Abstract
Background and purpose
To explore the prevalence, risk factors, time correlation, characteristics and clinical outcome of dural arteriovenous fistulas (dAVFs) in a cerebral venous thrombosis ...(CVT) population.
Methods
We included patients from the International CVT Consortium registries. Diagnosis of dAVF was confirmed centrally. We assessed the prevalence and risk factors for dAVF among consecutive CVT patients and investigated its impact on clinical outcome using logistic regression analysis. We defined poor outcome as modified Rankin Scale score 3–6 at last follow‐up.
Results
dAVF was confirmed in 29/1218 (2.4%) consecutive CVT patients. The median (interquartile range IQR) follow‐up time was 8 (5–23) months. Patients with dAVF were older (median IQR 53 44–61 vs. 41 29–53 years;
p
< 0.001), more frequently male (69% vs. 33%;
p
< 0.001), more often had chronic clinical CVT onset (>30 days: 39% vs. 7%;
p
< 0.001) and sigmoid sinus thrombosis (86% vs. 51%;
p
< 0.001), and less frequently had parenchymal lesions (31% vs. 55%;
p
= 0.013) at baseline imaging. Clinical outcome at last follow‐up did not differ between patients with and without dAVF. Additionally, five patients were confirmed with dAVF from non‐consecutive CVT cohorts. Among all patients with CVT and dAVF, 17/34 (50%) had multiple fistulas and 23/34 (68%) had cortical venous drainage. Of 34 patients with dAVF with 36 separate CVT events, 3/36 fistulas (8%) were diagnosed prior to, 20/36 (56%) simultaneously and 13/36 after (36%, median 115 IQR 38–337 days) diagnosis of CVT.
Conclusions
Dural arteriovenous fistulas occur in at least 2% of CVT patients and are associated with chronic CVT onset, older age and male sex. Most CVT‐related dAVFs are detected simultaneously or subsequently to diagnosis of CVT.
BACKGROUND AND PURPOSE—Cerebral venous thrombosis (CVT) is rare in older patients. We investigated whether clinical features and outcomes differ in older and younger patients.
METHODS—We used data ...from a multicenter observational registry of consecutive adult patients with CVT admitted between 1987 and 2016. We compared demographics, clinical manifestations, and outcomes between older (upper quartile of the age distribution) and younger (lower 3 quartiles of the age distribution) patients.
RESULTS—Data for 843 patients with CVT were available. The median age was 43 years (interquartile range, 30–55 years). Older patients (≥55 years; n=222) were less often women than younger patients (48% versus 71%; P<0.001) and less often reported headache (63% versus 87%; P<0.001). Cancer was more common in older patients (24% versus 9%; P<0.001), especially solid malignancies (19% versus 5%; P<0.001). Outcome at follow-up was worse in older patients (modified Rankin Scale, 3–6; adjusted odds ratio, 2.68; 95% confidence interval, 1.78–4.03; mortality, adjusted odds ratio, 2.13; 95% confidence interval, 1.09–4.19).
CONCLUSIONS—The sex ratio of CVT is evenly distributed in older patients, probably because of the dissipation of hormonal influences. Malignancy should be considered as a potential precipitant in older patients with CVT.
Abstract only Introduction: Adenovirus-based COVID-19 vaccines are extensively used in low- and middle-income countries (LMICs). In India alone, 1.67 billion ChAdOx1 nCoV-19 vaccines have been ...administered by August 23, 2022. Surprisingly however, there are only few reports of cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) from LMICs. We aimed to gain insight into the frequency, manifestations, treatment, and outcomes of CVST-VITT in LMICs. Methods: We report data from an international registry on CVST after COVID-19 vaccination. VITT was classified according to the Pavord criteria. We compared characteristics of CVST-VITT cases from LMICs to cases from high-income countries (HICs). Results: By August 15, 2022, 228 CVST cases after vaccination were reported, of which 63 cases from LMICs (all middle-income countries MICs: Brazil, China, India, Iran, Mexico, Pakistan, and Turkiye). Of these, 32/63 (51%) met the criteria for definite, probable or possible VITT. Only 5/32 (16%) CVST-VITT cases from MICs had definite VITT, mostly because anti-PF4 antibodies were not tested in 21/32 (66%) cases. Patients from MICs were diagnosed in a later time period than patients from HICs (1/32 3% vs 65/103 63% cases diagnosed before May 2021, respectively). Median age was 26 (IQR 20-37) vs 47 (IQR 32-58) years, and proportion of women was 25/32 (78%) vs 77/103 (75%) in MICs vs HICs, respectively. Clinical manifestations, such as focal neurologic deficits, coma, seizures, and intracranial hemorrhages, were similar. Concomitant venous thromboembolism was less frequent in MICs (3/31 10% vs 26/97 27%). Median platelet count nadir was higher in the MICs than the HICs group (65 x10 9 /L IQR 36-115 vs 33 x10 9 /L IQR 18-55, p =0.001). Intravenous immunoglobulin use was similar (19/30 63% vs 63/99 64%). In-hospital mortality was lower in the MICs than the HICs group (7/32 22%, 95%CI 11-39 vs 44/102 43%, 95%CI 34-53, p =0.031). Conclusions: The absolute number of CVST-VITT cases reported from LMICs was small despite the widespread use of adenoviral vaccines in these countries. Clinical manifestations and treatment of CVST-VITT cases were largely similar in MICs and HICs, while mortality was lower in patients from MICs.
Abstract Background Only few small studies have assessed rates of recanalization and impact of recanalization on outcome in patients after cerebral vein thrombosis (CVT). Methods In this ...retrospective cohort study , we included 91 consecutive patients—treated in Helsinki University Central Hospital—who had non-invasively verified CVT and follow-up imaging at 4 months or later, or autopsy. We categorized vessel status at follow-up as complete, partial, or no recanalization. A complete recovery was defined as a score of 0 on the modified Rankin Scale. Results Of the 91 patients (median age, 36 years; 70% females), 43 (47%) achieved complete recanalization, in 31 (34%) patients recanalization was partial, and 17 (19%) had no recanalization. Males, patients aged ≥ 37 years, and those with no identified risk factors for CVT had more frequently partial or no recanalization. Patients aged ≥ 37 years, those with chronic onset of symptoms (> 30 days), and those with no recanalization had worse outcome in univariate analysis. Only increasing age associated with no recanalization (OR, 1.04; 95% CI, 1.01–1.08) when adjusted for age, sex, and number of causes for CVT. Increasing age (OR 1.05; 95% CI 1.01–1.09) and chronic mode of onset (OR 9.41; 95% CI 1.02–87.07) predicted incomplete recovery or death when adjusted for age, sex, mode of onset, and status of recanalization. Headache was more common in patients with no recanalization (44%). Conclusions Half of the patients after CVT had complete recanalization. Despite the univariate association, recanalization did not associate with poor outcome in multivariate analysis. However, residual headache was more common in those with no recanalization.
Gene-gene interactions likely contribute to the etiology of multifactorial diseases such as cerebral venous thrombosis (CVT) and could be one of the main sources of known missing heritability. We ...explored Factor
(
) and
gene interactions among patients with CVT.
Patients with CVT of European ancestry from the large Bio-Repository to Establish the Aetiology of Sinovenous Thrombosis (BEAST) international collaboration were recruited. Codominant modelling was used to determine interactions between genome-wide identified
and
genes with CVT status.
We studied 882 patients with CVT and 1,205 ethnically matched control participants (age: 42 ± 15 vs 43 ± 12 years,
= 0.08: sex: 71% male vs 68% female,
= 0.09, respectively). Individuals heterozygous (AT) for the risk allele (T) at both loci (rs56810541/
and rs8176645/
) had a 3.9 (95% CI 2.74-5.71,
= 2.75e-13) increase in risk of CVT. Individuals homozygous (TT) for the risk allele at both loci had a 13.9 (95% CI 7.64-26.17,
= 2.0e-15) increase in risk of CVT. The presence of a non-O blood group (A, B, AB) combined with TT/rs56810541/
increased CVT risk by OR = 6.8 (95% CI 4.54-10.33,
= 2.00e15), compared with blood group-O combined with AA.
Interactions between factor
and
genes increase risk of CVT by 4- to 14-fold.
Background and purpose
A prognostic score was developed to predict dependency and death after cerebral venous thrombosis (CVT) to identify patients for targeted therapy in future clinical trials.
...Methods
Data from the International CVT Consortium were used. Patients with pre‐existent functional dependency were excluded. Logistic regression was used to predict poor outcome (modified Rankin Scale score 3–6) at 6 months and Cox regression to predict 30‐day and 1‐year all‐cause mortality. Potential predictors derived from previous studies were selected with backward stepwise selection. Coefficients were shrunk using ridge regression to adjust for optimism in internal validation.
Results
Of 1454 patients with CVT, the cumulative number of deaths was 44 (3%) and 70 (5%) for 30 days and 1 year, respectively. Of 1126 patients evaluated regarding functional outcome, 137 (12%) were dependent or dead at 6 months. From the retained predictors for both models, the SI2NCAL2C score was derived utilizing the following components: absence of female‐sex‐specific risk factor, intracerebral hemorrhage, infection of the central nervous system, neurological focal deficits, coma, age, lower level of hemoglobin (g/l), higher level of glucose (mmol/l) at admission, and cancer. C‐statistics were 0.80 (95% confidence interval CI 0.75–0.84), 0.84 (95% CI 0.80–0.88) and 0.84 (95% CI 0.80–0.88) for the poor outcome, 30‐day and 1‐year mortality model, respectively. Calibration plots indicated a good model fit between predicted and observed values. The SI2NCAL2C score calculator is freely available at www.cerebralvenousthrombosis.com.
Conclusions
The SI2NCAL2C score shows adequate performance for estimating individual risk of mortality and dependency after CVT but external validation of the score is warranted.
OBJECTIVETo assess the added diagnostic value of semiquantitative imaging markers on noncontrast CT scans in cerebral venous thrombosis (CVT).
METHODSIn a retrospective, multicenter, blinded, ...case-control study of patients with recent onset (<2 weeks) CVT, 3 readers assessed (1) the accuracy of the visual impression of CVT based on a combination of direct and indirect signs, (2) the accuracy of attenuation values of the venous sinuses in Hounsfield units (with adjustment for hematocrit levels), and (3) the accuracy of attenuation ratios of affected vs unaffected sinuses in comparison with reference standard MRI or CT angiography. Controls were age-matched patients with (sub)acute neurologic presentations.
RESULTSWe enrolled 285 patients with CVT and 303 controls from 10 international centers. Sensitivity of visual impression of thrombosis ranged from 41% to 73% and specificity ranged from 97% to 100%. Attenuation measurement had an area under the curve (AUC) of 0.78 (95% confidence interval CI 0.74–0.81). After adjustment for hematocrit, the AUC remained 0.78 (95% CI 0.74–0.81). The analysis of attenuation ratios of affected vs unaffected sinuses had AUC of 0.83 (95% CI 0.8–0.86). Adding this imaging marker significantly improved discrimination, but sensitivity when tolerating a false-positive rate of 20% was not higher than 76% (95% CI 0.70–0.81).
CONCLUSIONSemiquantitative analysis of attenuation values for diagnosis of CVT increased sensitivity but still failed to identify 1 out of 4 CVT.
CLASSIFICATION OF EVIDENCEThis study provides Class II evidence that visual analysis of plain CT with or without attenuation measurements has high specificity but only moderate sensitivity for CVT.
Background and purpose
Coma is an independent predictor of poor clinical outcomes in cerebral venous thrombosis (CVT). We aimed to describe the association of age, sex, and radiological ...characteristics of adult coma patients with CVT.
Methods
We used data from the international, multicentre prospective observational BEAST (Biorepository to Establish the Aetiology of Sinovenous Thrombosis) study. Only positively associated variables with coma with <10% missing data in univariate analysis were considered for the multivariate logistic regression model.
Results
Of the 596 adult patients with CVT (75.7% women), 53 (8.9%) patients suffered coma. Despite being a female‐predominant disease, the prevalence of coma was higher among men than women (13.1% vs. 7.5%, p = 0.04). Transverse sinus thrombosis was least likely to be associated with coma (23.9% vs. 73.3%, p < 0.001). The prevalence of superior sagittal sinus thrombosis was higher among men than women in the coma sample (73.6% vs. 37.5%, p = 0.01). Men were significantly older than women, with a median (interquartile range) age of 51 (38.5–60) versus 40 (33–47) years in the coma (p = 0.04) and 44.5 (34–58) versus 37 (29–48) years in the non‐coma sample (p < 0.001), respectively. Furthermore, an age‐ and superior sagittal sinus‐adjusted multivariate logistic regression model found male sex (odds ratio = 1.8, 95% confidence interval CI = 1.0–3.4, p = 0.04) to be an independent predictor of coma in CVT, with an area under the receiver operating characteristic curve of 0.61 (95% CI = 0.52–0.68, p = 0.01).
Conclusions
Although CVT is a female‐predominant disease, men were older and nearly twice as likely to suffer from coma than women.
Background and purpose
To explore the prevalence, risk factors, time correlation, characteristics and clinical outcome of dural arteriovenous fistulas (dAVFs) in a cerebral venous thrombosis (CVT) ...population.
Methods
We included patients from the International CVT Consortium registries. Diagnosis of dAVF was confirmed centrally. We assessed the prevalence and risk factors for dAVF among consecutive CVT patients and investigated its impact on clinical outcome using logistic regression analysis. We defined poor outcome as modified Rankin Scale score 3–6 at last follow‐up.
Results
dAVF was confirmed in 29/1218 (2.4%) consecutive CVT patients. The median (interquartile range IQR) follow‐up time was 8 (5–23) months. Patients with dAVF were older (median IQR 53 44–61 vs. 41 29–53 years; p < 0.001), more frequently male (69% vs. 33%; p < 0.001), more often had chronic clinical CVT onset (>30 days: 39% vs. 7%; p < 0.001) and sigmoid sinus thrombosis (86% vs. 51%; p < 0.001), and less frequently had parenchymal lesions (31% vs. 55%; p = 0.013) at baseline imaging. Clinical outcome at last follow‐up did not differ between patients with and without dAVF. Additionally, five patients were confirmed with dAVF from non‐consecutive CVT cohorts. Among all patients with CVT and dAVF, 17/34 (50%) had multiple fistulas and 23/34 (68%) had cortical venous drainage. Of 34 patients with dAVF with 36 separate CVT events, 3/36 fistulas (8%) were diagnosed prior to, 20/36 (56%) simultaneously and 13/36 after (36%, median 115 IQR 38–337 days) diagnosis of CVT.
Conclusions
Dural arteriovenous fistulas occur in at least 2% of CVT patients and are associated with chronic CVT onset, older age and male sex. Most CVT‐related dAVFs are detected simultaneously or subsequently to diagnosis of CVT.
This article describes dural arteriovenous fistulas (dAVFs) among adult patients diagnosed with cerebral venous thrombosis (CVT) included from the International CVT Consortium registries. dAVF was centrally confirmed among 2.4% patients (29/1218) and was most commonly detected simultaneously or subsequently to diagnosis of CVT. Half of the patients with dAVF had multiple fistulas, and fistulas were associated with chronic CVT onset, older age and male sex.
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