoV-2 infection shows asymptomatic or mild disease, hospitalized patients can develop critical condition, such as pneumonia, sepsis, and respiratory failure. Some cases deteriorate into sever systemic disease and multiorgan failure. Many patients of severe COVID-19 show hypercoagulable state and complicate with venous thromboembolism and atrial thrombosis. We herein reported a case of COVID-19 who developed cerebral venous thrombosis (CVT) co-incidence with pulmonary thromboembolism (PTE). A 56-year-old Japanese man was presented with fever and malaise and diagnosed with COVID-19. He was treated with ciclesonide and azithromycin, but his respiratory condition deteriorated. Thus, systemic corticosteroids and favipiravir were initiated and these treatments resulted in afebrile state, improving malaise and respiratory failure. However, he suddenly developed severe headache and vomiting with increased concentration of D-dimer. Brain CT and MRI showed typical images of CVT in the left transvers sinus and CT pulmonary angiography showed PE. Administration of unfractionated heparin followed by edoxaban treatment reduced the levels of D-dimer and improved his clinical presentation and thrombosis. Monitoring coagulopathy is important in COVID-19 patients and in case of venous thromboembolism, including cerebral venous system, appropriate anticoagulant therapy should be initiated.     

Dural venous sinus thrombosis after cerebellopontine angle surgery: Should it be treated?

IntroductionDural venous sinus thrombosis is an uncommon, but significant sequela that may occur after resection of a cerebellopontine angle lesion. The natural history and management of this pathology has not been sufficiently studied.MethodsAll operative cases for cerebellopontine angle lesions performed in our local institution dating from 1 January 2005 to 30 June 2018 were retrospectively reviewed to identify patients who developed new post-operative dural venous sinus thrombosis. Patients who developed a significantly narrowed sinus without intrinsic thrombus were also identified. Progression of sinus thrombosis through time was followed, with comparisons made between complications amongst patients with and without a compromised sinus.ResultsOf the 126 patients, 20 were found to have new sinus thrombosis, with another 16 developing a critically narrowed sinus without intrinsic thrombus. These cases are significantly associated with translabyrinthine resection of acoustic schwannoma. 4 patients amongst the thrombosed group were commenced on additional therapeutic anticoagulation or antiplatelets, whilst the rest were observed. Based on available follow up imaging, 10/17 patients had significantly improved sinus thrombosis on serial imaging, including 8/14 amongst those not given additional anticoagulation. Patients with a compromised sinus demonstrated a higher rate of cerebrospinal fluid leak requiring blindsac procedures. When involving a dominant sinus, there is also an association of an increased requirement for permanent CSF diversion.ConclusionTherapeutic anticoagulation should be considered for symptomatic post-operative dural venous sinus thrombosis or if it involves a dominant sinus. Further prospective studies are warranted to better elucidate the risk-benefit justification of treatment for postoperative sinus thrombosis.     

Behçet’s syndrome as a tool to dissect the mechanisms of thrombo-inflammation: clinical and pathogenetic aspects

Behçet’s syndrome (BS) is a complex disease with different organ involvement. The vascular one is the most intriguing, considering the existence of a specific group of patients suffering from recurrent vascular events involving the venous and, more rarely, the arterial vessels. Several clinical clues suggest the inflammatory nature of thrombosis in BS, especially of the venous involvement, thus BS is considered a model of inflammation-induced thrombosis. Unique among other inflammatory conditions, venous involvement (together with the arterial one) is currently treated with immunosuppressants, rather than with anti-coagulants. Although many in-vitro studies have suggested the different roles of the multiple players involved in clot formation, in-vivo models are crucial to study this process in a physiological context. At present, no clear mechanisms describing the pathophysiology of thrombo-inflammation in BS exist. Recently, we focused our attention on BS patients as a human in-vivo model of inflammation-induced thrombosis to investigate a new mechanism of clot formation. Indeed, fibrinogen displays a critical role not only in inflammatory processes, but also in clot formation, both in the fibrin network and in platelet aggregation. Reactive oxygen species (ROS)-derived modifications represent the main post-translational fibrinogen alterations responsible for structural and functional changes. Recent data have revealed that neutrophils (pivotal in the pathogenetic mechanisms leading to BS damage) promote fibrinogen oxidation and thrombus formation in BS. Altogether, these new findings may help understand the pathogenetic bases of inflammation-induced thrombosis and, more importantly, may suggest potential targets for innovative therapeutic approaches.     

不同介入方案治疗急性下肢静脉血栓的临床效果与安全性比较

目的 探讨不同介入方案治疗急性下肢静脉血栓(DVT)的临床效果与安全性。方法 选取我院2015年1月～2019年12月介入科收治的急性DVT患者54例作为研究对象,按照治疗方式的不同分为研究组27例和对照组27例。研究组采用血管腔内综合治疗,对照组采用导管介导溶栓治疗,比较两组患者疗效评价、治疗前后膝上、下15 cm与患肢周径差、治疗前后皮肤肿胀张力、静脉通畅率、住院时间和并发症发生情况。结果 经治疗后研究组患者膝上、下15 cm与患肢周径差均短于对照组(P0.05);经治疗后研究组患者皮肤肿胀张力恢复程度显著优于对照组(P0.05);经治疗后研究组患者静脉通畅率显著高于对照组(P0.05);研究组治疗有效率显著高于对照组(P0.05);研究组患者住院时间明显少于对照组,且其并发症发生率显著低于对照组(P0.05)。结论 血管腔内综合介入治疗能够有效改善患者下肢症状,提高DVT恢复情况,降低并发症的发生,从而有效提高患者生活质量,为临床治疗DVT提供重要参考。     

分析预防子宫内膜癌术后下肢深静脉血栓形成的护理干预效果

目的 探讨预防子宫内膜癌术后下肢深静脉血栓形成的护理干预措施及效果。方法 50例子宫内膜癌患者,按照护理方式不同分为研究组和对照组,各25例。对照组实施常规护理,研究组实施综合护理。对比两组患者术后下肢深静脉血栓形成率及生活质量评分。结果 研究组患者术后下肢深静脉血栓形成率0明显低于对照组的32.0%,差异具有统计学意义(P<0.05)。研究组患者活动能力、临床症状、日常生活质量评分及总分分别为(84.6±3.6)、(89.4±4.2)、(92.0±1.2)、(93.3±2.5)分,均明显高于对照组的(73.4±5.1)、(78.3±3.6)、(80.6±4.1)、(79.6±4.9)分,差异均有统计学意义(P<0.05)。结论 子宫内膜癌患者术后实施综合护理能够有效提升护理质量,降低术后下肢深静脉血栓形成率,缓解患者术后各类不适症状,提升患者术后生活质量,值得推广应用。     

骨科大手术患者中医体质类型与静脉血栓栓塞症相关性研究

目的:探讨骨科大手术患者中医体质类型分布特点及其与静脉血栓栓塞症(VTE)的相关性。方法:选取220例骨科大手术患者,其中术后3个月内并发VTE患者102例为观察组,术后3个月内未发生VTE患者118例为对照组。对两组患者进行中医体质判定并分析。结果:220例骨科大手术患者中,平和质64例(29.09%),偏颇体质156例(70.91%)。骨科大手术患者最常见体质类型为气虚质、血瘀质、平和质。观察组最常见体质类型为气虚质、血瘀质,对照组最常见体质类型为平和质、气虚质。Logistic回归分析发现气虚质、血瘀质与VTE具有显著相关性(P<0.05,P<0.01)。结论:偏颇体质是骨科大手术患者的中医体质类型特征;气虚质、血瘀质是骨科大手术并发VTE患者的危险因素。     

Complications during multiorgan retrieval and pancreas preservation

In pancreas transplantation, complications can arise at each step of the process, from the initial selection of donors and recipients through the surgical technique itself and the post-operative period, when lifelong immunosuppression is required. In the early steps, careful retrieval and preservation of the pancreas are crucial for the viability of the organ and ultimate success of the transplant. The pancreas is a low-flow gland, making it highly sensitive to transplantation conditions and presenting risk of pancreatitis due to periods of ischemia. The two groups of donors - after brain death (DBD) or after cardiac arrest (DCD) - require different strategies of retrieval and preservation to avoid or reduce the risk of complications developing during and after the transplantation. For DBD donor transplantation, multiorgan retrieval and cold preservation is the conventional technique. Asystole donor (DCD) transplantation, in contrast, can benefit from the newest technologies, such as hypothermic and especially normothermic preservation machines (referred to as NECMO), to optimize organ preservation. The latter has led to an increase in the pool of donors by facilitating recuperation of organs for transplantation that would have been discarded otherwise.