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PubMed2005

Anticoagulation in ischemic stroke: opportunities in arterial disease.

In the acute phase of ischemic stroke, there is no evidence that anticoagulants provide any benefit in terms of death or dependency. A small reduction in the incidence of recurrent stroke is offset by an equally small increase in intracranial hemorrhage (ICH). In the secondary prevention of stroke, in patients with transient ischemic attacks (TIAs) and moderately disabling ischemic stroke, the relative risk reduction of major vascular events by aspirin is rather modest: 13% (or 19% in a systematic review of arterial disease in general). Anticoagulants might well offer stronger protection, since they provide a 35-50% risk reduction after myocardial infarction or in patients with TIAs or nondisabling ischemic stroke in the presence of atrial fibrillation. Meanwhile, it has become clear that anticoagulation with high intensity (INR 3.0-4.5) is associated with a high risk of ICH in patients with cerebral ischemia who are in sinus rhythm, while INR values around 1.9 do not offer protection against major vascular events. An international clinical trial of anticoagulation with INR values between 2.0 and 3.0 (ESPRIT) is still in progress. In cerebral venous sinus thrombosis, anticoagulant treatment is associated with a nonsignificant reduction of the risk of death or dependence, but the treatment has nevertheless become widely adopted because it seems safe: no increase in the proportion of patients with hemorrhagic transformation of infarction has so far been demonstrated.

Anticoagulants↗
PubMed1995

Surgical management of the cloverleaf skull deformity.

The cloverleaf skull deformity, or Kleeblattschädel, is a rare malformation caused by synostosis of multiple cranial sutures. This anomaly has been reported to carry a dismal prognosis both in terms of neurological outcome as well as cosmetic appearance if treatment is delayed. Due to the paucity of data concerning the results of early operative intervention, it remains uncertain whether aggressive craniofacial decompressive/reconstructive procedures are effective in ameliorating the effects of the malformation on both neurological development and cosmetic appearance. This paper reports the treatment and outcome of 7 children with the cloverleaf skull malformation treated at our institution between 1981 and 1993. All children underwent an initial decompressive craniectomy with the removal of at least 50% of the cranial vault for relief of high intracranial pressure in early infancy. Our first 4 patients underwent near total calvariectomy whereas the 3 children treated subsequently have undergone a staged approach with anterior followed by posterior craniectomies with bone morcellation and replacement. Subsequent reconstructions, intended to further improve the cosmetic appearance, were performed later in infancy or in early childhood. Follow-up ranges from 17 months to 9 years, with a mean of 61 months. Long-term results are reported with regard to neurological outcome as well as normalization of skull shape in terms of both the cephalic indices and general cosmetic appearance. Of the 4 children initially treated with total calvariectomy, only 1 child is neurologically normal and has a good cosmetic appearance. One child is severely impaired neurologically following a sagittal sinus thrombosis suffered during a secondary reconstructive procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Cephalometry↗
PubMed2003

Recurrent thromboembolism in infants and children suffering from symptomatic neonatal arterial stroke: a prospective follow-up study.

BACKGROUND AND PURPOSE: The present study was performed to evaluate the rate of recurrent symptomatic thromboembolism with respect to prothrombotic risk factors and underlying clinical conditions. METHODS: In a series of 215 consecutively enrolled neonates with arterial ischemic stroke (AIS), the factor V G1691A mutation, factor II G20210A variant, methylenetetrahydrofolate reductase (MTHFR) T677T genotype, lipoprotein (Lp) (a), antithrombin, protein C, protein S, and anticardiolipin antibodies (ACA) were investigated. Patient median follow-up was 3.5 years (range, 1 to 8 years). RESULTS: During follow-up, 7 infants and children (3.3%) showed recurrent symptomatic thromboembolism (AIS, n=4; venous sinus thrombosis, n=2; deep vein thrombosis of the leg, n=1). The factor V mutation, factor II variant, elevated Lp(a) >30 mg/dL, protein C deficiency, and protein S or antithrombin deficiency were associated with first stroke onset. In 5 of 7 cases (71.4%), prothrombotic risk factors [MTHFR T677T, elevated Lp(a), hyperhomocysteinemia, protein C deficiency] were involved at the time of recurrence. Furthermore, a second thromboembolic event was triggered additionally by underlying diseases (71%), eg, cardiac malformation and immobilization, diarrhea, mastoiditis, and moyamoya syndrome. CONCLUSIONS: Data shown here give evidence that symptomatic recurrent thromboembolism is not common in children with neonatal AIS. The risk of a second event, however, is increased when underlying diseases occur and prothrombotic risk factors are involved.

Child↗
PubMed2006

Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline.

The aim of this new statement is to provide comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches for atherosclerotic disease, antithrombotic treatments for cardioembolism, and the use of antiplatelet agents for noncardioembolic stroke. Further recommendations are provided for the prevention of recurrent stroke in a variety of other specific circumstances, including arterial dissections; patent foramen ovale; hyperhomocysteinemia; hypercoagulable states; sickle cell disease; cerebral venous sinus thrombosis; stroke among women, particularly with regard to pregnancy and the use of postmenopausal hormones; the use of anticoagulation after cerebral hemorrhage; and special approaches for the implementation of guidelines and their use in high-risk populations.

Adult↗
PubMedDate not supplied

The predicted value of arteriography in nontraumatic intracerebral hemorrhage.

We retrospectively assessed the diagnostic value of cerebral arteriography for the search of an etiology in 102 patients with nontraumatic intracerebral hemorrhages evaluated between 1980 and 1985. Arteriography was diagnostic in 22 of 50 non-hypertensive patients and in only 6 of 47 hypertensive patients. Five patients with a bleeding diathesis had normal arteriography. From the total group, we found 12 saccular aneurysms, 9 arteriovenous malformations, 3 cases of moya-moya and 3 instances of superior sagittal sinus thrombosis. One patient had metastatic choriocarcinoma. Sites of hemorrhage among all patients with diagnostic arteriograms were: lobar 19, intraventricular 5, thalamic 2, caudate 1, and corpus callosum 1. Lobar hemorrhages in the non-hypertensive group and intraventricular hemorrhages in hypertensive individuals had the highest yield of arteriographic abnormalities. We believe cerebral arteriography is indicated in non-hypertensive patients with lobar hemorrhages. Most hypertensive patients, in particular those with putaminal hemorrhages, do not require arteriography.

Angiography↗
PubMedDate not supplied

Pulsatile tinnitus.

Pulse-synchronous tinnitus suggests a vascular etiology and is deemed rare by the otologic literature. During the period 1978-1985 we evaluated 20 patients with the sole or initial complaint of pulsatile tinnitus. Fourteen patients had objective pulsatile tinnitus, perceived by the patient and the examiner alike, and 6 had subjective pulsatile tinnitus, perceived by the patient only. Angiographic findings in patients with objective pulsatile tinnitus included dural or pial arteriovenous malformations, occlusive disease of the intra- or extracranial carotid arteries from atherosclerosis or dissection, panarterial ectasia, and venous sinus thrombosis. Most of the patients with subjective pulsatile tinnitus had normal evaluations, but other possible causes of subjective pulsatile tinnitus included a carotid occlusion and pseudotumor cerebri. Pulsatile tinnitus is an uncommon symptom produced by a variety of causes. Given the abnormalities present in our series, we would recommend intraarterial digital subtraction angiography or conventional angiography in the evaluation of objective pulsatile tinnitus and intravenous digital subtraction angiography for subjective pulsatile tinnitus. Increased intracranial pressure must also be considered.

Adult↗
PubMed1994

Cerebellar venous infarction in chronic suppurative otitis media. A case report with review of four other cases.

BACKGROUND: Cerebellar venous infarction is a rare condition. Thus far only four cases have been reported in the literature. We recently encountered a patient with chronic suppurative otitis media complicated by cerebellar venous infarction. The features of cerebellar venous infarction in the other four cases are also reviewed. CASE DESCRIPTION: A 20-year-old man presented with clinical features suggestive of chronic suppurative otitis media. Computed tomographic scan of the brain revealed left mastoiditis with cholesteatoma and moderate communicating hydrocephalus. The patient was subjected to left radical mastoidectomy, and an attico-antral cholesteatoma was removed. Subsequently the patient developed clinical features suggestive of cerebellar abscess. A repeat computed tomographic scan revealed normal posterior fossa. Four-vessel angiography revealed left sigmoid and lateral sinus thrombosis and nonopacification of the left-sided cerebellar veins. Magnetic resonance imaging showed a venous infarct in the left cerebellar hemisphere. The patient was treated with cerebral dehydration measures. The patient subsequently improved and had no neurological deficit 3 months after surgery. CONCLUSIONS: Although cerebellar venous infarction is rare, it can occur in chronic suppurative otitis media, pregnancy, antithrombin III deficiency, and diabetic osmolar coma. Sometimes no cause is found. Treatment includes correction of the underlying cause. The presence of a hemorrhagic lesion on computed tomographic scan and deep coma at presentation indicate poor prognosis.

Adult↗
PubMed1991

Fatal penetrating orbital injuries.

Three cases of penetrating orbital injuries are described, in two of which cavernous sinus thrombosis developed. The precautions necessary in cases of penetrating orbital injuries are discussed.

Adult↗
PubMedDate not supplied

Lethal rhinocerebral phycomycosis in a healthy adult: a case report and review of the literature.

A lethal case of rhino-orbital-cerebral phycomycosis (mucormycosis) in an otherwise healthy man is presented. The clinical, radiologic, and ante mortem surgical pathology associated with microbiologic examinations failed to yield the diagnosis of fungal infection as the cause of a clinical presentation of acute sphenoid sinusitis with a fulminant cavernous sinus thrombosis. No similar case report was found in review of the literature. There is a need for a high degree of suspicion in this condition to improve the uniformly poor prognosis in this devastating infectious disease. Emphasis is placed on the necessity for early tissue or microbiologic diagnosis with appropriate histologic stains and fungal cultures. Treatment consists of extensive surgical excision of all necrotic or questionably viable tissue in conjunction with alternate-day amphotericin B therapy.

Bone Diseases↗
PubMed2003

Anaesthetic management of the parturient with protein S deficiency and lumboperitoneal shunt.

Protein S, a vitamin K-dependent plasma protein, is a cofactor for protein C, an essential component of the regulatory system of coagulation. We describe the anesthetic management of a parturient with protein S deficiency and an indwelling lumboperitoneal shunt, which was placed following transverse and sagittal sinus thrombosis. She was treated with aspirin and enoxaparin during pregnancy and underwent caesarean section under general anaesthesia without complication.

Adult↗
PubMed2001

Langerhans' cell histiocytosis presenting as intracranial hypertension.

Benign intracranial hypertension is known to be associated with obesity, endocrine abnormalities, various medications, and cerebral venous sinus thrombosis. We report a patient presenting with headaches and vomiting attributed to benign intracranial hypertension. The diagnostic work-up revealed Langerhans' cell histiocytosis of the occipital bone. There was no evidence for cerebral vein thrombosis by cranial computed tomography scan, Doppler ultrasonography, planar and single photon emission computed tomography technetium 99m-labelled red blood cell scintigraphy, and magnetic resonance angiography. Excision of the occipital bone lesion and a short course of acetazolamide and prednisone were curative. We hypothesize that cytokines secreted by the tumor were responsible for the development of intracranial hypertension.

Child↗
PubMed1987

Magnetic resonance imaging in pediatric neurologic disorders.

We present our initial experience with magnetic resonance imaging (MRI) in 301 pediatric patients with a variety of neurologic disorders. MRI does not require ionizing radiation and can be done easily and safely in children. It is equal or superior to computed cranial tomographic (CT) scans in demonstrating most types of pediatric neurologic disorders. MRI is often superior to CT scans in demonstrating intracranial tumors, although both studies are usually abnormal in highly malignant tumors. No clear advantage was shown with either MRI or CT scans for fluid-filled intracranial lesions. Lesions of the brain stem and upper cervical region, such as Chiari malformation, are well delineated by MRI. Increased signal from the paranasal sinuses was frequently evident by MRI, but, in most instances, there was no clinical indication of sinus disease. Large arteries can be visualized as an area of diminished signal, and intracranial hemorrhage, dural sinus thrombosis, and cerebral infarction were demonstrated. The increased anatomic detail pictured by MRI allows the diagnosis of congenital defects, such as agenesis of the corpus callosum or septum pellucidum, that are not always apparent with CT scans. Although our experience with spinal cord lesions was not extensive, fluid-filled lesions within the cord can be reliably demonstrated.

Adolescent↗
PubMed1995

Benign intracranial hypertension: a non-thrombotic complication of the primary antiphospholipid syndrome?

Benign intracranial hypertension is a rare complication of systemic lupus erythematosus often attributed to cerebral sinus thrombosis which impairs venous drainage and cerebrospinal fluid outflow. We report the case of a woman with a primary antiphospholipid syndrome who developed benign intracranial hypertension with no actual evidence of venous cerebral thrombosis and with no other possible cause for this clinical manifestation than high titres of anticardiolipin antibodies and a lupus anticoagulant.

Adult↗
PubMed1996

Neurological aspects of antiphospholipid antibody syndrome.

Antiphospholipid antibodies (aPL) have been associated with a variety of neurological disorders, mostly linked to focal neuroparenchymal ischemia or infarction. Cerebral ischemia associated with the antiphospholipid syndrome (APS) occurs at a younger age than typical atherothrombotic cerebrovascular disease, is often recurrent, and high positive GPL values are usually linked to the presence of a lupus anticoagulant. When other features of the syndrome are not present and cerebral ischemia occurs only associated with anticardiolipin immunoreactivity, there appears to be no discerning features of these patients unless GPL > 40 for which recurrent thrombo-occlusive events appear to occur more frequently. Other neurological manifestations associated with aPL include cerebral venous sinus thrombosis, ocular ischemia, dementia, including ischemic encephalopathy, and chorea. The role of aPL in migrainous events is controversial and may not play a role in recent, large case-controlled studies. Most seizures in patients harboring aPL are associated with focal brain infarction.

Antiphospholipid Syndrome↗
PubMed1995

Granulocyte-macrophage colony stimulating factor (rh-GM-CSF) in the treatment of chemotherapy-induced neutropenia.

Neutropenic pediatric patients with solid tumors and malignant lymphomas were treated with recombinant granulocyte-macrophage colony stimulating factor (rh-GM-CSF). Eleven patients, including seven lympho-reticular malignancies, two Ewing's sarcoma and one patient in each group with the diagnosis of nasopharyngeal rhabdomyosarcoma, malignant mesenchymal tumor, entered the study. Six were females and five were males, the mean age was 10.4 yr, the range was 4 to 21 years. rh-GM-CSF was given at the dose of 5 micrograms/kg s.c. daily, starting either on the day following the last day of cytotoxic chemotherapy or when ANC < 1000/ml was determined. All patients received rh-GM-CSF for a total of seven days. Hematopoietic recovery occurred in all children except one. The response to rh-GM-CSF was achieved in a mean time of 7.4 days. Tolerance to rh-GM-CSF treatment was good. Adverse events were documented as fever, nausea, vomiting, fatigue, chills and itching. Sagittal sinus thrombosis developed in one patient 5 days following the completion of chemotherapy and rh-GM-CSF cycle. In conclusion, rh-GM-CSF can be applied during the intensive chemotherapy schedules of pediatric cancer patients.

Adolescent↗
PubMed2006

Development of an in vitro model to study clot lysis activity of thrombolytic drugs.

BACKGROUND: Thrombolytic drugs are widely used for the management of cerebral venous sinus thrombosis patients. Several in vitro models have been developed to study clot lytic activity of thrombolytic drugs, but all of these have certain limitations. There is need of an appropriate model to check the clot lytic efficacy of thrombolytic drugs. In the present study, an attempt has been made to design and develop a new model system to study clot lysis in a simplified and easy way using a thrombolytic drug, streptokinase. METHODS: Whole blood from healthy individuals (n = 20) was allowed to form clots in a pre-weighed sterile microcentrifuge tubes; serum was removed and clot was weighed. After lysis by streptokinase fluid was removed and remnants of clot were again weighed along with the tube. Percentage of Clot lysis was calculated on the basis of the weight difference of microcentrifuge tubes obtained before and after clot lysis. RESULTS: There was a significant percentage of clot lysis observed when streptokinase was used. On the other hand with water (negative control), minimal (2.5%) clot lysis was observed. There was a significant difference between clot lysis done by streptokinase and water. CONCLUSION: Our study could be a rapid and effective methodology to study clot-lytic effect of newly developed drugs as well as known drugs.

Journal Article↗