Microsurgical resection of vestibular schwannomas: complication avoidance.

Vestibular schwannoma (VS) surgery requires appropriate patient selection, meticulous microsurgical technique and optimal post-operative care. Focused radiation is an effective alternative for the treatment of smaller VSs. For VS surgery to remain a reasonable option, surgery must be performed with a limited number of complications. Complication rates for VS surgery have increased over the last decade. This is likely due to (1) decreased surgical volume and as a result decreased microsurgical experience, (2) larger tumors undergoing surgery while smaller tumors are reserved for radiation, and (3) surgery for previously radiated tumors resulting in more difficult anatomic dissection. Appropriate management of complications is paramount. Herein, we discuss complications related to VS microsurgery and methods of avoidance. Specifically, we discuss the most frequently encountered complications, intraoperative monitoring and finally, methods of addressing these complications. With meticulous microsurgical technique, careful intraoperative monitoring and vigilant perioperative care one will ensure optimal patient outcomes.

Antiphospholipid antibodies in neonates with stroke--a unique entity or variant of antiphospholipid syndrome?

OBJECTIVE: YB current affiliation: Department of Pediatrics, Hadassah-Hebrew University Medical Center, Mount Scopus, Israel YB and MJS contributed equally to the study and should be regarded as joint first authors on this manuscript. Antiphospholipid syndrome (APS) may present with thrombosis and persistently elevated titers of antiphospholipid antibodies (aPL) in the neonatal period. Our aim was to investigate the course and impact of elevated titers of aPL in a cohort of infants presenting with either perinatal arterial ischemic stroke (PAS) or cerebral sinus vein thrombosis (CSVT) during the perinatal period. STUDY DESIGN: Sixty-two infants with clinically and radiologically confirmed PAS or CSVT presenting in the neonatal period underwent thrombophilia workup that included Factor V Leiden (FVL), PII20210A mutation, MTHFR 677T polymorphism, protein C, protein S, aPL namely either circulating lupus anticoagulant (CLA), anticardiolipin antibodies (aCL) or anti-ß2-glycoprotein-1 (ß2GP1). Mothers also underwent thrombophilia workup. RESULTS: Twelve infants with persistently elevated aPL were prospectively followed. Infants with positive aPL showed no concordance with presence of maternal aPL. All children were followed for a median of 3.5 years (range: nine months to 19 years) with repeated aPL testing every three to six months. Anticoagulant therapy initiation and therapy duration varied at the physician's discretion. In 10/12 cases aPL decreased to normal range within 2.5 years; one female with complex thrombophilia risk factors required indefinite prolonged anticoagulation. None of the infants showed recurrent thrombosis or any other APS manifestations, despite lack of prolonged anticoagulation. CONCLUSIONS: The presence of aPL may be important in the pathogenesis of cerebral thrombosis in neonates. Nevertheless, the nature of thrombophilia interactions in this period and their therapeutic impact warrants further investigation.

Duration of anticoagulation after cerebral venous sinus thrombosis.

Cerebral venous sinus thrombosis (CVST) often occurs in young patients and is treated with acute and then long-term oral anticoagulation. It is important to decide when to discontinue anticoagulation, as lifelong anticoagulation exposes the patient to considerable cumulative risk. However, a lack of high quality studies makes choosing a duration of anticoagulation after CVST difficult. In this article, we review the evidence for different treatment durations in several common clinical scenarios of CVST. In addition, when no direct evidence is available, we discuss and extrapolate from the more comprehensively studied situation of systemic venous thromboembolic disease. Recommendations are graded using standard criteria for the level of evidence.

Analysis of Age and Prevention Strategy on Outcome after Cerebral Venous Thrombosis.

METHOD: We identified adult CVST patients in our centers. Functional outcome and prevention strategy were extracted from medical records. Modified Rankin Scale (mRS) ≤ 1 is considered a good functional outcome. RESULTS: A total of 113 patients were identified. The most common presenting symptoms were headache (86.72%) and nausea/vomiting (56.63%); the top two identified risk factors were local head/neck infection (27.43%) and pregnancy/puerperal period (19.47%). The medical encounter lag time was 0.04 d-120 d. Four enrolled patients were diagnosed as CVST again, and the interval time was 3-8 years from the first time. Thrombus was most frequently seen at superior sagittal sinus (53.10%) and sigmoid sinus (50.44%). 94 (83.19%) of the patients had good outcomes. In the acute phase, 91 (80.53%) patients received low molecular weight heparin, 29 (25.66%) took aspirin, 7 (6.19%) patients were put on low molecular weight heparin and aspirin together. During our follow up (6-24 m), there were 10 (8.85%) patients who suffered from thrombotic event recurrence. For the patients > 40 years old, they tended to suffer from neurological deficit (25.00%) and stupor/coma (16.67%) (p > 0.05), with a higher rate of hemorrhage (20.83%) and death (4.16%) when compared with the younger patients (10.77% and 1.53%, separately) (p > 0.05). CONCLUSION: Functional outcome after CVST appears good. For the patients over 40-year-old, neurological deficit and altered consciousness were more common, accompanied by a higher rate of hemorrhage and mortality. The recurrent rate of CVST was low, longer-term follow up needed. The prevention strategy after CVST was uncertain, further studies needed.

Management of Venous Sinus Thrombosis.

Cerebral venous sinus thrombosis (CVST) is a rare subtype of cerebrovascular disease representing 0.5% of strokes. The signs and symptoms of CVST are often nonspecific, and variable in duration, with the common results being delayed diagnosis and treatment. Increased awareness in the medical community and advancements in imaging modalities have produced faster diagnosis with improved patient outcomes. The preferred initial treatment is with a low molecular weight heparin. After the acute stage of CVST, treatment with a vitamin K antagonist (oral anticoagulant therapy) is recommended. Current evidence suggests that in the future, factor Xa inhibitor drugs may be used for long-term therapy.

Otogenic sigmoid sinus thrombosis: what is the role of anticoagulation?

OBJECTIVES: The treatment of otogenic sigmoid sinus thrombosis with surgery and antibiotics is well established. However, the role of anticoagulation remains unstudied. The study reviews the signs, symptoms, radiological evaluation, surgical treatment, and medical management of patients with otogenic sigmoid sinus thrombosis treated with or without anticoagulation. STUDY DESIGN: Retrospective review of nine patients from 1995 to 2001 with sigmoid sinus thrombosis. METHODS: Patients were identified by a review of all medical and radiological records. Signs, symptoms, diagnostic studies, treatments, and outcomes were recorded. In addition, telephone follow-up was performed. RESULTS Nine patients were identified over a 6-year period from 1995 to 2001. Patients had a mean follow-up time of 9 months (range, 1-24 mo). Of the nine patients identified, eight patients (89%) had tympanostomy tube placement, six patients (67%) had canal wall intact mastoidectomy, and one patient (11%) had canal wall down mastoidectomy. Needle aspiration of the sinus was performed in four of nine patients (44%), and incision of the sinus in two of nine (22%). Treatment with broad-spectrum antibiotics occurred in all patients with a mean duration of 12 days (range, 2-22 d) intravenously and 7 days (range, 0-21 d) orally. Sixty-seven percent of patients (six of nine) were anticoagulated: Five patients received low-molecular-weight heparin, and one patient received heparin-coumadin. No mortality occurred in either the anticoagulated or non-anticoagulated group. One anticoagulated patient did have persistent headaches and otorrhea. CONCLUSIONS: Surgery and antibiotic therapy are the cornerstones of the management of otogenic sigmoid sinus thrombosis. However, the role of anticoagulation remains unclear. Because complications of embolization and persistent sepsis are low in otogenic sigmoid sinus thrombosis patients treated with or without anticoagulation, withholding anticoagulation in selected patients is reasonable. Serial imaging to monitor for thrombus progression is advisable.

Life-threatening infection after extraction of third molars.

Life-threatening infection after the extraction of the right maxillary and mandibular third molars, and the minimal early treatment of the ensuing complications, has been described. Perhaps, if proper incision and drainage and adequate antibiotic treatment had been instituted immediately after extraction, the ensuing complications could have been avoided. There will never be total agreement regarding the optimal time to surgically remove a tooth. The latter is based on individual preferences, past experiences, and clinical successes of the practitioner. However, if extraction is decided on, the surgeon must be able to recognize the early development of complications and institute appropriate treatment.

Cerebral venous and sinus thrombosis in a patient with acute promyelocytic leukemia during all-trans retinoic acid induction treatment.

Cerebral venous and sinus thrombosis is a rare cerebrovascular disorder, which seldom represents a complication of acute promyelocytic leukemia (APL). As a part of the coagulopathy of APL, thrombosis is a less recognized and underestimated life-threatening manifestation and is overshadowed by the more obvious bleeding complications. Here, we described a 28-year-old woman with APL who developed massive thrombosis of the cerebral sinuses while on induction treatment with all-trans retinoic acid. On the basis of this report, the potential pathogenic mechanisms and the diagnosis based on magnetic resonance imaging (MRI) combined with magnetic resonance venogram (MRV) are discussed. Early anticoagulant therapy contributed to the progressive dissolution of the thrombosis, as documented by MRI, with the complete disappearance of neurological signs without sequelae. Given the increasing recognition of thromboembolic events in APL, the use of prophylactic anticoagulation during induction therapy may need to be redefined.

Complicaciones trombóticas y hemorrágicas en pacientes con aneurismas cerebrales tratados por vía endovascular y su relación con el uso de antiagregantes plaquetarios: evaluación descriptiva / Thrombotic and haemorrhagic complications in patients with cerebral aneurysms treated by endovascular approach and their association with the use of antiplatelet agents: Descriptive evaluation

Objetivo: El protocolo de medicación antiplaquetaria óptimo para prevenir las complicaciones trombóticas después de embolización de aneurismas cerebrales no es claro. Nuestro objetivo es describir las características de los pacientes que presentan complicaciones trombóticas o hemorrágicas secundarias al tratamiento endovascular. Métodos: Se realizó un estudio descriptivo de corte transversal. Se incluyó a todos los pacientes que requirieron manejo endovascular de aneurismas cerebrales en el Hospital Universitario San Ignacio desde noviembre del 2007 hasta enero del 2016. Se evaluaron las complicaciones trombóticas o hemorrágicas durante 6 meses de seguimiento, teniendo en cuenta el esquema de premedicación con antiagregantes plaquetarios, localización, tamaño del aneurisma y técnica de embolización utilizada. Resultados: Se evaluó a 122 pacientes en los cuales se realizaron 130 procedimientos para tratamiento endovascular de aneurismas cerebrales. Las complicaciones trombóticas fueron más frecuentes en pacientes que no recibieron premedicación (25%) comparados con aquellos que recibieron algún esquema de antiagregación (estándar 3,87% o carga 8,70%); esta diferencia fue estadísticamente significativa (p=0,043). Conclusiones: Los eventos tromboembólicos son la complicación más frecuente de la embolización de aneurismas cerebrales. Nuestro trabajo, al igual que la literatura revisada, sustenta el uso de terapia antiplaquetaria dual con ácido acetilsalicílico y clopidogrel para disminuir la tasa de complicaciones tromboembólicas sintomáticas independientemente del protocolo de administración

Objective: The protocol for optimal antiplatelet therapy to prevent thrombotic complications following brain aneurysm embolisation is not clear. Our objective is to describe the characteristics of patients presenting with thrombotic or haemorrhagic complications secondary to endovascular treatment. Methods: A cross sectional descriptive study was performed, which included all patients that required endovascular treatment for brain aneurysm at San Ignacio University Hospital from November 2007 to January 2016. Thrombotic and haemorrhagic complications over six months of follow-up were assessed, considering the premedication regimen with antiplatelet agents, location, size of the aneurysm and embolisation technique performed. Results: 122 patients were evaluated, on whom 130 procedures were performed for endovascular treatment of brain aneurysms. Thrombotic complications were more frequent in patients who did not receive premedication (25%) compared to those who did receive an antiplatelet treatment regimen (standard dose 3.87% or loading dose 8.70%), and this difference was statistically significant (P=.043). Conclusions Thromboembolic events are the most common complication of brain aneurysm embolisation. Both our study and the literature suggest that the use of dual antiplatelet therapy with aspirin and clopidogrel lowers the rate of symptomatic thromboembolic complications, regardless of the administration protocol

Cerebral venous sinus thrombosis in children with acute lymphoblastic leukemia carrying the MTHFR TT677 genotype and further prothrombotic risk factors.

BACKGROUND: The present study was designed to prospectively evaluate the role of prothrombotic risk factors in leukemic children treated according to the ALL-BFM 90/95 study protocols with respect to the onset of cerebral venous sinus thrombosis. PATIENTS: 317 consecutive leukemic children aged 6 months to 18 years were enrolled in this study. 288 of the 317 patients were available for thrombosis-free survival analysis. RESULTS: In 17 (5.9%) of these 288 patients cerebral venous sinus thrombosis occurred. The overall event-free survival of thrombosis in the central nervous system in patients with at least one prothrombotic defect (n = 12) was significantly reduced compared with patients without a prothrombotic defect (p < 0.0001). 15 patients showed acute clinical symptoms at onset of cerebral venous sinus thrombosis, two were asymptomatic. Three of the 17 patients affected (17.6%) died directly associated with the thrombotic event during induction therapy, the remaining 14 patients did not show prolonged clinical symptoms. CONCLUSIONS: Prothrombotic risk factors should be included in a screening program in ALL children treated according to the BFM study protocols. Further prospective studies are recommended to establish adequate prophylactic anticoagulant treatment during ALL (BFM) polychemotherapy.