Background: Inflammation was associated with the severity of severe cerebral venous thrombosis (CVT) on admission and poor prognosis at discharge. Hereditary protein C/S deficiency (hereditary ...PCD/PSD) not only promotes thrombosis but also activates the inflammatory response, further inducing venous thrombosis. However, conventional treatments such as standard anticoagulant/endovascular therapy (EVT) do not seem to improve prognosis. Anti-inflammatory therapy may be a new way to treat the disease. Methods: We enrolled five patients with acute/subacute severe CVT with hereditary PCD/PSD from January 2020 to July 2022. In addition to standard anticoagulant therapy, all of them were given short-term methylprednisolone pulse therapy. Neurological deficit, increased intracranial pressure, venous recanalization, serum and cerebrospinal fluid (CSF) inflammatory markers and adverse events were retrospectively described before and after treatment and at 6 months after discharge. Results: Inflammatory indexes of all patients were significantly elevated on admission. After methylprednisolone pulse therapy, serum inflammatory indexes including neutrophil-to-lymphocyte ratio (P=0.043); platelet-to-lymphocyte ratio (P=0.043); systemic immune inflammatory index (P=0.043); interleukin-6 (P=0.043) and hypersensitive C-reactive protein (P=0.022) reduced dramatically compared with baseline. CSF inflammatory indexes had a decreasing trend compared with baseline (P>0.05). In terms of venous recanalization, one patient achieved complete recanalization, four patients obtained partial recanalization. Compared with baseline on admission, the NIH Stroke Scale (NIHSS), modified Rankin Scale (mRS) and intracranial pressure were all considerably lower at discharge (P=0.029, P=0.041 and P=0.017). At 6-month follow-up, NIHSS and mRS further declined. During hospitalization and 6-month follow-up, none of the five patients experienced severe steroid-related adverse effects such as recurrence of venous thrombosis, spontaneous fracture or osteonecrosis, and gastroduodenal ulcer. Conclusion: Acute/subacute severe CVT with hereditary PCD/PSD has high levels of inflammation. In addition to conventional anticoagulant therapy, early anti-inflammatory therapy using steroids may be necessary. Nevertheless, substantial randomized controlled trials with larger sample sizes are required for further investigation. Keywords: severe cerebral venous thrombosis, hereditary protein C deficiency, hereditary protein S deficiency, thrombosis, inflammation, methylprednisolone pulse therapy
Objective
This study aimed to explore the effect of different administration routes of a low dose of tirofiban on acute ischemic stroke (AIS) patients with successful recanalization after ...endovascular treatment (EVT).
Methods
This is a cohort study that retrospectively analyzed data of patients with AIS who underwent EVT and achieved successful recanalization from a prospective registry. Eligible patients were divided into three groups according to their use of tirofiban. Propensity score matching (PSM) was used to balance baseline bias. Safety outcomes included any intracranial hemorrhage (ICH) and symptomatic ICH (sICH). Efficacy outcomes included arterial reocclusion, in‐hospital mortality, 3‐month mortality, and 3‐month functional outcomes.
Results
We included 821 patients with 306 in the no tirofiban group, 202 in the IA + IV tirofiban group, and 313 in the IV tirofiban group. After PSM, each group included 101 patients with balanced baseline characteristics. There was no difference between the IV tirofiban group and the no tirofiban group in terms of safety and efficacy outcomes (all p > 0.05). Compared with no tirofiban, IA + IV tirofiban group did not increase ICH (30.7% vs. 37.6%, p > 0.05) and sICH (6.9% vs. 17.8%, p > 0.05) whereas reduced 3‐month mortality (14.3% vs. 28.7%, p < 0.05) and improved 3‐month modified Rankin Scale (median 3 vs. 4, p < 0.05).
Conclusions
A low dose of tirofiban, regardless of their administration routes, was safe for AIS patients who achieved successful recanalization with EVT, whereas only IA + IV tirofiban improved clinical outcomes.
This study found that a low dose of intra‐arterial + intravenous tirofiban improved 3‐month clinical outcomes (reduced mortality and improved functional outcomes) of acute ischemic stroke patients with successful recanalization by endovascular treatment, while intravenous tirofiban did not.
The importance of evaluating performance of cloud systems has been increasing with the rapid growing market demands for cloud computing. However, the performance testers often have to go through the ...hassle of tedious manual operations when interacting with the cloud. A cloud performance evaluation framework is designed for both broad cloud support and good workload extensibility, which provides an automatic interface to monitor the capability and scalability of Infrastructure-as-a-Service cloud systems. Cloud API modules are implemented for Amazon EC2 service and OpenStack. It can achieve flexible control workflows for multiple of different workloads and user customization to test scenarios. With several built-in workloads and metric aggregation methods, a series of tests is performed on our private clouds to compare the performance and scalability from multiple aspects. A methodology is also proposed to build a cost-performance model to better understand and analyze the efficiency of different types of cloud systems. Based on the results of the experiments, the model indicates a polynomial relation between performance per instance and the overall cost.
Introduction: Cerebral venous thrombosis (CVT) is a rare subtype of stroke. However, existing scales were insufficient to evaluate the overall severity of CVT. The aim of this study is to develop and ...validate a CVT severity scale. Methods: Items 1-11 were directly derived from NIHSS. New items were generated from a literature review and focus group discussion. A total of 170 CVT patients were prospectively recruited from 26 top tertiary hospitals in China Mainland from January 2021 to May 2022 to validate the CVT severity scale. The CVT severity scale, NIHSS, mRS and GCS were rated at admission. The lumbar puncture opening pressure was also recorded. Twenty randomly selected CVT patients were rated with the CVT severity scale again 24 hours later. The clinical outcome of CVT was evaluated by mRS at 6 months after baseline. Results: We successfully established a CVT severity scale with 18 items. Exploratory factor analysis showed that 18 items were attributed to factor 1 (focal neurological deficits), factor 2 (diffuse encephalopathy), factor 3 (intracranial hypertension) and factor 4 (cavernous sinus syndrome). CVT severity scale was positively correlated with ICP, NIHSS and mRS, and negatively correlated with GCS at baseline. CVT severity scale >3 or factor 3 >2 indicated intracranial hypertension. CVT severity scale >10 indicated poor clinical outcome at 6 months of follow-up. Meanwhile, CVT severity scale showed high internal consistency and test--retest reliability. Conclusion: The CVT severity scale included 18 items encompassing 4 domains of focal neurological deficits, diffuse encephalopathy, IH and cavernous sinus syndrome. CVT severity scale correlated well with ICP, NIHSS, mRS and GCS. Patients with CVT severity scale >10 can be defined as severe CVT. The CVT severity scale may serve as a valid and reliable tool for measuring the overall severity of CVT. Keywords: cerebral venous thrombosis, clinical manifestations, severity scale, reliability, validity
Objective
Remote ischemic conditioning (RIC) has been demonstrated to be safe and feasible for patients with acute ischemic stroke (AIS), as well as for those receiving intravenous thrombolysis. We ...assessed the safety and feasibility of RIC for AIS patients undergoing endovascular treatment (ET).
Methods
We conducted a pilot study with patients with AIS who were suspected of having an emergent large‐vessel occlusion in the anterior circulation and who were scheduled for ET within 6 hours of ictus. Four cycles of RIC were performed before recanalization, immediately following recanalization, and once daily for the subsequent 7 days. The primary outcome was any serious RIC‐related adverse events.
Results
Twenty subjects, aged 66.1 ± 12.1 years, were recruited. No subject experienced serious RIC‐related adverse events. The intracranial pressure, cranial perfusion pressure, mean arterial pressure, heart rate, middle cerebral artery peak systolic flow velocity, and pulsatility index did not change significantly before, during, or after the limb ischemia (P > 0.1 for all). Of 80 cycles, 71 (89%) were completed before recanalization and 80 (100%) were completed immediately after recanalization; 444 of 560 cycles (78%) were completed within 7 days posttreatment. No patients had to stop RIC because it affected routine clinical managements. Six subjects (30%) experienced intracerebral hemorrhage, which was symptomatic in one case (5%). At the 3‐month follow‐up, 11 subjects (55%) had achieved functional independence, and two subjects (10%) died.
Interpretation
RIC appears to be safe and feasible for patients with AIS undergoing ET. Investigations are urgently needed to determine the efficacy of RIC in this patient population.
To evaluate the incidence of post-interventional contrast staining (PICS) in acute ischemic stroke (AIS) Chinese patients who were treated with endovascular thrombectomy (ET) and investigate ...potential association of PICS with functional outcome and intracerebral hemorrhage (ICH). This observational study was based on a single-center prospective registry study. AIS patients who underwent ET from January 2013 to February 2017 were recruited into this study. All patients had dual-energy CT (DECT) scan of the head at 12 to 24 hours post-ET. The primary outcome was the incidence of PICS. Secondary outcomes were total ICH, symptomatic ICH (sICH), 3-month functional outcome, and long-term functional outcome. One hundred and eighty patients were enrolled in this study. PICS was detected in 50 patients (28%) based on the post-interventional CT scan. We first used basic statistical analyses, showing that the incidence of both total ICH (60% vs. 25%, p<0.001) and sICH (18% vs. 8%, p=0.044) were higher in patients with PICS than those without, and fewer patients achieved no disability (mRS≤1) in the PICS group compared to the control group at both 3-month and long-term follow-up (p<0.01 each). However, multivariate regression analysis further revealed that PICS only increased total (adjusted odds ratio, 7.38; 95% confidence interval 1.66 to 32.9; p=0.009) but not sICH risk. Furthermore, the logistic regression analyses did not show statistical difference in good clinical outcomes or mortality between the two groups. PICS is a common phenomenon in Chinese AIS patients. It is associated with total ICH after ET, but it seems to have no effect on functional outcome and sICH. Further large-scale studies are warranted to validate these results.
Essential thrombocythemia (ET) is a rare cause of cerebral venous sinus thrombosis (CVST). Analysis of the risk factors and treatment therapies of CVST in ET has yielded controversial findings.
We ...retrospectively investigated the clinical characteristics of CVST events in ET and compared baseline characteristics, causative factors, hematological effects, and treatments between ET patients with and without CVST.
Overall, 91 of 115 patients who met the ET diagnosis were included in this study. Among them, 23 (25.27%) patients met the diagnostic criteria of ET with CVST for inclusion, 14 (60.87%) of whom were females, with a median age of 34 (range 25-50). CVST diagnosis was made concomitantly to ET in 19 patients (82.61%). The most common symptom and sites of thrombosis of CVST was an acute or subacute headache and sigmoid sinuses, respectively. Compared with ET patients without CVST, ET patients with CVST were significantly younger (37.65±14.45 vs 60.93±13.46,
<0.001) and had lower prevalence of hypertension (4.34 vs 32.35%,
=0.003) and coronary artery disease (0 vs 14.71%,
= 0.045). Patients with CVST presented with significant lower platelet count (510.39±176.71 vs 750.82±249.10,
< 0.001) and higher score of IPSET-thrombosis (
=0.017). Multivariate logistic regression analysis indicated that age (
=0.002, OR 1.096, 95% CI 1.035-1.161), at least one CVRF (
= 0.024, OR 0.037, 95% CI 0.002-0.649), platelet count (
=0.045, OR 0.994, 95% CI 0.989-1.001), and lower percentage of antiplatelet therapy (
=0.035, OR 0.307, 95% CI 0.001-1.280) significantly contributed to the risk of CVST in ET.
Most patients (95.65%) had a favorable outcome without recurrence after standard anticoagulant and cytoreductive treatment at last follow-up. These findings indicate that CVST may be the initial presentation of ET, with its detection crucial for early diagnosis and appropriate management. Anticoagulant and cytoreductive therapies should be recommended for preventing ET-related CVST with
V617F mutation.
Available knowledge about the impact of anticoagulation delay on outcomes of patients with cerebral venous thrombosis (CVT) is limited. We therefore assessed the factors influencing anticoagulation ...delay and investigated the effect of this delay on outcomes of CVT patients. Anticoagulation delay was defined as the time interval between symptom onset and anticoagulation initiation. The primary outcome was a modified Rankin Scale (mRS) score > 2 at the final follow-up. A total of 164 eligible patients were included. The median anticoagulation delay was 9 days. Cerebral hemorrhage on admission neuroimaging correlated with earlier anticoagulation (p = 0.040). Anticoagulation delay was not associated with poor functional outcome (mRS > 2), but it was associated with residual headache across the entire cohort (earlier anticoagulation: 15/76 19.7% vs. later anticoagulation: 28/79 35.4%; p = 0.029) and in the subgroup with isolated intracranial hypertension (earlier anticoagulation: 4/25 16.0% vs. later anticoagulation: 14/27 51.9%; p = 0.007). Anticoagulation delay was found to be common among patients with CVT. Anticoagulation delay was not associated with poor functional outcome, but may have led to an increased risk of residual headache across our entire cohort and in the subgroup with isolated intracranial hypertension.
Postinterventional sedation is commonly used in clinical practice to ensure patient safety and comfort. Although sedation or anesthesia during thrombectomy has been well studied, the association ...between postinterventional sedation and functional outcomes in endovascularly treated patients with acute ischemic stroke (AIS) has yet to be investigated. We describe the association between postinterventional sedation and functional outcomes in patients with AIS treated with endovascular therapy (EVT).
This observational study was based on a prospective registry. Patients with AIS treated with EVT from January 2013 to August 2017 at Xuanwu Hospital, Capital Medical University were included. Patients receiving postinterventional sedation were compared with patients not receiving sedation. The primary outcome was the 3 months modified Rankin Scale score.
A total of 268 patients were eligible for study: 112 patients (41.8%) receiving postinterventional sedation and 156 patients (58.2%) without sedation. At 3 months follow-up, the median modified Rankin Scale score was 4 (interquartile range, 3-6) in the sedation group and 2 (interquartile range, 1-4) in the nonsedation group (P < 0.001). Multivariable regression analysis suggested that the need for postinterventional sedation was associated with unfavorable outcomes, with an odds ratio of 0.20 for functional independence (95% confidence interval CI, 0.078-0.487; P < 0.001), 0.06 for freedom from disability (95% CI, 0.017-0.228; P < 0.001), and 8.37 for death (95% CI, 2.196-31.889; P = 0.002).
Postinterventional sedation worsens functional outcomes in patients with AIS with large-vessel occlusions treated with EVT. Whether the sedation is a causative factor or a surrogate for poor functional outcomes remains to be determined.
Objectives
To determine whether blood group influences development of cerebral venous thrombosis (CVT) after administration of the coronavirus disease 2019 (COVID-19) AstraZeneca ChAdOx1-S vaccine.
...Design
A case–control study. Univariate and multivariate logistic regression was used to determine the association between blood type and COVID-19 vaccination status.
Setting
Vaccinated and unvaccinated patients recruited from the international Bio-Repository to Establish the Aetiology of Sinovenous Thrombosis study and the Cerebral Venous Sinus Thrombosis With Thrombocytopenia Syndrome Study Group.
Participants
All patients were of European descent and age and sex matched. Cases (n = 82) were patients ≥18 years old who suffered a CVT within 28 days of a first dose of ChAdOx1-S vaccine. Controls (n = 441) were unvaccinated CVT patients ≥18 years old. All patients were of European descent.
Main outcome measures
Frequency of blood type and ABO allele distribution by vaccination status.
Results
Blood group O was found to be more prevalent among CVT patients with vaccine-induced thrombotic thrombocytopenia (VITT-CVT) after ChAdOx1-S vaccination compared with unvaccinated CVT cases (43% vs. 17%, respectively, p < 0.001). Blood group A was less prevalent, though still high, in the vaccinated group compared with the unvaccinated group (47% vs. 71%, respectively, p < 0.001). No significant differences were observed in the VITT-CVT non-ChAdOx1-S vaccine group and unvaccinated pre-COVID-19 CVT group for blood group.
Conclusions
Blood group O is more prevalent among patients with VITT-CVT after ChAdOx1-S vaccination compared with unvaccinated cases, independent of well-established CVT risk factors. A larger dataset may be able to determine whether those of blood groups B and/or AB may be safely vaccinated with the low cost, readily available and easily transported ChAdOx1-S rather than adopting a complete ban.
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