Do older patients with acute or subacute subdural hematoma benefit from surgery?

PURPOSE: According to the international guidelines, acute subdural hematomas (aSDH) with a thickness of >10 mm, or causing a midline shift of >5 mm, should be surgically evacuated. However, high mortality rates in older patients resulted in ongoing controversy whether elderly patients benefit from surgery. We identified predictors of outcome in a single-centre cohort of elderly patients undergoing surgical evacuation of aSDH or subacute subdural hematoma (saSDH). MATERIALS AND METHODS: This retrospective study included all patients aged ≥65 years undergoing surgical evacuation of aSDH/saSDH from 2000 to 2015. One-year outcome was dichotomized into favourable (Glasgow Outcome Scale (GOS) 4-5) and unfavourable (GOS 1-3). Predictors of outcome were identified by analysing patient characteristics. RESULTS: Eighty-four patients aged ≥65 years underwent craniotomy for aSDH/saSDH during the 16 year time period. Twenty-five percent regained functional independence, 11% survived severely disabled, and 64% died. Most patients died of respiratory failure following withdrawal of artificial respiration or following restriction of treatment. Age of the SDH or Glasgow Coma Scores ≤8/intubation did not predict unfavourable outcome. All patients with bilaterally absent pupillary light reflexes died, also those who still exhibited one normal-sized pupil. CONCLUSION: The low number of operated patients per year probably suggests that this cohort represents a selection of patients who were judged to have good chances of favouring from surgery. Functional independence at one-year follow-up was reached in 25% of patients, 64% died. Patients with bilaterally absent pupillary light reflexes did not benefit from surgery. The tendency to restrict treatment because of presumed poor prognosis may have acted as a self-fulfilling prophecy.

Clinical Outcome of Anticoagulant Treatment in Head or Neck Infection-Associated Cerebral Venous Thrombosis.

BACKGROUND AND PURPOSE: Local infections of the head or neck are a cause of cerebral venous thrombosis. Treatment of infectious cerebral venous thrombosis with heparin is controversial. We examined whether this treatment was associated with intracranial hemorrhagic complications and poor clinical outcome. METHODS: We retrieved data from a prospective cohort study of 624 cerebral venous thrombosis patients. We compared patients with and without an infection of the head or neck and anticoagulated versus not anticoagulated. We examined death or dependency and new intracerebral hemorrhages. RESULTS: Six hundred four of 624 patients were eligible for the study. Fifty-seven patients had an infection of the head or neck (9.4%). Comparing data between infection and noninfection patients, the frequency of therapeutic doses of heparin was similar in both groups (82.5% versus 83.7%). New intracerebral hemorrhages were more common in patients with an infection (12.3% versus 5.3%; P=0.04), but death or dependency did not differ between patients with and without an infection (15.8% versus 13.7%). In patients with an infection of the head or neck, there was no significant difference in the frequency of new intracerebral hemorrhages and poor outcome between patients who did or did not receive therapeutic doses of heparin. CONCLUSIONS: New intracerebral hemorrhages were more frequent in patients with an infection. The use of therapeutic doses of heparin did not seem to influence the risk of new intracranial hemorrhages or poor clinical outcome, but the number of patients who did not receive anticoagulation was too small to draw firm conclusions about safety of heparin in adults with cerebral venous thrombosis and an infection of the head or neck.

Cerebral venous thrombosis in the absence of headache.

BACKGROUND AND PURPOSE: Although headache is the most common symptom in cerebral venous thrombosis, 5% to 30% of patients do not report headache at baseline. Characteristics of these patients have not been investigated. METHODS: In post hoc analysis of the International Study on Cerebral Vein and Dural Sinus Thrombosis study, patients who might not have been able to report headache (aphasia, stupor, coma, or mental status disorder) were excluded. RESULTS: Three hundred eighty-two of the original 624 patients (61%) were included, of whom 38 (10%) did not report headache at baseline. Patients without headache were older (mean age, 45 versus 37; P=0.001) and less often female (63% versus 77%; P=0.06). Paresis (42% versus 27%; P=0.05) and seizures (58% versus 32%; P=0.001) were more common in patients without headache, whereas papilledema was less common (8% versus 35%; P=0.001). Isolated cortical vein thrombosis (16% versus 2%; P=0.001), brain parenchymal lesions (66% versus 46%; P=0.02), and malignancies (18% versus 6%; P=0.009) were more common among patients without headache. Outcome at last follow-up was worse in patients without headache (modified Rankin Scale, 0-1; 76% versus 89%; P=0.04; mortality, 13% versus 5%; P=0.05), but after adjustment for prognostic variables, headache was not an independent predictor of outcome. CONCLUSIONS: Patients with cerebral venous thrombosis but without headache are a heterogeneous subgroup, in which older patients, men, and some associated conditions are over-represented. Patients without headache had a worse clinical outcome, but after adjustment for imbalances, headache was not an independent predictor of outcome.

Mechanical thrombectomy in cerebral venous thrombosis: systematic review of 185 cases.

BACKGROUND AND PURPOSE: Cerebral venous thrombosis is generally treated with anticoagulation. However, some patients do not respond to medical therapy and these might benefit from mechanical thrombectomy. The aim of this study was to gain a better understanding of the efficacy and safety of mechanical thrombectomy in patients with cerebral venous thrombosis, by performing a systematic review of the literature. METHODS: We identified studies published between January 1995 and February 2014 from PubMed and Ovid. We included all cases of cerebral venous thrombosis in whom mechanical thrombectomy was performed with or without intrasinus thrombolysis. Good outcome was defined as normal or mild neurological deficits at discharge (modified Rankin Scale, 0-2). Secondary outcome variables included periprocedural complications and recanalization rates. RESULTS: Our study included 42 studies (185 patients). Sixty percent of patient had a pretreatment intracerebral hemorrhage and 47% were stuporous or comatose. AngioJet was the most commonly used device (40%). Intrasinus thrombolysis was used in 131 patients (71%). Overall, 156 (84%) patients had a good outcome and 22 (12%) died. Nine (5%) patients had no recanalization, 38 (21%) had partial, and 137 (74%) had near to complete recanalization. The major periprocedural complication was new or increased intracerebral hemorrhage (10%). The use of AngioJet was associated with lower rate of complete recanalization (odds ratio, 0.2; 95% confidence interval, 0.09-0.4) and lower chance of good outcome (odds ratio, 0.5; 95% confidence interval, 0.2-1.0). CONCLUSIONS: Our systematic review suggests that mechanical thrombectomy is reasonably safe but controlled studies are required to provide a definitive answer on its efficacy and safety in patients with cerebral venous thrombosis.

Association Between Anemia and Cerebral Venous Thrombosis: Case-Control Study.

BACKGROUND AND PURPOSE: Anemia is often considered to be a risk factor for cerebral venous thrombosis (CVT), but this assumption is mostly based on case reports. We investigated the association between anemia and CVT in a controlled study. METHODS: Unmatched case-control study: cases were adult patients with CVT included in a single-center, prospective database between July 2006 and December 2014. Controls were subjects from the control population of the Multiple Environmental and Genetic Assessment of Risk Factors for Venous Thrombosis (MEGA) study. Anemia was defined according to World Health Organization criteria: nonpregnant women hemoglobin<7.5 mmol/L, pregnant women<6.9 mmol/L, and men<8.1 mmol/L. We used logistic regression analysis, adjusting for age, sex, malignancy, oral contraceptive use, and pregnancy/puerperium. RESULTS: We included 152 cases and 2916 controls. Patients with CVT were younger (mean age, 40 versus 48 years) and more often women (74% versus 53%) than controls. Anemia was more frequent in cases (27.0%) than in controls (6.5%; P<0.001). Anemia was associated with CVT, both in univariate analysis (odds ratio, 5.3; 95% confidence interval [CI], 3.6-7.9) and after adjustment for potential confounders (adjusted odds ratio, 4.4; 95% CI, 2.8-6.9). Hemoglobin as a continuous variable was inversely associated with CVT (adjusted odds ratio per 1 mmol/L change 0.53; 95% CI, 0.42-0.66). Stratification by sex showed a stronger association between anemia and CVT in men (adjusted odds ratio, 9.9; 95% CI, 4.1-23.8) than in women (3.6; 95% CI, 2.1-6.0). CONCLUSION: Our data suggest that anemia is a risk factor for CVT.

Small juxtacortical hemorrhages in cerebral venous thrombosis.

OBJECTIVE: Intracerebral hemorrhages (ICHs) are common in patients with cerebral venous thrombosis (CVT). We examined whether small juxtacortical hemorrhages (JCHs) are characteristic for CVT and studied their radiological and pathological properties. METHODS: We identified all patients with CVT and an ICH at baseline admitted between 2000 and 2011 (prospectively from July 2006). JCH was defined as a hemorrhage (diameter < 20mm) located in the white matter just below the cortex. To determine the specificity of JCHs for CVT, we examined the frequency of JCHs in a control group of patients of similar age with an ICH not related to CVT. RESULTS: Of 114 patients with CVT, 53 had an ICH. JCHs were present in 14 of the 53 (26%). The remaining 39 had other kinds of hemorrhages. Papilledema was more common among patients with a JCH compared to patients with other types of ICHs (44% vs 9%, p = 0.01). All patients with a JCH except 1 had thrombosis of the superior sagittal sinus, compared to 49% of patients with CVT and other kinds of hemorrhages (p = 0.004). Reanalysis of all imaging data and histopathologic analysis in 1 patient showed that JCHs are located near the U-fibers and that they follow the curvature of the cortex. Among 196 control patients (spontaneous ICH, not caused by CVT), only 3 patients had a JCH. One of these 3 appeared on re-examination of all imaging results to have had CVT. INTERPRETATION: Small nontraumatic JCHs are a characteristic feature of CVT and are rarely encountered in other conditions.

Quality of life after surgical decompression for a space-occupying middle cerebral artery infarct: A cohort study.

BACKGROUND: In patients with a space-occupying middle cerebral artery (MCA) infarct surgical decompression reduces the risk of death, but increases the chance of survival with severe disability. We assessed quality of life (QoL), symptoms of depression, and caregiver burden at long-term follow-up. METHODS: Patients treated in two academic centres between 2007 and 2012 were included. Follow-up was at least six months. Patients and caregivers were interviewed separately. QoL was assessed with a visual analogue scale and the 36-item Short-Form health survey (SF-36); depression with the Hospital Anxiety and Depression Scale; and caregiver burden with the Caregiver Strain Index. RESULTS: Twenty five patients were enrolled, of whom seven had an infarct in the dominant hemisphere. After a median follow-up of 26 months (IQR 11-46) the median SF-36 mental component score was 54.4 (IQR 45-60), indicating a mental QoL comparable to that in the general population. The median SF-36 physical component score was 32.7 (IQR 22-38), indicating a worse physical QoL. Dominance of the hemisphere did not influence QoL. 79 % of patients and 65 % of caregivers would, in retrospect, again choose for surgery. 26 % of patients had signs of depression and 64 % of caregivers were substantially burdened in their daily life. CONCLUSIONS: Mental QoL after surgical decompression for space-occupying MCA infarct is comparable to that in the general population, whereas physical QoL is worse. Dominance of the hemisphere did not influence QoL. The majority of caregivers experience substantial burden. Most patients and caregivers stand by their decision for hemicraniectomy.

Clinical Course of Cerebral Venous Thrombosis in Adult Acute Lymphoblastic Leukemia.

BACKGROUND: Venous thromboembolism (VTE) is a frequent complication in patients with acute lymphoblastic leukemia (ALL). A significant proportion of patients develop cerebral venous thrombosis (CVT). METHODS: To investigate risk factors for and the clinical course of CVT in ALL patients, we describe all cases of CVT which occurred in a well-defined cohort of 240 adults, treated for newly diagnosed ALL in the HOVON (Dutch-Belgian Hemato-Oncology Cooperative Group)-37 study. We conducted a nested case-control study to explore the relevance of early symptoms and risk factors for CVT in ALL patients. RESULTS: Nine of 240 patients developed CVT (4%). CVT occurred during or shortly after L-asparaginase therapy (in 8 cases) and shortly after intrathecal methotrexate injections (in all cases) during cycle I of remission induction treatment. CVT was associated with prior headache and seizures. In 5 of 9 patients with CVT, headache before the diagnosis of CVT occurred within 3 days after lumbar puncture and initially had a postural character. CONCLUSIONS: CVT is relatively common in adult ALL patients. Our data suggest that CVT in adult ALL patients results from the additive effects of multiple risk factors, with a particular role for asparaginase and the effects of lumbar punctures for intrathecal therapy.

Declining mortality in cerebral venous thrombosis: a systematic review.

BACKGROUND AND PURPOSE: Cerebral venous thrombosis (CVT) is nowadays considered a disease with a good outcome in most cases, but in the past, these patients were thought to have a grave prognosis. We systematically studied the apparent decline in mortality of patients with CVT over time. METHODS: A systematic review of the literature (MEDLINE and EMBASE) was performed. Studies with ≥40 patients with CVT that reported mortality at discharge or follow-up were eligible. Duplicate publications based on the same patient cohort were excluded. Studies were ranked according to the year halfway the period of patient inclusion. Two of the authors independently screened all eligible studies. RESULTS: We screened 4585 potentially eligible studies, of which 74 fulfilled the selection criteria. The number of patients per study varied from 40 to 706 (median, 76). Data from 8829 patients with CVT, included from 1942 to 2012, were analyzed. The average age was 32.9 years, and 64.7% were women. There was a significant inverse correlation between mortality and year of patient recruitment (Pearson correlation coefficient, -0.72; P<0.001). In a sensitivity analysis, the correlation remained significant after exclusion of studies published before 1990, retrospective studies, or single-center studies. Both the frequency of focal neurological deficits and coma also decreased significantly over time (correlation coefficient, -0.50 and -0.52). CONCLUSIONS: There is a clear trend in declining mortality among patients with CVT over time. Possible explanations are improvements in treatment, a shift in risk factors, and, most importantly, the identification of less severe cases by improved diagnostic methods.

Isolated cortical vein thrombosis: systematic review of case reports and case series.

BACKGROUND AND PURPOSE: Isolated cortical vein thrombosis is a distinct subtype of cerebral venous and sinus thrombosis. Because of the rarity of isolated cortical vein thrombosis, limited knowledge on its clinical and radiological manifestations is available. METHODS: We performed a systematic review of published data. Isolated cortical vein thrombosis had to have been diagnosed by MRI, conventional angiography, computed tomography venography, autopsy, or surgery. Cases with concurrent thrombosis of a cerebral sinus were excluded. RESULTS: Of 175 potentially relevant studies, 47 were included in the analysis, with a total of 116 patients. All studies were case reports and case series. Mean age was 41 years and 68% were women. The most common symptoms were headache (71%), seizures (58%), and focal neurological deficits (62%). Papilledema was not reported in any patient, and increased cerebrospinal fluid pressure was reported only in 2. Infection (19%), pregnancy or puerperium (35% of women), and oral contraceptive use (21% of women) were the most common risk factors. Most cases (73%) were diagnosed with MRI, but conventional angiography was also performed in 47%. A total of 81% had a parenchymal brain lesion and 80% were treated with anticoagulation. In-hospital mortality was 6%. CONCLUSIONS: Signs of increased intracranial pressure seem to be less common in isolated cortical vein thrombosis compared with cerebral venous and sinus thrombosis. MRI and in some cases conventional angiography are the most frequently used diagnostic modalities and anticoagulation is the most widely used therapy.

Cerebral venous thrombosis causing posterior fossa lesions: description of a case series and assessment of safety of anticoagulation.

BACKGROUND: Isolated posterior fossa parenchymal lesions associated with cerebral venous thrombosis (CVT) are rare. Posterior fossa lesions are an independent predictor of death in CVT. We aim to describe the characteristics and outcome of patients with CVT and isolated posterior fossa lesions and assess the safety of anticoagulation in patients with posterior fossa lesions associated with CVT. METHODS: We retrieved data from all patients with posterior fossa parenchymal lesions in the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT) cohort related to clinical features, therapy and outcome. Fisher's exact test was used to evaluate associations. To assess the safety of anticoagulation in CVT patients with posterior fossa lesions we considered all patients with a lesion in this topography, either isolated or with concomitant supratentorial lesions, and compared the rate of new intracranial haemorrhages on repeated imaging with the remaining cohort. RESULTS: Out of 624 patients, 12 had isolated posterior fossa lesions and 14 had posterior fossa lesion with accompanying supratentorial lesions. The lateral sinus was most frequently occluded (n = 11). Involvement of the superior sagittal sinus was significantly less frequent compared to the remaining patients of the cohort (p = 0.013). None of the patients with isolated posterior fossa lesion died but 3 remained dependent on follow-up. Poor outcome (modified Rankin Scale ≥3) was more frequent in patients with any posterior fossa lesion, even when on anticoagulation (29.2% vs. 11.9%; OR 3.04; 95% CI 1.2-7.6; p = 0.018). Of the 24 anticoagulated patients with a posterior fossa lesion, 3 (12.5%) had new haemorrhages on repeated imaging, compared with 30 out of 495 anticoagulated patients (6.1%) without posterior fossa lesions (p = 0.19). CONCLUSIONS: We describe the largest series of CVT patients with associated posterior fossa lesions. When compared to anticoagulated CVT patients without posterior fossa lesions, CVT patients with posterior fossa lesions on full anticoagulation did not have a significant increase in the rate of new intracranial haemorrhages.

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.

The incidence of cerebral venous thrombosis: a cross-sectional study.

BACKGROUND AND PURPOSE: The purpose of this study was to determine the incidence of adult cerebral venous thrombosis. METHODS: A retrospective cross-sectional study was conducted among all 19 hospitals located in 2 Dutch provinces serving 3.1 million people. Adult cerebral venous thrombosis cases diagnosed between January 1, 2008, and December 31, 2010, were identified using the Dutch financial coding system for hospital care and the International Classification of Diseases, 9th Revision. Medical records of potential patients were hand searched to identify cerebral venous thrombosis cases. The Dutch National Bureau for Statistics provided population figures of the 2 provinces during 2008 to 2010. RESULTS: Among 9270 potential cases, we identified 147 patients diagnosed with cerebral venous thrombosis. Of these, 53 patients did not meet the inclusion criteria; therefore, 94 patients were included in the analysis. The overall incidence was 1.32 per 100 000 person-years (95% CI, 1.06-1.61). Among women between the ages of 31 and 50 years, the incidence was 2.78 (95% CI, 1.98-3.82). CONCLUSIONS: The incidence of cerebral venous thrombosis among adults is probably higher than previously believed.

Prognosis of cerebral vein thrombosis presenting as isolated headache: early vs. late diagnosis.

OBJECTIVE: To analyse the outcome of cerebral venous thrombosis (CVT) patients presenting with isolated headache, specifically to compare isolated headache patients with early vs. late CVT diagnosis. METHOD: In the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT) database we compared the outcome of patients with isolated headache and a CVT diagnosed early (≤7 days from onset) vs. late (>7 days). We retrieved 100 patients with isolated headache, 52 patients with early CVT diagnosis (early isolated headache) and 48 with late CVT diagnosis (late isolated headache). RESULTS: Neurological worsening was more frequent within early isolated headache patients (23% vs. 8%) (p = 0.045). At the last follow-up (median 411 days), 93% patients had a complete recovery, and 4% were dead or dependent, with no significant difference between early isolated headache and late isolated headache. CONCLUSION: The outcome of CVT patients with isolated headache diagnosed early or late was similarly favourable, but there was a higher proportion of neurological worsening in the acute phase among early isolated headache patients, who need close neurological monitoring.

In Situ Optical Spectroscopy Demonstrates the Effect of Solvent Additive in the Formation of All-Polymer Solar Cells.

1-Chloronaphthalene (CN) has been a common solvent additive in both fullerene- and nonfullerene-based organic solar cells. In spite of this, its working mechanism is seldom investigated, in particular, during the drying process of bulk heterojunctions composed of a donor:acceptor mixture. In this work, the role of CN in all-polymer solar cells is investigated by in situ spectroscopies and ex situ characterization of blade-coated PBDB-T:PF5-Y5 blends. Our results suggest that the added CN promotes self-aggregation of polymer donor PBDB-T during the drying process of the blend film, resulting in enhanced crystallinity and hole mobility, which contribute to the increased fill factor and improved performance of PBDB-T:PF5-Y5 solar cells. Besides, the nonradiative energy loss of the corresponding device is also reduced by the addition of CN, corresponding to a slightly increased open-circuit voltage. Overall, our observations deepen our understanding of the drying dynamics, which may guide further development of all-polymer solar cells.

Quantitative analysis of phase formation and growth in ternary mixtures upon evaporation of one component.

We perform a quantitative analysis of Monte Carlo simulation results of phase separation in ternary blends upon evaporation of one component. Specifically, we calculate the average domain size and plot it as a function of simulation time to compute the exponent of the obtained power law. We compare and discuss results obtained by two different methods, for three different models: two-dimensional (2D) binary-state model (Ising model), 2D ternary-state model with and without evaporation. For the ternary-state models, we study additionally the dependence of the domain growth on concentration, temperature and initial composition. We reproduce the expected 1/3 exponent for the Ising model, while for the ternary-state model without evaporation and for the one with evaporation we obtain lower values of the exponent. It turns out that phase separation patterns that can form in this type of systems are complex. The obtained quantitative results give valuable insights towards devising computable theoretical estimations of size effects on morphologies as they occur in the context of organic solar cells.

Sublingual microvascular changes in patients with cerebral small vessel disease.

BACKGROUND AND PURPOSE: It is unknown whether changes in cerebral small vessel disease (SVD) are limited to the brain or part of a generalized vascular disorder. METHODS: We examined the sublingual microcirculation of 10 healthy controls, 10 patients with large vessel disease, and 8 with SVD, with side-stream dark field imaging. We analyzed 146 video fragments masked to the origin of the videos. Imaging software measured the functional capillary density per tissue surface unit. We scored the percentage of blood vessels with abnormal flow (abnormal flow index) and the presence of extravascular erythrocyte material as presumed evidence of past microbleeds or obliterated vessels. RESULTS: Functional capillary density differed between the 3 groups (SVD, large vessel disease, and controls; means, 14.8, 17.0, and 16.1 mm/mm2; P=0.01). Abnormal flow was more frequent in SVD patients compared with large vessel disease patients and controls (medians, 10.5%, 6.1%, 5.5%; P=0.04). Extravascular erythrocyte material was almost exclusively present in patients with SVD (P=0.004). CONCLUSIONS: We found evidence of pathological changes in the sublingual microcirculation in patients with cerebral small vessel disease, which suggests that cerebral SVD is part of a generalized vascular disorder.

Decompressive surgery in cerebrovenous thrombosis: a multicenter registry and a systematic review of individual patient data.

BACKGROUND AND PURPOSE: Herniation attributable to unilateral mass effect is the major cause of death in cerebral venous thrombosis (CVT). Decompressive surgery may be lifesaving in these patients. METHODS: Retrospective registry of cases of acute CVT treated with decompressive surgery (craniectomy or hematoma evacuation) in 22 centers and systematic review of all published cases of CVT treated with decompressive surgery. The primary outcome was the score on the modified Rankin Scale (mRS) score at last follow-up, dichotomized between favorable (mRS score, 0-4) and unfavorable outcome (mRS score, 5 or death). Secondary outcomes were complete recovery (mRS score 0-1), independence (mRS score, 0-2), severe dependence (mRS score, 4-5), and death at last available follow-up. RESULTS: Sixty-nine patients were included and 38 were from the registry. Decompressive craniectomy was performed in 45 patients, hematoma evacuation was performed in 7, and both interventions were performed in 17 patients. At last follow-up (median, 12 months) only 12 (17.4%) had un unfavorable outcome. Twenty-six (37.7%) had mRS score 0 to 1, 39 (56.5%) had mRS score 0 to 2, 4 (5.8%) were alive with mRS score 4 to 5, and 11 (15.9%) patients died. Three of the 9 patients with bilateral fixed pupils recovered completely. Comatose patients were less likely to be independent (mRS score 0-2) than noncomatose patients (45% versus 84%; P=0.003). Patients with bilateral lesions were more likely to have unfavorable outcomes (50% versus 11%; P=0.004) and to die (42% versus 11%; P=0.025). CONCLUSIONS: In CVT patients with large parenchymal lesions causing herniation, decompressive surgery was lifesaving and often resulted in good functional outcome, even in patients with severe clinical conditions.

Ethnicity and thrombolysis in ischemic stroke: a hospital based study in Amsterdam.

BACKGROUND: Ethnic differences have been reported with regard to several medical therapies. The aim of this study was to investigate the relation between ethnicity and thrombolysis in stroke patients. METHODS: Retrospective single-centre study. Patients admitted with an ischemic stroke between 2003 and 2008 were included. Ethnicity was determined by self-identification and stratified into white and non-white (all other ethnicities). The main outcome measure was the difference in thrombolysis rate between white and non-white patients. Logistic regression analysis was used to identify potential confounders of the relation between ethnicity and thrombolysis. RESULTS: 510 patients were included, 392 (77%) white and 118 (23%) non-white. Non-white patients were younger (median 69 vs. 60 years, p<0.001), had a higher blood pressure at admission (median systolic 150 vs. 160 mmHg, p=0.02) and a lower stroke severity (median NIHSS 5 vs. 4, p=0.04). Non-white patients were significantly less often treated with thrombolysis compared to white patients (odds ratio 0.34, 95% CI 0.17-0.71), which was partly explained by a later arrival at the hospital. After adjustment for potential confounders (late arrival, age, blood pressure above upper limit for thrombolysis, and oral anticoagulation use), a trend towards a lower thrombolysis rate in non-whites remained (adjusted odds ratio 0.38, 95% CI 0.13 to 1.16). CONCLUSIONS: Non-white stroke patients less often received thrombolysis than white patients, partly as a result of a delay in presentation. In this single centre study, potential bias due to hospital differences or insurance status could be ruled out as a cause. The magnitude of the difference is worrisome and requires further investigation. Modifiable causes, such as patient delay, awareness of stroke symptoms, language barriers and treatment of cardiovascular risk factors, should be addressed specifically in these ethnic groups in future stroke campaigns.

Licorice consumption as a cause of posterior reversible encephalopathy syndrome: a case report.

INTRODUCTION: A 49-year-old woman was admitted to our hospital because of thunderclap headache and blurred vision. At the time of presentation, her blood pressure was 219/100 mmHg, her arterial pH was 7.64 and her potassium level was 2.7 mM/l. METHODS: The combination of sequential computed tomography (CT) and the triad of hypertension, hypokalemia and metabolic alkalosis in this patient suggested the diagnosis. Supplementary anamnesis and long-term follow-up confirmed it. RESULTS: Brain computed tomography imaging showed minor bleeding in the left Sylvian fissure and bilateral occipital edema, suggestive of posterior reversible encephalopathy syndrome (PRES). Repeated brain CT after 10 days showed a complete resolution of radiological signs. The patient informed us that she had quit smoking 2 weeks ago and had started consuming large amounts of licorice instead of smoking. After she abandoned licorice consumption, her blood pressure normalized. Her latest blood pressure reading was 106/60 mmHg without the use of any antihypertensive drugs. CONCLUSIONS: To the best of our knowledge, this is the first case report describing licorice consumption as a cause of PRES. Glycyrrhizic acid, a component of licorice, inhibits 11ß-hydroxysteroid dehydrogenase and subsequently causes mineralocorticoid excess. Mineralocorticoid excess in turn causes high blood pressure and ultimately gives rise to malignant hypertension. Physicians should remember that licorice use is a very easy-to-treat cause of hypertension, hypertensive encephalopathy and PRES.