经血管内治疗多发性脑静脉窦血栓

目的：报告３６例多发性脑静脉窦血栓的治疗。方法：随机分为常规治疗和动脉内治疗两组；动脉内治疗采用多次颈动脉内注入尿激酶做溶栓，全身应用华法令抗凝结合抗感染等处理；常规组为静滴蝮蛇抗栓酶和口服新抗凝的方法。结果：动脉组在治疗１０天内全部停用甘露醇且颅内压均降至２．９４ｋＰａ以下；在７天时复查脑血管造影示静脉窦再通。结论：经颈动脉入路注入高浓度纤溶药物，可直接弥散并作用到各静脉窦，而全身有效的抗凝防止了血栓再形成。     

联合治疗方案与全身抗凝治疗脑静脉窦血栓形成

目的 比较脑静脉窦血栓形成的联合治疗方案与全身抗凝在临床应用中的有效性和安全性.方法 网顾性连续收集脑静脉窦血栓形成116例患者资料,根据治疗方式不同分为联合治疗组30例和全身抗凝组86例.其中联合治疗组在全身抗凝的基础上,接受改良溶栓方案介入治疗,即脑动脉及静脉窦造影明确诊断后行机械性破栓及吸栓术,于静脉窦内留置微导管行尿激酶微量泵点接触性溶栓.采用NIHSS评分对两组患者治疗前后神经功能缺损评分,应用改良Rankin量表(mRS)评价出院时情况.结果 联合治疗组30例,男9例;全身抗凝组86例,男23例.治疗前神经功能缺损:联合治疗组0～19分,全身抗凝组0～17分,差异无统计学意义(Z=-0.474,P=0.636);治疗后联合治疗组神经功能缺损程度减轻,出院时mRS评分较低,两组颅内出血发生率差异无统计学意义.结论 联合治疗较全身抗凝有利于神经功能恢复.两种治疗方法颅内出血发生率无明显差异.     

出血性脑静脉窦血栓的血管内治疗

目的探讨合并颅内出血的脑静脉和静脉窦血栓治疗方法。方法对17例患弥漫性脑静脉和静脉窦血栓合并蛛网膜下腔和脑实质内出血者，采用经颈动脉和椎动脉内间断溶栓和静脉窦内留置微导管连续溶栓5-10d；同时辅以全身抗凝治疗2年。结果治疗后经脑CT复查证实，15例颅内出血在1周内得以控制，1个月内蛛网膜下腔出血和脑内血肿均完全吸收。颅内压在治疗2周后，基本稳定在280mm H2O以下。2例颅内出血严重，于治疗3d后死亡。结论同时应用血管内溶栓和全身抗凝是治疗合并蛛网膜下腔和脑内出血的脑静脉和静脉窦血栓的较为可靠和安全的方法之一。     

An onion variety has natural antithrombotic effect as assessed by thrombosis/thrombolysis models in rodents

INTRODUCTION: Prevention of arterial thrombotic diseases has a high priority in developed countries. As inappropriate diet has been shown to be an important risk factor for thrombotic events, regular antithrombotic diet may offer a convenient and effective way of prevention. The aim of the present study was to test onion extracts for antithrombotic effect and to identify the effective varieties in Allium cepa. MATERIALS AND METHODS: A shear-induced platelet function test (haemostatometry) was used to screen for antithrombotic potential. Onion extracts showing significant antithrombotic activity in vitro were further assessed in vivo by using a laser-induced thrombosis test in mice. RESULTS AND CONCLUSIONS: An onion variety, Toyohira, showed significant antithrombotic activity both in vitro and in vivo. Toyohira showed thrombolytic activity in addition to the antiplatelet effect. Superkitamomiji, 2935A, and K83211 showed only thrombolytic activity. Quercetin, the richest flavonoid in onion, was measured, but no correlation was found between quercetin content and antithrombotic activity. It is concluded that onion A. cepa can be classified into varieties with or without antithrombotic and thrombolytic effects. This should be taken into account in future population studies on the antithrombotic effects of vegetables.     

Upper limb compartment syndrome: An unusual complication of stroke thrombolysis

Bleeding is the most important complication of treatment with intravenous tissue plasminogen activator for acute ischemic stroke. Neurologists are familiar with intracranial hemorrhage, the most feared site for bleeding following thrombolysis, but extracranial bleeding can also occur resulting in substantial morbidity and mortality. We describe an 88-year-old woman with an acute stroke who developed bleeding into the left arm complicated by hemodynamic instability and compartment syndrome following intravenous thrombolysis. The patient was treated conservatively in view of the risks associated with fasciotomy and her other medical comorbidities.     

Effects of argatroban and heparin on thrombus formation and tissue plasminogen activator-induced thrombolysis in a microvascular thrombosis model

Effects of (2R,4R)-4-methyl-1-[N(2)-(3-methyl-1,2,3,4-tetrahydro-8-quinolinesulfonyl)-L-arginyl]-2-piperidine-carboxylic acid monohydrate (argatroban) and unfractionated heparin (UFH) were compared with respect to thrombus formation and tissue-type plasminogen activator (t-PA)-induced thrombolysis in a microvasculature thrombosis model. The antithrombotic activities of anticoagulants were evaluated with respect to the time required for the initiation of thrombus formation (T(i)) and the time required for the thrombus to stop blood flow (T(s)). The effects of anticoagulants administered with t-PA were evaluated by percent stenosis of the vessel and percent area of the thrombus. Argatroban (1-3 mg/kg/bolus) significantly prolonged T(i) and T(s) in a dose-dependent fashion compared to control. Argatroban (3 mg/kg/bolus) significantly prolonged both the T(i) and T(s) more effectively than UFH (100 anti-XaU (a-XaU)/kg/bolus), despite equivalent prolongation of the activated partial thromboplastin time (aPTT). Higher doses of UFH (300-500 a-XaU/kg) were required to significantly prolong T(i) and T(s), but at these doses, UFH caused over-prolongation of aPTT (>180 s), which might consequently cause bleeding complications. Argatroban (0.1-0.3 mg/kg/h) significantly accelerated thrombolysis by t-PA in both a dose- and time-dependent fashion. Although argatroban (0.1-0.2 mg/kg/h) did not significantly prolong the aPTT and bleeding time (BT) as compared with control, it significantly accelerated thrombolysis by t-PA at these doses of lower bleeding risk. Argatroban (0.3 mg/kg/h) significantly enhanced thrombolysis by t-PA, while UFH (12.5 anti-XaU/kg/h) attenuated it again, despite equivalent prolongation of the aPTT and BT. We conclude that argatroban seems to be a more efficient and safer anticoagulant than UFH for the prevention of thrombus formation and acceleration of t-PA-induced thrombolysis.     

D-dimer and factor VIII are independent risk factors for recurrence after anticoagulation withdrawal for a first idiopathic deep vein thrombosis

Background and objectives: To assess the predictive value of D-dimer (D-d) and Factor VIII (FVIII) in combination for recurrent venous thromboembolism (VTE) after vitamin K antagonist (VKA) therapy suspension. Design and methods: Consecutive outpatients with a first episode of idiopathic proximal deep vein thrombosis of the lower limbs were enrolled on the day of VKA suspension. After 30+/-10 days, D-d (cut-off value: 500 ng/mL), chromogenic FVIII activity and inherited thrombophilia were determined. Follow-up was 2 years. Results: Overall recurrence rate was 16.4% (55/336; 95% CI:13-21%). The multivariate hazard ratio (HR) for recurrence was 2.45 (95% CI: 1.24-4.99) for abnormal D-d and 2.76 (95% CI:1.57-4.85) for FVIII above the 75th percentile (2.42 U/mL) after adjustment for age, sex, thrombophilia, VKA duration and residual venous obstruction. When compared with normal D-d and FVIII, the multivariate HR was 4.5 (95% CI: 1.7-12.2) for normal D-d with FVIII above 2.42 U/mL and 2.7 (95% CI: 1.2-6.6) and 7.1 (95% CI:2.8-17.6) for abnormal D-d with FVIII, respectively, below and above 2.42 U/mL. Interpretation and conclusions: D-d and FVIII at 30+/-10 days after VKA withdrawal are independent risk factors for recurrent VTE.     

Saving the ischemic penumbra: Endovascular thrombolysis versus medical treatment

Endovascular thrombolysis may allow rapid arterial recanalization in patients with acute ischemic stroke. We present the first study to our knowledge comparing the ischemic penumbra saved with endovascular versus medical therapy. A retrospective review of 21 patients undergoing endovascular intervention for stroke from 2010 to 2011 was contrasted with 21 consecutive patients treated with antiplatelet agents alone. Immediate computed tomography perfusion (CTP) scan of the head and neck was obtained in all patients. Patients with lacunar and posterior circulation infarcts, and those who were medically unstable for MRI post-operatively were excluded. CTP and MRI underwent volumetric calculation. CTP penumbra was correlated with diffusion restriction volumes on MRI, and an assessment was made on the volume of ischemic burden saved with either endovascular treatment or antiplatelet agents. The median age was 70 years (interquartile range 62–80). Median National Institutes of Health Stroke Scale score was 18 and 14 in the control and endovascular groups, respectively. Intravenous tissue plasminogen activator was administered in 22 of 42 patients (52%). Median penumbra calculated was 32,808 mm³ in the control group and 46,255 mm³ in the endovascular group. Median penumbra spared was 9550 mm³ (4980–18,811) in the control group versus 38,155 mm³ in the endovascular group (p = 0.0001). Endovascular thrombolysis may be more efficient than medical therapy alone in saving ischemic penumbra. Future advances in recanalization techniques will further improve the efficacy of endovascular therapy.     

D-dimer,FVIII and thrombotic burden in the acute phase of deep vein thrombosis in relation to the risk of post-thrombotic syndrome

Background

Post-thrombotic syndrome (PTS) is the most common complication of deep vein thrombosis (DVT), but few data are available on the risk factors for PTS.

Aims

To assess whether the time-course of D-dimer, FVIII, and thrombotic burden are related to PTS development.

Methods

Patients (n = 59) with proximal DVT of the lower limbs (age 64; range:20-88 years; male 56%) were enrolled on the day of diagnosis (D0) and all received heparin for 5-7 days, overlapped and followed by vitamin K antagonists (VKA) for 3 months. Whole-leg compression ultrasound examination was conducted on D0 and 7 (D7), 30 (D30), and 90 (D90) days afterwards, when blood samples were also taken for D-dimer (STA Liatest) and FVIII (chromogenic assay) testing. Thrombotic burden was defined at each time point according to a score, which considered thrombosis extent and occlusion degree. Villalta score was evaluated at D30, D90, and D180.

Results

At D90, 12 patients developed PTS (Villalta score ≥ 5) and the median Villalta score was 1 (IQR 0.3-3.0) and was not correlated with either D-dimer or FVIIII time course. At D180, 13 patients had PTS and they had similar thrombotic score at D0, D30 to those without PTS, but higher at D90 (7.6 ± 5.1 vs. 3.2 ± 3.6; p = 0.011). Thrombotic score at D90 was correlated with Villalta score at D90 (rho = 0.374, p = 0.009) and at D180 (rho = 0.436, p = 0.006).

Conclusions

Thrombotic burden after 90 days of VKA is correlated with PTS.     

The influence of baseline prognostic variables on outcome after thrombolysis

Thrombolysis increases case fatality but reduces the proportion of disabled survivors in recent trials in acute ischaemic stroke, although some trials show much higher mortality rates than others. One possible explanation for the different outcomes between trials is that the treatment effect with thrombolysis varies with baseline prognostic factors such as stroke severity. We examined the interaction between baseline risk and thrombolysis on outcome using individual patient data from the Multicentre Acute Stroke Trial–Italy (MAST-I). A multiple logistic regression of the MAST-I data was performed to identify which factors, identifiable at randomisation, most strongly predict a poor functional outcome. We then stratified the patients into those with severe strokes and those with mild strokes and examined the effect of thrombolysis on (a) case fatality and (b) dependency at 6 months after the stroke in the 157 patients who received streptokinase alone and the 156 controls. Streptokinase was found to cause an absolute increase of about 3% in case fatality in both “severe” and “mild” strokes; however, there was a 12% reduction in the number of dead or dependent “mild” strokes but a 6% increase in “severe” strokes. The number of patients was small, and therefore neither finding was statistically significant. In this exploratory analysis, the hazard with streptokinase appears similar in “severe” and “mild” strokes, but the benefit may be greater in “mild” strokes. Thrombolysis may be more effective in patients with “mild” strokes, but more information is required to confirm this hypothesis. Received: 29 January 1999 Received in revised form: 13 April 1999 Accepted: 5 May 1999     

The post-thrombotic syndrome after upper extremity deep venous thrombosis in adults: a systematic review

BACKGROUND: Post-thrombotic syndrome is a chronic, potentially debilitating complication of deep vein thrombosis (DVT) of the lower extremity. Comparatively little is known about post-thrombotic syndrome after upper extremity DVT (UEDVT). OBJECTIVE: To perform a systematic review of clinical studies that have examined the incidence, clinical features, risk factors and management of post-thrombotic syndrome after UEDVT. METHODS: Using combinations of keywords venous thrombosis, postphlebitic syndrome, thrombophlebitis, arm swelling, post-thrombotic syndrome, UEDVT, Paget-Schroetter syndrome, thoracic outlet syndrome, axillary vein, subclavian vein, and central venous catheter, the MEDLINE database was searched for English language articles published between January 1967 and December 2004. Retrieval and review of articles were restricted to clinical studies in humans that described long-term outcomes after objectively confirmed UEDVT. RESULTS: Seven studies were reviewed. The frequency of PTS after UEDVT ranges from 7-46% (weighted mean 15%). Residual thrombosis and axillosubclavian vein thrombosis appear to be associated with an increased risk of PTS, whereas catheter-associated UEDVT may be associated with a decreased risk. There is currently no validated, standardized scale to assess upper extremity PTS, and little consensus regarding the optimal management of this condition. Quality of life is impaired in patients with upper extremity PTS, especially after DVT of the dominant arm. CONCLUSIONS: PTS is a frequent complication of UEDVT, yet little is known regarding risk factors and optimal management. A standardized means of diagnosis would help to establish better management protocols. The impact of upper extremity PTS on quality of life should be further quantified.     

Galen静脉血栓临床和影像学表现

目的探讨Galen静脉血栓的病因、发病机制、临床、影像学表现及治疗。方法收集10例Galen静脉血栓患者的临床资料和影像学图像,结合Galen静脉解剖学及其血栓形成后病理学改变进行分析。结果 10例患者中,女性7例,男性3例,年龄16~49岁,平均年龄29.1±9.06岁,均急性起病,多以头痛、呕吐为首发症状,病情逐渐进展,可出现意识不清并伴有抽搐等症状。经治疗,6例治愈,2例好转,2例死亡。结论 Galen静脉血栓的病因多种;以急性颅内压增高表现为主,临床表现多样,多出现头痛、呕吐、抽搐及意识障碍等;Galen静脉血栓在急性期CT上呈高密度影,在亚急性期MRI上T_1WI、T_2WI均呈高信号有助于诊断;及时应用低分子肝素抗凝有望取得良好效果。     

经皮血管内成形术治疗锁骨下动脉盗血综合征的疗效观察

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Quality of life in patients with idiopathic subclavian vein thrombosis

Introduction

Idiopathic subclavian vein thrombosis (SVT) is a rare disease but these otherwise healthy patients often suffer from prolonged clinical manifestations. The aim of this retrospective study was to assess the range and severity of thrombosis-related disability of the upper extremity in patients after an episode of documented idiopathic SVT in the long-term follow-up.

Materials and Methods

The quality of life (QoL) of 37 patients with documented idiopathic SVT was assessed by two standardized questionnaires (DASH and SF 36). The DASH and SF-36 questionnaire each use a 100 point scale. 0 stands for uncompromised functioning, 100 for maximum limitation in the DASH, while in the SF-36 0 marks the lowest rating of QoL and 100 indicates the best imaginable quality of life.

Results

Mean follow-up time was 120 ± 80.1 months (range: 14 to 286 months). The mean DASH score was 10.7 ± 12 and the mean scores for the SF-36 dimensions Physical Component Summary (PCS) and Mental Component System (MCS) were 52 ± 9.3 and 46.3 ± 9.5, respectively.

Conclusions

Patients suffering from idiopathic SVT report good overall QoL judged by the mean DASH and satisfactory QoL by the SF-36 score in the long-term follow-up. These patients deal well with their physical limitations.     

High prevalence of recurrent thrombosis in subsets of cancer patients with isolated gonadal vein thrombosis: A single center retrospective study

Purpose

Cancer patients are a high-risk population for venous thromboembolism (VTE); the natural history of gonadal vein thrombosis (GVT) occurring in cancer patients is not well described in the medical literature.

Methods

Utilizing a software program the computerized tomographic scan reports of patients at a single cancer center from January 1, 2004 to June 30, 2011 were searched for the term GVT. Patients included in this analysis had a diagnosis of cancer, an isolated GVT (i.e. no evidence of thrombosis at another site), no symptoms referable to the GVT, and at least six months of follow-up information. All subsequent recurrent VTE events were confirmed by imaging studies.

Results

196 cancer patients with GVT were identified. The majority of patients in this analysis had metastatic disease (118, 61.2%) as well as active cancer (167, 85.2%). Twenty patients (10.8%) developed recurrent VTE (median follow-up 14.5 months); median time to recurrent VTEs was 5.5 months (range 0–19 months). When considering only patients with without a recent history of gynecologic surgery, VTE recurrence rates were 14.3%. Active cancer was the only risk factor significantly associated with recurrent VTE (P = 0.047).

Conclusions

Based upon the patient’s risk factors for VTE, treatment of an incidentally detected GVT in cancer patients with anticoagulation, as per guidelines for other VTE sites, may be indicated in certain high risk subgroups, especially those patients with active cancer who have not had prior pelvic surgery.     

颅内静脉窦血栓形成临床特征及血管内机械取栓+溶栓联合抗凝治疗

目的分析颅内静脉窦血栓形成(CVST)的临床特征,探讨应用血管内机械取栓+溶栓联合抗凝的治疗效果。方法选取茂名市人民医院收治的42例CVST患者为研究对象,分析观察其临床特征及实验室检查结果,其中22例患者接受血管内机械取栓+溶栓联合抗凝治疗(联合治疗组),另20例患者仅行持续抗凝治疗(对照组),比较2组治疗效果。结果治疗组抗凝治疗3个月后mRS评分0~1分比率显著高于对照组,治疗后1例评分为3分的患者出现瘫痪但达到出院条件。对照组治疗3个月后血栓再通率40.00%,治疗组为86.36%,组间比较差异有统计学意义(P<0.05)。结论CVST患者多存在脑实质损害,临床表现以头痛、瘫痪位置,采取血管内取栓+溶栓联合抗凝治疗的治疗方式可取得良好效果。     

Risk of deep venous thrombosis (DVT) in bedridden or wheelchair-bound multiple sclerosis patients: A prospective study

Background

Multiple sclerosis (MS) often causes progressive loss of mobility, leading to limb paralysis. Venous and lymphatic stasis is a risk condition for venous thromboembolism (VTE). There is, however, no data on the frequency of VTE complicating the progression of MS. The aim of this study was to assess the frequency of deep vein thrombosis (DVT) in patients with late-stage MS attending a neurology center for rehabilitation.

Patients and Methods

A total of 132 patients with MS were enrolled, 87 women and 45 men, mean age 58 ± 11 years. The disease had started on average 18.7 years before; patients reported 9.6 hours bedridden per day or 14.3 hours wheelchair-bound. Only 25 patients reported a residual ability to walk alone or with help. Lower limb edema was present in 113 patients, bilateral in 41 cases. At admission all patients underwent extended compression ultrasonography. Their plasma D-dimer levels were measured. No antithrombotic prophylaxis was given.

Results

DVT was found in 58 patients (43.9%); 32 had a history of VTE. Forty of these patients (69%) had chronic lower limb edema, in 19 cases bilateral. D-dimer levels in the DVT patients were significantly higher than in patients without DVT (553 ± 678 vs. 261 ± 152 ng/mL, p = 0.0112, Mann-Whitney Test). Nearly half the DVT patients (26, 45%) had high D-dimer levels (701 ± 684 ng/mL). Of the 74 patients without DVT, 48 had normal D-dimer (193.37 ± 67.28 ng/mL) and 26 high (387.61 ± 187.42 ng/mL).

Conclusions

The frequency of DVT in late-stage MS may be over 40%. The long history of the disease means the onset of each episode cannot be established with certainty. A number of patients with positive CUS findings had negative D-dimer values, suggesting a VTE event in the past. However, the level of DVT risk in this series should lead physicians to consider the systematic application of long-term preventive measures.