Cerebral veins contain about 70% of the total cerebral blood volume, but cerebral venous thrombosis (CVT) occurs about a thousand times less often than arterial stroke. CVT affects mostly young adults and children, and in about one quarter of cases the cause remains unknown. Written by international experts, this publication is dealing with epidemi
Abstract Prognostic assessment in patients with acute venous thromboembolism is essential to drive clinical management in terms of disposition for hospitalization or home treatment, and revascularization strategies or anticoagulation alone. In these patients, single predictors, combinations of predictors, or prognostic models can be used for prognostic assessment. Overall, the risk for short-term death is about tenfold higher after acute pulmonary embolism than after acute deep vein thrombosis. Localization of thrombosis (proximal or distal) and comorbidities are the main predictors of prognosis in patients with deep vein thrombosis. In patients with pulmonary embolism, prognostic assessment includes the evaluation of clinical features, findings at imaging (computed tomography angiography, echocardiography, and/or ultrasonography of the lower limbs), or biomarkers of right ventricular dysfunction or injury. The presence of shock or sustained hypotension is the main criterion for the identification of high-risk patients. Clinical models with high negative predictive value have been validated to identify patients at low risk for short-term death. Whether the assessment of right ventricular dysfunction in these patients can further improve the negative predictive value of clinical models remains to be defined. Right ventricular dysfunction as assessed by echocardiography or computed tomography angiography as well as right ventricular damage by troponin levels are associated with an about twofold increase in the risk for short-term death in intermediate risk patients. However, prognostic assessment in these patients requires further improvement before it can be used to drive decisions on treatment.
Background and Purpose— The beneficial effect of intravenous thrombolytic therapy in patients with acute ischemic stroke attributable to internal carotid artery (ICA) occlusion remains unclear. The aim of this study was to evaluate the efficacy and safety of intravenous recombinant tissue-type plasminogen activator in these patients. Methods— ICARO was a case-control multicenter study on prospectively collected data. Patients with acute ischemic stroke and ICA occlusion treated with intravenous recombinant tissue-type plasminogen activator within 4.5 hours from symptom onset (cases) were compared to matched patients with acute stroke and ICA occlusion not treated with recombinant tissue-type plasminogen activator (controls). Cases and controls were matched for age, gender, and stroke severity. The efficacy outcome was disability at 90 days assessed by the modified Rankin Scale, dichotomized as favorable (score of 0–2) or unfavorable (score of 3–6). Safety outcomes were death and any intracranial bleeding. Results— Included in the analysis were 253 cases and 253 controls. Seventy-three cases (28.9%) had a favorable outcome as compared with 52 controls (20.6%; adjusted odds ratio (OR), 1.80; 95% confidence interval [CI], 1.03–3.15; P =0.037). A total of 104 patients died, 65 cases (25.7%) and 39 controls (15.4%; adjusted OR, 2.28; 95% CI, 1.36–3.22; P =0.001). There were more fatal bleedings (2.8% versus 0.4%; OR, 7.17; 95% CI, 0.87–58.71; P =0.068) in the cases than in the controls. Conclusions— In patients with stroke attributable to ICA occlusion, thrombolytic therapy results in a significant reduction in the proportion of patients dependent in activities of daily living. Increases in death and any intracranial bleeding were the trade-offs for this clinical benefit.
The management of patients with acute pulmonary embolism is made challenging by its wide spectrum of clinical presentation and outcome, which is mainly related to patient haemodynamic status and right ventricular overload. Mechanical embolic obstruction and neurohumorally mediated pulmonary vasoconstriction are responsible for right ventricular overload. The pathophysiology of acute pulmonary embolism is the basis for risk stratification of patients as being at high, intermediate and low risk of adverse outcomes. This risk stratification has been advocated to tailor clinical management according to the severity of pulmonary embolism. Anticoagulation is the mainstay of the treatment of acute pulmonary embolism. New direct oral anticoagulants, which are easier to use than conventional anticoagulants, have been compared with conventional anticoagulation in five randomised clinical trials including >11 000 patients with pulmonary embolism. Patients at high risk of pulmonary embolism (those with haemodynamic compromise) were excluded from these studies. Direct oral anticoagulants have been shown to be as effective and at least as safe as conventional anticoagulation in patients with pulmonary embolism without haemodynamic compromise, who are the majority of patients with this disease. Whether these agents are appropriate for the acute-phase treatment of patients at intermediate–high risk pulmonary embolism (those with both right ventricle dysfunction and injury) regardless of any risk stratification remains undefined.
<b><i>Introduction and Objective:</i></b> Even though the introduction of less cumbersome anticoagulant agents has improved, the rates of<b><i></i></b>overall anticoagulant treatment in eligible patients with atrial fibrillation (AF) remain to be defined. We aimed to assess the rates of and determinants for the use of anticoagulation treatment before stroke in patients with known AF since the introduction of direct oral anticoagulants (DOAC) in clinical practice. <b><i>Methods:</i></b> Consecutive patients admitted to an individual stroke unit, from September 2013 through July 2019, for acute ischemic stroke or transient ischemic attack (TIA) with known AF before the event were included in the study. Logistic regression analysis was used to identify independent predictors of the use of anticoagulant treatment. <b><i>Results:</i></b> Overall, 155 patients with ischemic stroke/TIA and known AF were included in this study. Among 152 patients with a CHA<sub>2</sub>DS<sub>2</sub>-VASc score &#x3e;1, 43 patients were not receiving any treatment, 47 patients were receiving antiplatelet agents, and the remaining 62 patients were on oral anticoagulants. Among 34 patients on DOAC, 13 were receiving a nonlabeled reduced dose and 18 out of 34 patients on vitamin K antagonists had an INR value &#x3c;2 at the time of admission. Before stroke, only 34 out of 155 patients (21.9%) were adequately treated according to current guidelines. Previous stroke/TIA was the only independent predictor of the use of anticoagulant therapy. <b><i>Conclusions:</i></b> Only 21.9% of the patients hospitalized for a stroke or TIA with known AF before the event were adequately treated according to recent treatment guidelines. It is important to improve medical information about the risk of AF and the efficacy of anticoagulants in stroke prevention.
