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.

Association of anemia with functional outcomes in patients with mechanical thrombectomy.

INTRODUCTION: Anemia at presentation is associated with worse outcomes in patients with acute ischemic stroke (AIS). We aim to investigate the association of anemia parameters with functional dependence and mortality in patients who undergo mechanical thrombectomy (MT). METHODS: We performed a retrospective chart review of patients who underwent MT for an anterior circulation large vessel occlusion at a comprehensive stroke center from 1/2015-6/2020. Anemia was considered as a dichotomous categorical variable with a cutoff point of hemoglobin (Hb) < 12.0 g/dL in women and < 13.0 g/dL in men, as per the definition of the World Health Organization. Mean values of Hb and hematocrit (HCT) were obtained over the first five days of admission. Hemoglobin and HCT variability were measured using standard deviation (SD), and coefficient variability (CV) over the first five days of admission. Values of variance and difference (the difference between peak and trough of Hemoglobin or HCT) were also recorded. Multivariate logistic regression analyses were performed, including the predictor variables which were contributing significantly to the model (P < 0.05) in the univariate analysis, with 30-day functional dependence (mRS 3-6) (primary outcome) and 30-day mortality (secondary outcome) as the dependent variables. RESULTS: 188 patients met our inclusion criteria. Anemia on presentation, lower mean and minimum values of five-day Hb and HCT, and higher variability in five-day Hb and HCT parameters were associated with higher 3-month mortality. Men with lower mean and minimum values of five-day Hb and HCT had a significantly higher likelihood of functional dependence at 3-months. This finding was not replicated amongst women in our cohort. CONCLUSION: Our study demonstrated higher 3-mortality in patients with anemia and Hb variability. Our study also demonstrated a higher likelihood of functional dependence in patients amongst men with anemia.

Cerebral venous thrombosis after vaccination against COVID-19 in the UK: a multicentre cohort study.

BACKGROUND: A new syndrome of vaccine-induced immune thrombotic thrombocytopenia (VITT) has emerged as a rare side-effect of vaccination against COVID-19. Cerebral venous thrombosis is the most common manifestation of this syndrome but, to our knowledge, has not previously been described in detail. We aimed to document the features of post-vaccination cerebral venous thrombosis with and without VITT and to assess whether VITT is associated with poorer outcomes. METHODS: For this multicentre cohort study, clinicians were asked to submit all cases in which COVID-19 vaccination preceded the onset of cerebral venous thrombosis, regardless of the type of vaccine, interval between vaccine and onset of cerebral venous thrombosis symptoms, or blood test results. We collected clinical characteristics, laboratory results (including the results of tests for anti-platelet factor 4 antibodies where available), and radiological features at hospital admission of patients with cerebral venous thrombosis after vaccination against COVID-19, with no exclusion criteria. We defined cerebral venous thrombosis cases as VITT-associated if the lowest platelet count recorded during admission was below 150 × 109 per L and, if the D-dimer was measured, the highest value recorded was greater than 2000 µg/L. We compared the VITT and non-VITT groups for the proportion of patients who had died or were dependent on others to help them with their activities of daily living (modified Rankin score 3-6) at the end of hospital admission (the primary outcome of the study). The VITT group were also compared with a large cohort of patients with cerebral venous thrombosis described in the International Study on Cerebral Vein and Dural Sinus Thrombosis. FINDINGS: Between April 1 and May 20, 2021, we received data on 99 patients from collaborators in 43 hospitals across the UK. Four patients were excluded because they did not have definitive evidence of cerebral venous thrombosis on imaging. Of the remaining 95 patients, 70 had VITT and 25 did not. The median age of the VITT group (47 years, IQR 32-55) was lower than in the non-VITT group (57 years; 41-62; p=0·0045). Patients with VITT-associated cerebral venous thrombosis had more intracranial veins thrombosed (median three, IQR 2-4) than non-VITT patients (two, 2-3; p=0·041) and more frequently had extracranial thrombosis (31 [44%] of 70 patients) compared with non-VITT patients (one [4%] of 25 patients; p=0·0003). The primary outcome of death or dependency occurred more frequently in patients with VITT-associated cerebral venous thrombosis (33 [47%] of 70 patients) compared with the non-VITT control group (four [16%] of 25 patients; p=0·0061). This adverse outcome was less frequent in patients with VITT who received non-heparin anticoagulants (18 [36%] of 50 patients) compared with those who did not (15 [75%] of 20 patients; p=0·0031), and in those who received intravenous immunoglobulin (22 [40%] of 55 patients) compared with those who did not (11 [73%] of 15 patients; p=0·022). INTERPRETATION: Cerebral venous thrombosis is more severe in the context of VITT. Non-heparin anticoagulants and immunoglobulin treatment might improve outcomes of VITT-associated cerebral venous thrombosis. Since existing criteria excluded some patients with otherwise typical VITT-associated cerebral venous thrombosis, we propose new diagnostic criteria that are more appropriate. FUNDING: None.

Neutrophil-to-lymphocyte Ratio Predicts the Outcome of Cerebral Venous Thrombosis.

BACKGROUND: Increasing evidences suggest that Neutrophil-to-Lymphocyte Ratio (NLR) is an independent predictor of poor prognosis in patients with cardiovascular disease. However, the relationship between NLR and prognosis in patients with Cerebral Venous Thrombosis (CVT) has not been studied. METHODS: Consecutive CVT patients from November 2011 through April 2019 were retrospectively identified. Poor outcome was defined as a modified Rankin Scale (mRS) of 3-6. Multivariate regression analysis was conducted to assess the relationship between total and differential leukocyte counts, NLR and clinical outcome in CVT patients. The Receiver Operating Characteristic (ROC) analysis was further performed to evaluate the ability to predict mortality, and subgroup analysis was conducted to explore the potential interaction effects. RESULTS: A total of 360 CVT patients were included, and the median duration of follow-up was 9.0 months. Multivariate logistic regression analysis suggested that NLR value, as a continuous variable, was significantly associated with a high risk of poor outcome (adjusted odds ratio [OR]=1.06, 95% confidence intervals [CI] 1.01-1.11, P = 0.013) and mortality (adjusted OR = 1.08; 95% CI, 1.03-1.14; P = 0.002). Compared with the total and differential leukocyte counts, the best discriminating variable to predict the risk of mortality was NLR, and the area under the receiver operating curve was 0.81. The optimal cut-off value of NLR to predict mortality was 5.6 (sensitivity 84.2%, specificity 69.9%). Multivariate Cox regression analysis indicated that the mortality rate was significantly higher in patients with a high NLR level group (>5.6) (adjust hazard ratio=5.65, 95% CI 2.33-12.73, P<0.001). There was no potential heterogeneity in the further subgroup analysis across age (above vs. below 45 years old), sex, history of infections and pregnancy/postpartum, presence of coma and intracerebral hemorrhage. CONCLUSION: Elevated NLR value is associated with a high risk of poor outcomes in CVT patients.

Cerebral Venous Thrombosis: Finnish Nationwide Trends.

BACKGROUND AND PURPOSE: Epidemiology of cerebral venous thrombosis (CVT) has been reported to be changing. Because long-term nationwide data are needed to confirm this, we studied CVT occurrence between 2005 and 2014 in Finland. METHODS: All acute CVT admissions were retrieved from a mandatory registry covering mainland Finland. Patients aged ≥18 years were included. One admission per patient was allowed. RESULTS: We identified 563 patients with CVT (56.5% women). Overall incidence was 1.32/100 000 (95% CI, 1.21-1.43) per year with a 5.0% annual increase. In people <55 years of age, incidence was 0.92/100 000 (0.76-1.10) for men and 1.65/100 000 (1.43-1.89) for women, whereas for those 55 years or older incidence was 1.61 (1.34-1.91) for men and 1.17 (0.96-1.41) for women. In-hospital mortality was 2.1% with no sex difference. One-year mortality was 7.9%. Long-term mortality was higher in men (adjusted hazard ratio, 1.61 [1.09-2.38]) and in older patients (1.95 [1.69-2.24]; per 10-year increment). CONCLUSIONS: Overall incidence of CVT in Finland was similar to that reported in the Netherlands and in Australia. There was a 5.0% yearly increase in the rate of admissions while in-hospital mortality was low. Sex-specific incidence rates differed markedly between younger and older people. Long-term mortality increased with age and was higher in men.

Trombosis séptica de seno cavernoso: reporte de caso / Septic thrombosis of cavernosus sinus: case report

La trombosis séptica del seno cavernoso se conoce como una complicación rara y potencialmente mortal de las infecciones en el área de la cabeza y el cuello. Aunque el uso de antibióticos ha mejorado el pronóstico, todavía es conocida por sus altas tasas de mortalidad y morbilidad. Objetivo: Analizar la presencia de la trombosis séptica de seno cavernoso mediante el estudio de un caso único. Metodología: De tipo observacional, cualitativa y de corte transversal, apoyado con sustento bibliográfico. Resultado: Caso de una paciente joven de sexo femenino que presenta una semana después de tener sintomatología de Covid, cefalea holocraneana, oftalmoplejía derecha, disminución de la agudeza visual, dolor, eritema, edema, tumefacción orbitaria, secreción ocular amarillenta supurativa derecha, se le realiza tomografía de cerebro evidenciándose de forma incidental trombosis del seno cavernoso. Conclusiones: Se determinó que la trombosis séptica de seno cavernoso es un diagnóstico de poca frecuencia y rara. Asimismo, la trombosis del seno cavernoso tiene la tasa más alta de mortalidad. En raras ocasiones, la infección del oído medio puede ser una causa de trombosis séptica del seno cavernoso y la respuesta al tratamiento es deficiente(AU)

Cavernous sinus septic thrombosis is a rare and life-threatening complication of infections in the head and neck area. Although the use of antibiotics has improved the prognosis, it still known for its high mortality and morbidity rates. Objective: To analyze the presence of cavernous sinus septic thrombosis by studying a single case. Methodology: Observational, qualitative and cross-sectional, supported by bibliographic support. Result: Case of a young female patient who presented one week after having symptoms of Covid, holocranial headache, right ophthalmoplegia, decreased visual acuity, pain, erythema, edema, orbital swelling, right suppurative yellowish eye discharge, was performed brain tomography, incidentally showing cavernous sinus thrombosis. Conclusions: It was determined that cavernous sinus septic thrombosis is an infrequent and rare diagnosis. In addition, cavernous sinus thrombosis has the highest mortality rate. In rare cases, middle ear infection can be a cause of cavernous sinus septic thrombosis and response to treatment is poor(AU)

Incidence and Mortality of Cerebral Venous Thrombosis in a Norwegian Population.

BACKGROUND AND PURPOSE: There are conflicting figures of the incidence of cerebral venous thrombosis (CVT). The incidence was previously estimated to around 0.5/100 000/y, but more recent studies have suggested 1 to 1.5/100 000/y. The purpose of this study was to explore the incidence and mortality of CVT in a Norwegian population. METHODS: A retrospective cross-sectional hospital population-based study conducted at Akershus University Hospital serving roughly 10% of the total Norwegian population. Patients were identified through chart reviews based on the relevant International Classification of Diseases(Tenth Revision) codes for new CVT cases in a 7-year period between January 1, 2011, and December 31, 2017. Only inhabitants living in the hospital's catchment area were included. RESULTS: Sixty-two patients aged 0 to 80 years were identified and included. The median age was 46 years and 53% were females. The overall incidence of CVT was 1.75 (95% CI, 1.36-2.23) per 100 000/y with no significant sex differences. The incidence for children and adolescents (<18 years, n=9) was lower than for adults (≥18 years, n=53); 1.08 (0.52-1.97) versus 1.96 (1.49-2.55) per 100 000/y per year, with the highest incidence for those >50 years with 2.10 (1.38-3.07)/100 000/y. Headache was the most prevalent symptom, reported in 83%, followed by nausea, motor deficits, and seizures observed in 45%, 32%, and 32% of the patients. Transverse sinuses and the jugular vein were the most frequent sites of thrombosis. In most patients (61%), thrombosis occurred in multiple sinuses/veins. Risk factors were found in 73% of the patients, and most of the patients had a combination of 2 or more risk factors. The 30-day and 1-year mortality rates were 3% and 6%. CONCLUSIONS: The incidence of CVT in this population was higher than previously reported. The mortality rate was similar to previous studies.

Cerebral venous thrombosis in Argentina: clinical presentation, predisposing factors, outcomes and literature review.

BACKGROUND: Cerebral venous thrombosis (CVT) is a rare medical condition that primarily affects young adults. The clinical spectrum is broad and its recognition remains a challenge for clinicians. Limited information is available on CVT in Argentina. Our goal was to report the results of the first National registry on CVT in Argentina and to compare clinical presentation, predisposing factors and outcomes with other international registries. MATERIAL AND METHOD: The Argentinian National Registry on CVT (ANR-CVT) is a multicenter retrospective cohort study comprising patients aged 18 and older with a diagnosis of CVT from January 2015 to January 2019. We evaluated demographics, predisposing factors, clinical presentation, and radiological characteristics (e.g. number of involved sinuses, venous infarction or hemorrhage on CT and MRI scans at admission), therapeutic interventions and functional outcomes at discharge and at 90 days. Our results were compared to a literature review of CVT registries. RESULTS: Overall, one hundred and sixty-two patients met the inclusion criteria. The mean age was 42 (±17) years; 72% were women. Seventy percent of patients were younger than 50 years. The most common presenting symptom was headache (82%). The transverse sinus was the most common site of thrombosis (70%) followed by the sigmoid sinus (46%). The main predisposing factor in women was contraceptive use (44%), 3% of the events occurred during pregnancy and 9% during the puerperium. Participants 50 years and older had a higher frequency on malignancy related (7.5% vs. 30%, p = 0.0001) and infections (2% vs. 11%, p = 0.001). The modified Rankin Scale (mRS) ≤2 at discharge was 81% and the rate of mortality at discharge was 4%. At 90 days, the mRS≤2 was 93%. When the ANR-CVT was compared with larger registries from Europe and Asia, the prevalence of cancer among patients with CVT was two to five-fold higher (15% vs. 7% and 3%, respectively; p = 0.002 and p < 0.001). Anticoagulation rates at discharge were also higher (94%) compared to registries from Asia (ASCVT - 68%) or Turkey (VENOST - 67%). CONCLUSION: Participants in the first ANR-CVT had a low mortality and disability at 90 days. Clinical and radiological characteristics were similar to CVT from other international registries with a higher prevalence of cancer. There was a high variability in treatment adherence to guidelines as reflected by anticoagulation rates (range 54.5%-100%) at discharge.

Cerebral venous thrombosis in traumatic brain injury: a cause of secondary insults and added mortality.

OBJECTIVE: Cerebral venous thrombosis (CVT) is increasingly recognized in traumatic brain injury (TBI), but its complications and effect on outcome remain undetermined. In this study, the authors characterize the complications and outcome effect of CVT in TBI patients. METHODS: In a retrospective, case-control study of patients included in the Oslo University Hospital trauma registry and radiology registry from 2008 to 2014, the authors identified TBI patients with CVT (cases) and without CVT (controls). The groups were matched regarding Abbreviated Injury Scale 1990, update 1998 (AIS'98) head region severity score 3-6. Cases were identified by AIS'98 or ICD-10 code for CVT and CT or MR venography findings confirmed to be positive for CVT, whereas controls had no AIS'98 or ICD-10 code for CVT and CT venography or MR venography findings confirmed to be negative for CVT. All images were reviewed by a neuroradiologist. Rates of complications due to CVT were recorded, and mortality was assessed both unadjusted and in a multivariable logistic regression analysis adjusting for initial Glasgow Coma Scale score, Rotterdam CT score, and Injury Severity Score. Complications and mortality were also assessed in prespecified subgroup analysis according to CVT location and degree of occlusion from CVT. Lastly, mortality was assessed in an exploratory subgroup analysis according to the presence of complications from CVT. RESULTS: The CVT group (73 patients) and control group (120 patients) were well matched regarding baseline characteristics. In the CVT group, 18% developed venous infarction, 11% developed intracerebral hemorrhage, and 19% developed edema, all representing complications secondary to CVT. Unadjusted 30-day mortality was 16% in the CVT group and 4% in the no-CVT group (p = 0.004); however, the difference was no longer significant in the adjusted analysis (OR 2.24, 95% CI 0.63-8.03; p = 0.215). Subgroup analysis by CVT location showed an association between CVT location and rate of complications and an unadjusted 30-day mortality of 50% for midline or bilateral CVT and 8% for unilateral CVT compared with 4% for no CVT (p < 0.001). The adjusted analysis showed a significantly higher mortality in the midline/bilateral CVT group than in the no-CVT group (OR 8.41, 95% CI 1.56-45.25; p = 0.032). CONCLUSIONS: There is a significant rate of complications from CVT in TBI patients, leading to secondary brain insults. The rate of complications is dependent on the anatomical location of the CVT, and midline and bilateral CVT is associated with an increased 30-day mortality in TBI patients.

Acute ischaemic stroke interventions: large vessel occlusion and beyond.

Care for acute ischaemic stroke is one of the most rapidly evolving fields due to the robust outcomes achieved by mechanical thrombectomy. Large vessel occlusion (LVO) accounts for up to 38% of acute ischaemic stroke and comes with devastating outcomes for patients, families and society in the pre-intervention era. A paradigm shift and a breakthrough brought mechanical thrombectomy back into the spotlight for acute ischaemic stroke; this was because five randomised controlled trials from several countries concluded that mechanical thrombectomy for acute stroke offered overwhelming benefits. This review article will present a comprehensive overview of LVO management, techniques and devices used, and the future of stroke therapy. In addition, we review our institution experience of mechanical thrombectomy for posterior and distal circulation occlusion.

Thromboembolic events in inflammatory bowel disease.

GOAL OF THE STUDY: Inflammatory bowel disease (IBD) is associated with an increased risk of thromboembolic events (TEE) during outbreaks, increasing morbidity and mortality. The aim of our study was to specify the prevalence of TEE in IBD patients and to determine their epidemiological, clinical and evolutionary characteristics. MATERIEL AND METHODS: This is a retrospective study collecting all patients with IBD, who had a thromboembolic complication confirmed by imagery, between January 2012 and December 2018. RESULTS: One hundred patients with IBD were diagnosed during the study period. A TEE occurred in 6 patients (5.9%). These patients had an average age of 41 years, divided into 4 women and 2 men. Five patients had Crohn's disease and one patient had ulcerative colitis. The IBD was active in all patients. Five patients were already hospitalized and under preventive heparin therapy. Patients had deep venous thrombosis of the lower limbs in 3 cases, associated with pulmonary embolism in 1 case, cerebral venous thrombosis in 2 cases and pulmonary embolism isolated in 1 case. Thrombophilia investigations were negative in all patients. Evolution under medical treatment was favorable in 4 patients and fatal in 2 patients. CONCLUSION: In our study, the prevalence of TEE in patients with IBD was 5.9%. Thrombosis occurred during the active phase of IBD in all cases.

Cerebral Venous Thrombosis in Hematological Malignancy: Balancing the Risks.

BACKGROUND AND AIM: The coexistence of cerebral venous thrombosis (CVT) and hematological neoplasms is rare. Currently available therapeutic options raise problems concerning the balance of thrombotic and hemorrhagic risks. Our purpose is to characterize a series of cases of CVT and concomitant hematological malignancy, focusing on predisposing factors and treatment strategies. METHODS: We performed a descriptive retrospective analysis of the cases of CVT and hematological neoplasms diagnosed in a tertiary center from 2006 to 2015. RESULTS: From the 111 CVT cases diagnosed, only 7 coexisted with hematological malignancy (lymphoma, leukemia, multiple myeloma, and myelodysplastic syndromes). These included 4 women; median age was 44 years old. Median follow-up time was 72 days. The hematological condition was already known in 5 cases. Besides malignancy, we identified other prothrombotic conditions in all cases. Several anticoagulant strategies were used during the acute phase, after which 5 patients remained on warfarin indefinitely. One patient died due to cerebral hemorrhage during the acute phase. In the remaining 6 patients, there was no recurrence of CVT or other complications of anticoagulation. CONCLUSIONS: Although these results reiterate the role of hematological malignancy as predisposing factor to CVT, in all cases other factors contributed to CVT etiology, potentiating the risk. We report 1 death directly attributable to a fatal hemorrhagic complication of anticoagulation, evidencing the delicate balance of thrombotic and hemorrhagic risk. Nevertheless, most patients benefited of long-term anticoagulation, which proved a reasonable option. A multidisciplinary approach is paramount in making decisions regarding the time and type of anticoagulation.

Chronic Kidney Disease and Outcome Following Endovascular Thrombectomy for Acute Ischemic Stroke.

BACKGROUND AND OBJECTIVES: Chronic kidney disease (CKD) is present in 20% to 35% of acute ischemic stroke patients and may increase the risk of poor functional outcome or death. We aimed to determine whether CKD was associated with worse outcome in stroke patients treated with endovascular thrombectomy (EVT). DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Consecutive EVT patients were identified from a prospective registry and dichotomized into patients with and without CKD, defined as an eGFR of less than 60 mL/min/1.73m2. The primary outcome was 3-month mortality following EVT. Secondary outcomes included symptomatic intracerebral hemorrhage (defined by the Safe Implementation of Thrombolysis in Stroke-Monitoring Study), early neurological recovery (defined as change in National Institutes of Health Stroke Scale [NIHSS] score of ≥8 at 24 hours or an NIHSS of 0-1 at 24 hours) and functional independence (defined as a modified Rankin Scale [mRS] score of 0, 1 or 2) at 3 months. RESULTS: 378 EVT patients (223 men; mean ± SD age 65 ± 15 years) were included. The median (IQR) admission eGFR was 71 (58-89) mL/min/1.73 m² and 117 (31%) patients had CKD. Multiple logistic regression adjusted for potential confounders demonstrated that CKD was a significant predictor of lower rates of functional independence (OR = .54, 95% CI, .31 to .90, P = .02), higher mRS scores (common OR = 1.78, 95% CI, 1.14 to 2.81, P = .01), and increased mortality (OR = 2.19, 95% CI, 1.16 to 4.12, P = .01). There was no association between CKD and early neurological recovery (OR = .92, 95% CI, .55 to 1.49, P = .71) or symptomatic intracerebral hemorrhage (OR = 1.18, 95% CI, .38 to 3.69, P = .77). CONCLUSIONS: CKD was a significant predictor of worse functional outcome and mortality in stroke patients treated with EVT. The presence of CKD should not preclude patients from proceeding to EVT, but may help with prognostication and improve shared decision-making between patients, families and physicians.

mtDNA Copy Number Contributes to All-Cause Mortality of Lacunar Infarct in a Chinese Prospective Stroke Population.

The study aimed to investigate the relationship between mtDNA copy number and the risk of all-cause mortality in stroke. One thousand four hundred eighty-four stroke patients were documented including 273 deaths (127 thrombosis, 52 lacunar, 94 hemorrhage). Patients in the third quartile had the lowest mortality rates in overall stroke and the three subtypes. The lowest quartile of mtDNA copy number (Q1 < 85.85) indicated an increased risk of all-cause mortality in stroke patients (adjusted HR, 1.52; 95% CI, 1.08-2.14; p = 0.017). In the subtype analysis, the risk of all-cause mortality appeared only in lacunar infarct, and the patients in the Q1 (< 87.76) and Q4 (> 150.61) mtDNA copy number groups showed significantly higher risks of HRs (Q1, adjusted HR, 3.87, 95% CI, 1.52-9.83; Q4, adjusted HR, 3.08, 95% CI, 1.16-8.18). Stroke patients with lacunar infarct in mtDNA copy number < 87.76 or > 150.61 were at a high risk of poor outcomes in all-cause mortality.

Asian Study of Cerebral Venous Thrombosis.

BACKGROUND/OBJECTIVE: Most of the studies and registries related to cerebral venous thrombosis (CVT) are reported from European countries and the United States. The objective of the present study is to identify risk factors, presentation, and outcome of CVT in Asian patients. METHODS: Asian CVT registry is a prospective multinational observational study that included patients (aged > 16 years) with symptomatic CVT. RESULTS: Eight hundred and twelve patients (59% women) from 20 centers in 9 Asian countries were included. Mean age of the patients was 31 years. Motor weakness in limbs was present in 325 (40%) patients. One hundred and eighty (22.1%) patients had a normal Glasgow coma scale (GCS) at presentation, and another 529 patients (65%) had GCS between 11 and 14. The rest (103; 13%) had a GCS of less than 10 at presentation. Permanent risk factors were present in 264 (33%) patients, transient in 342 (42%) patients, both in 43 (5%) patients and no risk factors were found in 163 (20%) patients. Anemia was present in 51%, use of oral contraceptive pills (OCP) was present in 12% women and a hypercoaguable state was present in more than 40% of those tested. One hundred and forty-three cases (18%) were in women who were either pregnant (18; 2%) or in the puerperium (up to 6 weeks postpartum; N = 125; 15%). A total of 86 (10.5%) patients were diagnosed with infection in any part of the body. The most common MRI finding was local brain edema or ischemia (53.3%) followed by hemorrhage (26.7%). Twenty-seven patients (3.3%) died during hospital stay. The mRS score at discharge was available for 661 (81%) patients. Of these, 577 (87.3%) had good functional outcome at discharge. Motor weakness at presentation, GCS of 9 or less and mental status disorder were the strongest independent predictors of mortality at last follow-up among patients with CVT. CONCLUSIONS: Important differences were identified as compared to western data including younger age, high frequency of anemia, low use of OCP, and high frequency of hypercoaguable states. Functional outcome at discharge was good.

Endovascular Thrombolysis or Thrombectomy for Cerebral Venous Thrombosis: Study of Nationwide Inpatient Sample 2004-2014.

BACKGROUND AND PURPOSE: 15% of cerebral venous thrombosis (CVT) patients have poor outcomes despite anticoagulation. Uncontrolled studies suggest that endovascular approaches may benefit such patients. In this study, we analyze Nationwide Inpatient Sample (NIS) data to evaluate the safety and efficacy of endovascular therapy (ET) versus medical management in CVT. We also examined the yearly trends of ET utilization in the United States. METHODS: International Classification of Diseases, Ninth Revision, Clinical Modification codes were utilized to identify CVT patients who received ET. To make the data nationally representative, weights were applied per NIS recommendations. Since ET was not randomly assigned to patients and was likely to be influenced by disease severity, propensity score weighting methods were utilized to correct for this treatment selection bias. Outcome variables included in-hospital mortality and discharge disposition. To determine if our primary outcomes were associated with ET, we used weighted multivariable logistic regression analyses. RESULTS: Of the 49,952 estimated CVT cases, 48,704 (97%) received medical management and 1248 (3%) received ET (mechanical thrombectomy [MT] alone, N = 269 [21%], MT ± thrombolysis, N = 297 [24%], and thrombolysis alone, N = 682 [55%]). Patients who received ET were older with more CVT associated complications including venous infarct, intracranial hemorrhage, coma, seizure, and cerebral edema. There was a significant yearly rise in the use of ET, with a trend favoring MT versus thrombolysis alone. ET was independently associated with an increased risk of death (odds ratio 1.96, 95% confidence interval 1.15-3.32). CONCLUSIONS: Patients receiving ET experienced higher mortality after adjusting for age and CVT associated complications. Large, well designed prospective randomized trials are warranted for further evaluation of the safety and efficacy of ETs.

Comparing incomparables with the wrong analytics: Anticoagulation, disability, intracranial hemorrhage, and mortality in acute cerebral vein thrombosis.

Significant progress has been made in the prevention and management of hypercoagulation. Unfractionated heparin (UF) and low molecular weight heparin (LMWH) are indicated for acute cerebral vein thrombosis with or without intracranial hemorrhage (ICH). A recent meta-analysis of four trials comparing UF and LMWH aimed to evaluate the efficacy and safety of both agents in terms of disability, intracranial hemorrhage, and mortality. However, several methodological aspects of the meta-analysis warrant further discussion. It appears that the disability outcome was not sufficiently harmonized by design or statistical standardization, some inputs could not be validated, incorrect statistical analyses were performed, major results could not be replicated, and conclusions were not supported by the statistical results. The conclusion of a statistically significant reduction in mortality is not supported by the data.

Body mass index and fatal stroke in young adults: A national study.

Rates of stroke and obesity have increased in recent years. This study aimed to determine the body mass index (BMI) of fatal stroke cases amongst young adults, their clinical characteristics and the association with BMI with risk factors. All cases aged 15-44 years where death was attributed to stroke for whom BMI was available were retrieved from the National Coronial Information System (1/1/2009-31/12/2016). 179 cases were identified: haemorrhagic (165), ischaemic (5), thrombotic (6), mycotic (3), embolic (0). Proportions in each BMI category were: underweight (5.6%), normal weight (37.4%), overweight (27.4%), obese (29.6%). There was a significant linear trend in the proportion of subarachnoid haemorrhages as BMI increased (p < 0.05), and between higher BMI and hypertension (p < 0.001). There were no group differences in cardiomegaly or left ventricular hypertrophy where known causes were other than hypertension, cardiomyopathy, severe coronary artery atherosclerosis, endocarditis or cerebral arteries atherosclerosis. A history of alcoholism (p < 0.01) was less likely with higher BMI. There was no association between BMI and previous stroke, diabetes, vasculitis, gravid/post-partum, tobacco use, psychostimulant use or injecting drug use. Overweight and obese cases were prominent among young fatalities of stroke. Reducing rates of obesity, and associated hypertension, would be expected to reduce the escalating stoke rates among young adults.

Validation of iScore and PLAN Score for Death in Thrombectomy in Acute Stroke Due to Anterior Circulation Large Artery Occlusion.

BACKGROUND: To validate iScore and PLAN score in acute anterior circulation large vessel occlusion stroke patients undergoing thrombectomy. METHODS: iScore and PLAN score were calculated for consecutive acute ischemic stroke undergoing thrombectomy were included and death at 1 month and death at 3 months were recorded. The area under the receiver operating characteristic curve was used to assess the discrimination ability of the scales for death. RESULTS: Two hundred and twenty-nine patients were included, 25.3% (58 of 229) of patient died at 1 month after thrombectomy and 25.8% (59 of 229) of them died at 3 months after thrombectomy. The receiver operator curve analysis found that iScore (area under the curve [AUC] = .76, 95% confidence interval [CI] .69-.83) was numerically better than PLAN score (AUC = .73, 95% CI .66-.81) for predicting death at day 90. The cut-off for iScore is 193, with sensitivity 64%, specificity 79%, positive predictive value 75% and negative predictive value 69%. CONCLUSIONS: The iScore scale is a valid predictive tool for death in anterior circulation large vessel occlusions undergoing thrombectomy.

Long-Term Outcomes in Patients with Anemia And Cerebral Venous Thrombosis.

BACKGROUND: Anemia is associated with unfavorable functional outcome in ischemic and hemorrhagic stroke. However, the relationship between anemia and prognosis in patients with cerebral venous thrombosis (CVT) has not been studied. METHODS: Consecutive CVT patients were retrospectively identified from November 2011, through January 2017. Anemia was defined according to the World Health Organization criteria (non-pregnant female hemoglobin level < 120 g/L, pregnant female < 110 g/L and male < 130 g/L), which was further classified as mild, moderate, and severe anemia according to hemoglobin concentration, and as microcytic, normocytic, and macrocytic anemia according to mean corpuscular volume. Unfavorable outcome was defined as modified Rankin Scale (mRS) of 3-6. Factors such as age, sex, coma, malignancy, intracerebral hemorrhage, and straight sinus and/or deep CVT involved, premorbid mRS were adjusted to evaluate the relationship between anemia and prognosis in CVT patients. RESULTS: A total of 238 CVT patients were included, among whom 73 patients (30.67%) were diagnosed with anemia. Multivariate logistic regression analysis showed that patients with anemia had a higher risk of mRS of 3-6 (OR = 3.62; 95% CI, 1.45-9.01; P = 0.006) and mortality (OR = 5.46; 95% CI, 1.90-15.70; P = 0.002). Subgroup analysis showed that severe anemia was independently associated with mRS of 3-6 (OR = 8.80; 95% CI, 1.90-40.81; P = 0.005) and mortality (OR = 9.82; 95% CI, 1.81-53.25; P = 0.010). Similarly, microcytic anemia increased the risk of mRS of 3-6 (OR = 4.64; 95% CI, 1.48-14.52; P = 0.008) and mortality (OR = 9.68; 95% CI, 2.61-35.91; P = 0.001). In addition, our study also revealed that lower hemoglobin level, evaluated as a continuous variable, was inversely associated with mRS of 3-6 (OR = 0.98; 95% CI, 0.96-0.99; P = 0.007) and mortality (OR = 0.97; 95% CI, 0.95-0.99; P = 0.005). CONCLUSIONS: Anemia was a significant and independent predictor of unfavorable functional outcome in patients with CVT.