Cerebral Sinus Research Articles

Morphofunctional Alteration of Mesenteric Lymph Nodes in the Inflammation of the Abdominal Cavity.

This paper provides data regarding the ratios of the functional structures of lymph nodes after inflammation in the abdominal organs. Lymph systems, including lymph nodes, function as filters of tissues and tissue fluids and are places of origin and lymphocyte production for normal physiological functions. They display specific morphological and functional responses in reaction to endogenous and exogenous substances. The morphological pattern of the mesenteric lymph node in experimental rat groups reflects a decrease in its immune function due to the processes of inflammation in the abdominal cavity. These processes work together with the associated organs and their involvement in the abdominal lymph nodes, in which there are discharges of the structure of the paracortical zone under conditions of reduced lymphogenic processes, according to the decrease in the size of the paracortex and the ratios of lymphoid nodes with and without germinal centers. Histological and morphometric analyses show changes in the mesenteric lymph node. These analyses are characterized by changes in the cortical and medullary substances, while the proportion of the cortical structure decreases. We also noted an increase in the number of macrophages in the lymphoid nodes and cerebral sinus, as well as a decrease in the number of mature plasmocytes, the paracortex, and the pulp strands. These changes indicate immunosuppressive effects on the lymph node. Under the conditions of inflammation, the formation of a mixed immune response occurs.

Cerebral Sinus Hemodynamics in Adults Revealed by 4D Flow MRI.

The hemodynamics of the cerebral sinuses play a vital role in understanding blood flow-related diseases, yet the hemodynamics of the cerebral sinuses in normal adults remains an unresolved issue. To evaluate hemodynamics in the cerebral sinus of adults using 4-dimensional flow MRI (4D Flow MRI). Cross-sectional. Ninety-nine healthy volunteers (mean age, 42.88 ± 13.16 years old; females/males, 55/44). 3 T/4D Flow MRI. The blood flow velocity, average blood flow rate (Q), and vortexes at the superior sagittal sinus (SSS), straight sinus (STS), transverse sinus, sigmoid sinus, and jugular bulb of each volunteer were evaluated by two independent neuroradiologists. The relationship between the total cerebral Q and sex and age was also assessed. Twelve volunteers underwent two scans within a month. The intraclass correlation coefficient (ICC) evaluated the inter-observer agreement. Blood flow parameters among volunteers were compared by the independent-sample t-test or Mann-Whitney U test. The multiple linear regression equation was used to evaluate the relationship between total cerebral Q and age and sex. P < 0.05 indicated statistical significance. The test-retest and interobserver reliability of average velocity and Q were moderate to high (ICC: 0.54-0.99). Cerebral sinus velocity varied by segment and cardiac cycle. The SSS's velocity and Q increased downstream and Q near torcular herophili was 3.5 times that through the STS. The total cerebral Q decreased by 0.06 mL/s per year (β = -0.06 ± 0.013) and was sex-independent within the group. Vortexes were found in 12.12%, 8.9%, and 59.8% of torcular herophili, transverse-sigmoid junction, and jugular bulb, respectively, and were related to higher upstream flow. Cerebral sinuses could be measured visually and quantitatively in vivo by 4D Flow MRI, providing a basis for future research on pulsating tinnitus, multiple sclerosis, and other related diseases. 2 TECHNICAL EFFICACY: Stage 1.

Clinical Significance of D-dimer Level and Numeric Rating Scale with Amount of Sinus Involvement in Cerebral Sinus Thrombosis Patients.

Cerebral venous sinus thrombosis (CVST) is a cerebral vascular disorder that currently occurs quite often and has very varied clinical symptoms. Headache is the main symptom most commonly found in patients with CVST and multiple sinus involvement often have a more severe prognosis and poor clinical outcome. This study aimed to learn the relationship between D-dimer level, numeric rating scale (NRS), and amount of sinus involvement in CVST patients. This study was a retrospective observational analytic study with a cross-sectional approach using medical records and supporting data (D-dimer level and imaging finding) on patients diagnosed with CVST at Dr Hasan Sadikin Hospital Bandung. Sixty-five CVST patients met the study criteria with mean age of 47 years and mostly female (76.9%). Patients with single sinus involvement had a median initial NRS of 4 (range 2-6) and multiple sinus involvement was higher at 8 (range 5-9). Statistical test results showed a significant difference between D-dimer level, NRS and amount of sinus involvement (P<0.001). D-dimer level, NRS, and amount of sinus involvement are associated with amount of sinus involvement in CVST patients. Involvement of multiple sinus will cause higher NRS with higher D-dimer level.

Post -contrast Three -dimensional MP RAGE T1WI Sequence Compared to Brain MRV Sequence for Diagnosing Brain Sinus Venous Thrombosis.

Dural sinus thrombosis is considered as a one of the clinical and radiological emergencies that require special attention and high index of suspicion and needs combined effort of both the treating physician and the radiologist to obtain proper diagnosis and subsequently proper management. The aim of this article was to compare the accuracy of MRV TOF and post contrast MP-RAGE sequences in diagnosis of cerebral sinus venous thrombosis. After all informed consents were obtained and upon ethical committee approval from the ethical committee in Joradanian Royal medical services in Amman we perform this study as a retrospective study done on 50 patients with cerebral sinus venous thrombosis with 50 pateints control group done at king Hussein medical center in Amman Jordan. The guidelines and regulations of studies conducted in Royal medical services were followed. 68 females and 32 males with age range between 19 and 52 years. All patients underwent brain MRI for evaluation of cerebral sinus thrombosis, all studies were done on seimens skyra 3 Tesla machine with standardized protocol including 2 D TOF MRV, axial T2WI, axial FLAIR, Axial T1, SWI and diffusion weighted images along with 3D MP-RAGE post contrast. Images were reviewed by two well experienced neuroradiologists (Maysoon and Qamar) in separate sessions, each MRI sequence was reported separately without knowing patients name or clinical history. Conclusion: The results for T2 WI, SWI, MRV TOF and MP-RAGE post contrast were reported. We used a confidence level score to standardize the results. Then the results were analyzed using simple statistical methods.

Optimizing surgical technique in microvascular decompression for hemifacial spasm - Results from a surgical series with contemporary use of neuronavigation and intraoperative neuromonitoring.

Microvascular decompression (MVD) through a retrosigmoid approach is considered the treatment of choice in cases of hemifacial spasm (HFS) due to neurovascular conflict (NVC). Despite the widespread of neuronavigation and intraoperative neuromonitoring (IONM) techniques in neurosurgery, their contemporary application in MVD for HFS has been only anecdotally reported. Here, we report the results of MVD performed with a combination of neuronavigation and IONM, including lateral spread response (LSR) in 20 HFS patients. HFS clinical outcome and different surgical-related factors, such as craniotomy size, surgical duration, mastoid air cell (MAC) opening, postoperative cerebral spinal fluid (CSF) leakage, sinus injury, and other complications occurrence, and the length of hospitalization (LOS) were studied. Postoperatively, residual spasm persisted only in two patients, but at the latest follow-up (FU) (mean: 12.5 ± 8.98 months), all patients had resolution of symptoms. The mean surgical duration was 103.35 ± 19.36 min, and the mean LOS was 2.21 ± 1.12 days. Craniotomy resulted in 4.21 ± 1.21 cm2 in size. Opening of MAC happened in two cases, whereas no cases of CSF leak were reported as well as no other complications postoperatively and during FU. MVD for HFS is an elective procedure, and for this reason, surgery should integrate all technologies to ensure safety and efficacy. The disappearance of LSR is a crucial factor for identifying the vessel responsible for NVC and for achieving long-term resolution of HFS symptoms. Simultaneously, the benefits of using neuronavigation, including the ability to customize the craniotomy, contribute to reduce the possibility of complications.

A case of hyper-homocysteinemia carrying MTHFR gene polymorphism in cerebral sinus thrombosis and pulmonary embolism

A case of hyper-homocysteinemia carrying MTHFR gene polymorphism in cerebral sinus thrombosis and pulmonary embolism

MORPHOFUNCTIONAL STATE AND MICROSTRUCTURE OF REGIONAL LYMPH NODES IN EXPERIMENTAL HYPOTHYROIDISM AND UNDER CORRECTION

Lymph nodes play an important role in the life of humans and animals. In the modern concept, the lymph nodes are the main homeostatic organs of the internal environment of the body, the lymph nodes are part of the lymphatic bed, on the other hand, they are the organs of the lymphoid (immune) system. Purpose: The work presents data on the morphofunctional state and microstructure of regional lymph nodes in experimental hypothyroidism and under correction. Materials and Methods: Experimental hypothyroidism in animals was induced by per os administration of mercazolil at a dose of 20 mg per 100 g of body weight with drinking water for 21 days. To correct thyroid disorders, starting from the 22nd day of the experiment, the animals received for 30 days an iodine-containing dietary supplement "Renaissance Plus" balm in powder at the rate of 2 μg/100 g of body weight and a decoction of the roots of the white cinquefoil (Potentilla alba L.) 50 ml per 100 g per day with drinking water. Results: The results of the study showed that in conditions of hypothyroidism, the lymph node becomes compacted with a decrease in the main structural and functional zones against the background of reduced lymphopoietic function. In the lymphoid nodule, there is a decrease of 1.43 times in the number of lymphoblasts, 1.56 times in the number of medium lymphocytes, 1.50 times in the number of small lymphocytes due to an increase of 1.29 times in the number of macrophages per unit area of the lymphoid nodule in the lymph node. There was a static decrease in the number of small lymphocytes in all structural and functional areas; the number of blasts decreases in the lymphoid nodule and increases in the paracortex and Billroth's strand; the number of macrophages increases in the lymphoid nodule, cerebral sinus, the number of mature plasma cells decreases in the paracortex and Billroth's strand, and there is also inhibition of cellular reactions in the lymph node, which reflects a decrease in the lymphopoietic function of immune activity and as a result of the immunosuppressive action of mercazolil. Conclusions: After an administration of corrigents, the area of the medulla and paracortex was restored to the control level and the ratio of cortical and medulla in the overall structure of the lymph node was leveled.

Digital subtraction angiography findings of stroke in young adult population: a multi-center record-based study

BackgroundStroke is one of the main causes of disability, in which nearly 2/3 of survivors experience disability and interferes with the patient’s daily functional activities. Hypertension, dyslipidemia, obesity, and smoking habits are the main causes of stroke in young adults. Vascular abnormalities are also risk factor for stroke in young adults. Advanced imaging examinations such as cerebral digital subtraction angiography (DSA) can provide a clear picture of the vasculature of the blood vessels of the human brain and provide a real-time picture of the hemodynamic status, blood flow and collateral circulation of the cerebral vessels.ResultsThere were approximately 999 patients who had DSA cerebral examination during the study period. The total young adult population was 147 [92 males (62.4%) and 55 females (37.6%)]. There were 82 patients with ischemic stroke (60.7%). The main etiology of ischemic stroke in this study was intracranial atherosclerotic disease (ICAD) [44 (53.65%)]. The young adult population had 53 hemorrhagic stroke patients (39.3%). The main cause of hemorrhagic stroke is hypertensive vasculopathy (41.5%), followed by a ruptured cerebral arteriovenous malformation (CAVM) (37.7%). There were 12 patients with cerebral sinus venous thrombosis (CSVT). Headache is the main complaint of patients with venous stroke, followed by seizures and hemiparesis. The transverse sinus is the most common site for occlusion (66.7%).ConclusionThis study describes the characteristics and prevalence of stroke in young adults based on the results of cerebral DSA examination. Stroke in young adults is not uncommon. Several traditional risk factors in old age are now found in young people. Lifestyle modification is needed to reduce the prevalence of stroke in young adults.

Potential Impact of Public Communication on Emergency Presentations due to Headache during the Covid-19 Pandemic

Headache is a frequent presenting symptom in the emergency department. While most cases are of benign aetiology, it is crucially important to identify potentially dangerous underlying disorders. We hypothesized an increase in headache-related emergency presentations after venous thrombosis of cerebral sinuses had been identified as a rare side effect of vaccination with adenovirus vector-based Coronavirus-disease 2019 (COVID-19) vaccines and that information had been publicly communicated by the Paul Ehrlich Institute. Data from patients with the diagnosis of primary headache disorders or unspecified headache presenting to the Interdisciplinary Emergency Department of the University Medicine Mannheim were retrospectively analysed. Based on vaccination dashboard data published by the Federal Ministry of Health, calendar weeks 14-30 and 47-48, on the one hand, and 1-13 and 31-46, on the othe, were categorized into a variable "vaccination epoch" (14-30, 47-48: high vaccination activity if≥3 million weekly vaccinations in Germany; 1-13, 31-46: low vaccination activity if<3 million weekly vaccinations). The number of patients with headache was the dependent variable. A Poisson regression was performed to analyze whether the frequency of events, i. e., patient presentations, was a function of year (2019, 2021), epoch (high, low) and an interaction of year and epoch - the latter reflecting an impact of vaccination activity during the pandemic and expressed as incidence rate ratio. Compared to 2019, there was a more than 70% increase in presentations due to headache during periods of high vaccination activity in 2021 (p<0.001; 95% confidence interval 1.272-2.316), in 25% of presentations in 2021, patients considered their headache as vaccination-associated. Public communication and resulting nocebo effects may, among other factors, have contributed to our observation of increased numbers of emergency headache presentations, illustrating the impact of public distribution of medical information on practical aspects of emergency care during crises.

Venous Thrombo-Embolism Is Rare in Transgender and Gender Non-Binary Adolescents and Youth: A Multicenter Observational Study

Introduction An increasing number of adolescents and youth identify as transgender or gender non-binary (TNB). Gender-affirming hormone treatment (GAHT), including estrogen or testosterone therapy increase appearance congruence and psychological functioning, and decrease depression, anxiety and suicidal ideation. In adult TNB patients, estrogen therapy is associated with an increased risk of venous thromboembolism (VTE), while the thromboembolic risk of testosterone is less clear. A recent cross-sectional study conducted at Boston Children's Hospital (BCH) suggested that VTE is rare in TNB adolescents and youth and typically occurs in the setting of additional risk factors. Additionally, GAHT was not identified as a significant risk factor for thrombosis in this cohort. Herein, we sought to confirm our preliminary findings across 49 free-standing children's hospitals using an administrative database. Methods The study was deemed exempt by the Institutional Review Board at BCH. Administrative approval was obtained through the Children's Hospital Association. Data for this study were obtained from Pediatric Health Information System (PHIS), an administrative database that contains clinical and resource utilization data from inpatient, ambulatory surgery, emergency department, and observation encounters across 49 tertiary-care children's hospitals in the United States. Data quality and reliability are assured through a joint effort between CHA and participating institutions. International Classification of Disease, 9 th and 10 th Editions (ICD9/ICD10) codes were used to identify eligible subjects, defined as children (from birth to 21 years of age) hospitalized with VTE between 1/1/2012-12/31/2021 at one of 49-participating hospitals. ICD9/ICD10 codes for gender dysphoria were used to identify TNB adolescents and youth. Mean (SD) or median (range) were calculated for continuous data, and frequency with 95% confidence interval for categorical data. Results During the study period, 39,503 unique patients (birth-assigned females: 18,395 [47%]) were diagnosed with VTE. Mean age (SD) at VTE diagnosis was 7.7 (7.3) years. Only 23 (0.06%) patients had an ICD9/ICD10 diagnosis code for gender dysphoria. Of these 23 patients, six (26%) were birth-assigned males and 17 (74%) were birth-assigned females. Among these 23 patients, the median (range) age at VTE diagnosis was 16.2 (11.6, 20.5) years. VTE location for patients identified as TNB included: lower extremities (n=8), upper extremities (n=5), pulmonary embolism (n=5), cerebral sinus venous thrombosis (CSVT) (n=1), and other (n=4). Demographic data for the overall cohort and the subset of TNB patients are summarized in Table 1. 2,790 patients with a VTE diagnosis died prior to hospital discharge, while none of the 23 VTE patients identified as TNB died prior to hospital discharge. Only 2/23 (8.7%) TNB patients with VTE had a diagnosis code for hormone replacement therapy (HRT). One patient was a birth-assigned male, and one was a birth-assigned female. Among the 23 TNB patients with VTE, none had congenital heart disease, ten (43%) were obese, three (13%) had chronic renal disease, two (9%) had cancer and one (4%) had inflammatory bowel disease (Table 1). Discussion These data support our initial observation that VTE is extremely rare in TNB adolescents and youth and typically occurs in the setting of additional risk factors for VTE including cancer, renal disease, obesity, and inflammatory bowel disease. Only 2/23 TNB patients had a simultaneous code for HRT, suggesting that HRT may not be a significant risk factor for VTE in this cohort. A limitation of this investigation is the inability to estimate how many TNB patients received care at the participating centers during the study period.

The Prevalence of JAK2 Mutation in High-Altitude Patients with Unprovoked Thrombosis and Thrombosis at Unusual Sites

Introduction Thrombosis, both arterial and venous, is a major source of morbidity and mortality in patients with myeloproliferative neoplasms (MPNs). Thrombosis can be the initial presentation of MPN and sometimes can predate its diagnosis. Most MPN-related thrombosis occurs on usual sites such as the cerebral and coronary arteries, and lower limbs deep venous thrombosis and pulmonary embolism. Rare thromboses can also occur with MPN, such as splanchnic and cerebral dural vein thromboses, with the former having a stronger correlation. Stroke in young people (under 50) and venous thrombosis at unusual sites (cerebral, splanchnic, renal and upper limbs) represent special scenarios for which workup includes exploring unusual etiologies, including inherited and acquired hypercoagulable states. JAK2 mutation is invariably present in polycythemia vera (PV), occurs in a significant proportion of other classical MPNs, and is directly associated with risk of thrombosis due to associated leukocytosis, platelet activation, and altered vascular endothelial function. JAK2-mutated MPNs are associated with higher thrombosis risk compared to JAK2 unmutated MPNs, and greater allele burden corresponds to greater risk. The association of JAK2 mutation with hepatic and splanchnic vein thrombosis is well established. There are evidence-based guidelines for testing in idiopathic splanchnic vein thrombosis; however, its association with other unusual site thrombosis is unclear. Clinicians may request JAK2 mutation testing in individuals with unprovoked VTE and VTE at unusual sites to uncover the underlying etiology. This is despite a low diagnostic yield, particularly in people with normal CBC. Cerebral sinus thrombosis, for example, occurs in 1% of MPNs, and an underlying MPN accounts for only 3.8% of CVT. Most documented MPNs presenting with thrombosis had abnormal CBC at presentation, either thrombocytosis or erythrocytosis. The aim of this analysis is to explore whether JAK2 mutation without overt MPN contributes to the unusual site venous thrombosis and stroke in young people in a high altitude population. Method: We collected lab records for all JAK2 requests made over three years (2020-2022) in two referral hospitals serving a population residing at an altitude of 2,270-3,000 meters above sea level. Requests that listed thrombosis as an indication were analyzed, and labs and imaging related to the corresponding requests were reviewed. Results: Among 208 JAK2 tests, 40 (19.2%) were requested during the evaluation of thrombotic events. Patients were relatively young, with a median age of 41, and the gender breakdown was 17 (42.7%) males and 23 females. About half (23, 57.5%) of the cohort had normal CBC. Those with abnormal CBC at presentation included 3 patients with leukocytosis, 10 with thrombocytosis, and 10 with erythrocytosis. Among males, 2 had an ischemic stroke, 5 had cerebral sinus thrombosis, 5 had splanchnic vein thrombosis, 4 had unprovoked DVT/PEs, and 1 had renal vein thrombosis. Among females, 4 experienced ischemic strokes, 3 had cerebral venous thrombosis, 10 had splanchnic vein thrombosis, 5 had unprovoked DVT/PEs, and 2 had renal vein thrombosis. Only 2 patients (5%) were positive for JAK2 mutations: a 17-year-old boy who presented with portal vein thrombosis and was diagnosed with polycythemia vera and a 31-year-old lady who presented with hepatic vein thrombosis and normal CBC. Conclusion: JAK2 mutation was rare in our high-altitude cohort with unprovoked DVT/PE/thrombosis at unusual sites. Outside the splanchnic venous system and with normal CBC, the diagnostic yield of JAK2 mutation testing is low. Hence, such testing might not be indicated.

Spplaash Study: A Randomized Study to Evaluate the Incidence of Postdural Puncture Headache with the Use of Atraumatic Needles in Hematology

Introduction - Postdural-puncture headache (PDPH) is the most common complication after lumbar puncture, probably due to leakage of cerebrospinal fluid (CSF) from the dural defect into the epidural space. Most cases of PDPH occur within 8 days of a lumbar puncture and may be associated with other symptoms, such as photophobia, nausea or neurological complications. In this context, PDPH is a debilitating condition that significantly impacts quality of life. While several risk factors have been proposed to participate in PDPH etiology, no preventive or therapeutic measures have robustly proven their efficacity . Among PDPH-related risk factors, needle tip shape has been shown to influence the incidence of PDPH, especially in the context of diagnostic LP. The purpose of this study was to assess the incidence of PDPH using conventional (cutting-type) or atraumatic (pencil-point) spinal needles in hematological patients. Methods -This was a randomized, double-blind study of 68 adult patients scheduled for a diagnostic and/or therapeutic lumbar puncture (LP) (SPPLAASH study, NCT03126045). Subjects were randomly assigned to receive one of two needles : 22-gauge cutting (n=36) and 26-gauge atraumatic (n=32). LP and CSF collection were performed in accordance with standardized procedures. The main outcome was the occurrence of severe headache (≥4 out of 10 on the numerical rating scale (NRS)) as measured by interviews for 8 days after LP, repeated until headache resolution. Secondary outcomes included maximum intensity and duration of PDPH as well as procedural failure. Results - The median age at the time of LP was 60 years (Q1-Q3, 46-70) and 40% of patients were women. Demographic and procedural characteristics are summarized in Table 1. No significant difference was statistically observed between the two treatment groups, except for LP indication. The overall rate of severe PDPH was 19.7% (95% CI - 10.9-31.3). Interestingly, the incidence of severe PDPH was statistically reduced from 31.3% (95% CI - 16.9-49.3) in the conventional needle group to 6.5% (95% CI - 0.8-21.4) in the atraumatic group (p=0.011). High body mass index (OR 0.72, 95% - CI 0.57-0.91) and male sex (OR 0.29, 95% CI 0.08-1) were factors associated with a lower risk of PDPH. Means of maximum intensity of PDHP at 8 days were estimated to be 2.3 (sd 3.1) in the conventional needle group and 0.7 (sd 1.31) in the atraumatic group, with a statistically difference when considering median intensities (p=0.032) and number of days with NRS ≥4 (p=0.030). We used Sankey flow diagram to map the trajectories of PDPH intensities during the 8-day follow-up (Figure 1). First attempt LP success, failure rate, mean number of attempts, and the frequency of analgesic prescritions did not statistically differ between the two needle groups. Conclusion - Lumbar puncture is an essential and common procedure in hematologic clinical care and research. Our data indicate that atraumatic needles were associated with a decrease in the incidence of severe PDPH as well as in the duration of PDPH event. Moreover, the use of atraumatic needle was safe and feasible. Given that PDPH has a major impact on quality-of-life already altered by hematological treatments, and that headache might be caused by a differential diagnosis (e.g. cerebral sinus venous thrombosis due to Asparaginase in acute lymphoblastic leukemia), the use of atraumatic needles should be encouraged in this population, which often benefits from multiple LP.

Apixaban versus no anticoagulation for the prevention of venous thromboembolism in children with newly diagnosed acute lymphoblastic leukaemia or lymphoma (PREVAPIX-ALL): a phase 3, open-label, randomised, controlled trial

Paediatric patients with acute lymphoblastic leukaemia or lymphoma are at increased risk of venous thromboembolism resulting in increased mortality and morbidity. We hypothesised that apixaban, a direct oral anticoagulant, would safely reduce venous thromboembolism in this patient population. PREVAPIX-ALL was a phase 3, open-label, randomised, controlled trial conducted in 74 paediatric hospitals in 9 countries. Participants aged 1 year or older to younger than 18 years with newly diagnosed acute lymphoblastic leukaemia (pre-B cell or T cell) or lymphoblastic lymphoma (B cell or T cell immunophenotype) and a central venous line in place throughout induction were randomly assigned 1:1 to standard of care (SOC, ie, no systemic anticoagulation) or weight-adjusted twice-daily apixaban during induction. Randomisation was performed centrally and stratified by age (those <10 years or those ≥10 years). Participants weighing 35 kg or less were administered 2·5 mg twice daily of apixaban as a 2·5 mg tablet, 0·5 mg tablets, or 0·4 mg/mL oral solution, while those weighing more than 35 kg were administered weight-adjusted prophylactic doses using 0·5 mg tablets or the 0·4 mg/mL oral solution twice daily. Primary outcomes were assessed by a blinded central adjudication committee. The primary efficacy outcome for the intention to treat population was the composite of symptomatic or clinically unsuspected venous thromboembolism, the primary safety outcome was major bleeding, and secondary safety outcomes included clinically relevant non-major (CRNM) bleeding. Patients were screened for venous thromboembolism by ultrasound and echocardiogram at the end of induction. The trial was registered with ClinicalTrials.gov (NCT02369653) and is now complete. Between Oct 22, 2015, and June 4, 2021, 512 participants were randomly assigned and included in analyses (222 [43%] female and 290 [57%] male; 388 [76%] White, 52 [10%] Asian, 24 [5%] Black or African American, and 48 [9%] other races; and 122 [24%] Hispanic or Latino ethnicity). During a median follow-up period of 27 days (IQR 26-28), 31 (12%) of 256 patients on apixaban had a composite venous thromboembolism compared with 45 (18%) of 256 participants receiving SOC (relative risk [RR] 0·69, 95% CI 0·45-1·05; p=0·080). Two major bleeding events occurred in each group (RR 1·0, 95% CI 0·14-7·01; p=1·0). A higher incidence of CRNM bleeding, primarily grade 1 or 2 epistaxis, occurred in the apixaban group (11 [4%] of 256 participants) compared with the SOC group (3 [1%] of 256; RR 3·67, 95% CI 1·04-12·97, p=0·030). The most frequent grade 3-5 adverse events in both groups were thrombocytopenia (n=28 for the apixaban group and n=20 for the SOC group) or platelet count decreased (n=49 and n=45), anaemia (n=77 and n=74), febrile neutropenia (n=27 and n=20), and neutropenia (n=16 and n=17) or neutrophil count decreased (n=22 and n=25). Five deaths occurred, which were due to infection (n=3 in the SOC group), cardiac arrest (n=1 in apixaban group), and haemorrhagic cerebral sinus vein thrombosis (n=1 in the SOC group). There was one apixaban-related death (coagulopathy and haemorrhage after cardiac arrest of unknown cause). PREVAPIX-ALL is, to our knowledge, the first trial assessing primary thromboprophylaxis using a direct oral anticoagulant in paediatric patients with acute lymphoblastic leukaemia or lymphoma. No statistically significant treatment benefit was identified in participants receiving apixaban. Major and CRNM bleeding were infrequent overall, but a higher incidence of CRNM bleeding (primarily epistaxis in younger children) occurred in participants receiving apixaban. For patients deemed to be at particularly high risk of thrombosis, PREVAPIX-ALL provides encouraging safety data for the use of apixaban in clinical settings in which the potential benefits are thought to outweigh the risk of bleeding. Bristol Myers Squibb-Pfizer Alliance.

Clinical Characteristics and Outcomes of Unusual Venous Thrombosis Sites Among Veterans with Myeloproliferative Neoplasms

Myeloproliferative Neoplasms (MPNs) may be complicated by venous thrombosis at unusual sites, which may include portal veins, hepatic veins, and cerebral sinuses. We have previously reported on the association of Agent Orange and the development of MPNs among Veterans. The incidence and timing from Service-Connected Exposures (SCE) of Veterans to the development of MPNs and thrombosis at atypical sites have not been defined. We examine the natural history, clinical characteristics, and outcomes of the Veterans with MPNs, who developed Renal Vein Thrombosis (RVT), Splanchnic Vein Thrombosis (SVT), Budd Chiari Syndrome (BCS), and Cerebral Venous Sinus Thrombosis (CVST). Utilizing the Veterans Affairs Informatics and Computing Infrastructure (VINCI) database from January 1, 2006 - January 26, 2023, Veterans with MPNs, RVT, SVT, BCS, and CVST were identified through ICD-9 and -10 codes, and, subsequently, a retrospective chart review was performed upon those Veterans with MPNs and unusual thrombosis sites. Military toxin exposures were verified through Veterans' duration and location of service. Time to MPN diagnosis refers to time from first year of cumulative SCE until year of MPN diagnosis. Among 12,352,664 Veterans, there were 435 RVT, 156 SVT and BCS, 140 CVST, and 93,269 MPNs identified. Among those with MPNs, there were 9 BCS, 4 RVT, 5 SVT, 2 RVT &amp; SVT, and 9 CVST. CVST was observed only in Vietnam Veterans; 13/20 (65%) of RVT, SVT or BCS cases had SCE from the Gulf War (Table 1). Five/20 of the MPN subjects with RVT, SVT, or BCS had documented pre-existing thrombophilic risk factors, which included malignancy, heparin-induced thrombocytopenia, and splenectomy, whereas 2/9 CVST with MPN had associated alcohol abuse and tooth infection. All non-MPN Veterans with RVT, SVT, or BCS had thrombophilic risk factors, including malignancy, infection, and surgery. One had BCS from Paroxysmal Nocturnal Hemoglobinuria. Median time to MPN diagnosis from SCE was 20 (3-62) years with 13 (65%) thrombotic events occurring at the same time of MPN diagnosis among Veterans with RVT, SVT, or BCS. Six (30%) had their thrombosis recognized prior to their MPN diagnosis, median 6 (1-10) years, while 1 had a thrombotic event 16 years after his MPN diagnosis (Figure 1). Veterans with MPN and CVST had a substantially longer median time from SCE to the time of MPN diagnosis, 42 (24-52) years. No CVST was observed concurrent to the time of MPN diagnosis. Among Veterans with MPN and CVST, 5 (56%) had thrombosis before MPN diagnosis and 4 (44%) had thrombosis after MPN diagnosis, median 5 (2-10) years and 7 (1-21) years, respectively. Among Veterans with MPN and RVT, SVT, or BCS, 17 (85%) had portal hypertension complications, 8 (40%) had undergone endovascular interventions, and all individuals were placed on indefinite systemic anticoagulation, with warfarin most commonly prescribed. Among Veterans with BCS, 3 underwent liver transplantation. Among Veterans with CVST, 2 (22%) had concurrent CNS hemorrhage, 5 (56%) had persistent neurologic symptoms, and 1 had transformation of his MPN to Chronic Myelomonocytic Leukemia. In summary, thrombotic episodes at unusual sites among Veterans with MPNs are rare events but convey substantial morbidity and mortality, particularly among those with RVT, SVT, and BCS. We describe a significantly shorter median time to MPN diagnosis in Veterans with RVT, SVT, and BCS compared to CVST with a difference of 22 years. All MPN subjects with RVT, SVT, or BCS had JAK2 V617F mutations, with majority of thromboses noted at the time of MPN diagnosis. Future studies should include potential role of SCE in acquisition of driver mutations and CHIPs and progression of mutagenesis.

Клинико-рентгенологические особенности церебральных венозных тромбозов на примере клинических случаев

Venous blood accounts for more than 80% of cerebral blood flow. At the same time, the incidence of cerebral venous thrombosis in patients with ischaemic stroke is only 3%. Cerebral venous thrombosis includes both sinus thrombosis and thrombosis of the cerebral veins themselves. The difficulty in diagnosing this condition may explain its low incidence. The clinical picture of cerebral venous thrombosis is similar to that of arterial infarction. Thrombosis of the cerebral sinuses can occur under the guise of a variety of conditions: subarachnoid haemorrhage, meningitis and even migraine or tension headache. It is therefore necessary to make a differential diagnosis between these nosologies. This article presents an analysis of cases of deep cerebral venous thrombosis and transverse sinus thrombosis. The analysis focuses on such features of the clinical picture as a pronounced hypertensive syndrome and the discrepancy between focal symptoms in cases of damage to the arterial and venous blood circulation areas. The results of x-ray computer and magnetic resonance tomography imaging are compared with literature data. In the case of transverse sinus lesions, blood testing for genetic and acquired hypercoagulability factors was performed. The article presents the results of the ultrasound examination of the cerebral veins, as well as an assessment of the dynamics of the patient's condition against the background of taking anticoagulant treatment for one year. After one year, magnetic resonance angiography showed recanalisation of the sinus. The cases presented highlight the need for more thorough investigation in patients with cerebral vascular pathology who present with an atypical clinical picture. It is essential that these investigations include a CT angiogram and a blood test to identify inherited and acquired thrombophilia factors.

Cerebral sinovenous thrombosis as a cause of subdural hemorrhage in the pediatric population: Is there a correlation?

Cerebral sinovenous thrombosis is an increasingly recognized cause of stroke in children and neonates. Its true incidence appears to be underestimated. Despite being a rare event, certain studies have found a correlation between subdural hemorrhage and cerebral sinus thrombosis. The literature suggests that spontaneous cerebral sinovenous thrombosis in the pediatric population may lead to the occurrence of a subdural hemorrhage. In this report, we present a case of cerebral venous thrombosis associated with chronic subdural hematoma and review the literature to highlight the importance of these conditions. An 11-year-old boy was admitted in the neurosurgery department with headache and a neurological examination without changes. The imaging studies identified a heterogeneous subdural collection in the fronto-temporo-parietal region. The patient underwent surgical drainage of the subdural hematoma, and the procedure was performed without complications. The magnetic resonance and angiography showed an extensive thrombosis of the superior sagittal sinus, extending downward to the occipital sinus and partially to the right transverse sinus. Appropriate management in the diagnosis and an early treatment of dural sinus thrombosis associated with subdural hemorrhage can reduce the risk of recurrence and improve the clinical outcome.

Cerebral venous thrombosis in reproductive age

Relevance. Cerebral venous thrombosis is a relatively rare pathological condition that often leads to the development of ischemic and/or hemorrhagic stroke.Objective. Describe a clinical case of cerebral venous thrombosis, accompanied by the ischemic stroke with hemorrhagic transformation, in a reproductive age woman taking a combined estrogen-progestin drug from the group of oral contraceptives.Patients and methods. The analysis based on the anamnesis data, clinical, laboratory and instrumental examination of the patient.Results. A clinical case of a 23-year-old patient who had an acute ischemic stroke with hemorrhagic transformation is presented. According to the history data and instrumental methods, the stroke was caused by thrombosis of the cerebral sinuses, which developed on the background of hormonal contraception use. The clinical case is accompanied by MRI images of the patient's brain.Conclusions. The risk of cerebral venous thrombosis in women with hormonal contraceptives use is almost 8 times higher than in those who do not receive hormone therapy. The occurrence of neurological symptoms in women of reproductive age requires a thorough study of the life history, obstetric/gynecological and pharmacological history to establish the fact of estrogen-progestin drugs use for contraception or treatment of hormonal disorders. The described case focuses on the importance of a delicate approach to prescribing hormonal therapy in the treatment of gynecological and other pathological conditions, and indicates the necessity to consider and recommend other contraceptives for young patients.

Bilateral Cerebral Venous Thrombosis with a Rare Presentation in a COVID-19 Patient: A Case Report

AbstractSince the COVID-19 pandemic started, millions of peoples are involved. The presentation of the disease varies from mild respiratory symptoms and multiple organ failure to coma and death. Neurological symptoms such as headache or seizure are also coincident with COVID-19. Thromboembolic events increase in COVID-19 patients due to hypercoagulability and inflammation, particularly in severely ill patients. Thrombosis may cause venous thrombosis, pulmonary embolism, or cerebral sinus venous thrombosis (CSVT). Cerebral sinus venous thrombosis is a rare phenomenon that is usually found in critically ill patients with bad prognoses. In the present case report, we present a 40-year-old man with COVID-19 confirmed by real-time polymerase chain reaction (RT-PCR) who was admitted due to acute bilateral visual loss due to bilateral transverse sinus thrombosis. Pseudotumor cerebri disease was confirmed through high lumbar puncture. Early surgical intervention (optic nerve fenestration) was performed and, fortunately, his visual acuity improved. Cerebral sinus venous thrombosis is a rare incident in COVID-19 patients, but due to irreversible complications, an early diagnosis is fundamental. In any neurologic change in COVID-19 patients, CSVT must be considered. Also, prophylactic thrombolytic therapy should be kept in mind as the patient is admitted.

Prognostic factors in patients with cerebral sinus venous thrombosis presenting with hemorrhage and papilledema

ObjectiveThe thromboinflammatory process is considered to play a role in the pathogenesis and prognosis of cerebral sinus vein thrombosis (CSVT). The purpose of the study was to compare the thromboinflammatory parameters between individuals with CSVT and healty controls. Additionally, the study sought to compare these parameters among CSVT subgroups with and without haemorrhage, as well as with and without papilledema. Furthermore, the investigation also aimed to identify which parameters had a more significant impact on the risk of hemorrhage and the development of papilledema in CSVT. MethodsThromboinflammatory parameters were compared retrospectively between the CSVT group of 88 patients and 80 age- and sex-matched healthy controls, and in the CSVT subgroups with (n = 35) /without hemorrhage (n = 53) and with (n = 52) /without papilledema (n = 36) after ethics committee approval. In both groups, parameters contributing to the risk of hemorrhage and papilledema development were determined by univariate and multivariate analyses. ResultsRegarding the risk of hemorrhage in CSVT patients, the most significant factors included hematocrit of <30.2 (%), mean platelet volume of ≤8.9 fL, neutrophil count of >5600, and hsCRP of >9 mg/L. Regarding the risk of papilledema development, the most important risk factors were age of ≤49, presence of vomiting, presence of blurred vision, HDL of >47 mg/dL, and D-dimer of >178 ng/mL. ConclusionIt was suggested that evaluating serum thromboinflammatory parameters, as well as demographic characteristics and neurological examination findings, had a critical role regarding prognosis and predictive factors in CSVT.

SAT345 Disappearing Adrenal Masses: A Tale Of Two Lesions

Abstract Disclosure: A. arooj: None. A. Lansdown: None. Introduction: Adrenal lesions are being increasingly detected on CT scans performed for other reasons. Adrenal lesions that “disappear” on subsequent imaging are rare, most commonly due to adrenal hematomas, cysts or infection. Case: 1 73-year-old man was admitted with a collapse and fall. CT head &amp; angiogram demonstrated cerebral sinus thrombosis, subarachnoid hemorrhage and right parietal hematoma. Furthermore, high density4cm left adrenal lesion on CT abdomen(Fig 1) Consideration was given to COVID vaccine induced thrombotic thrombocytopenia. ACTH, aldosterone, renin, aldosterone renin ratio normal. Slightly low cortisol (386) after short synacthen test. Later, CT showed the left adrenal lesion had disappeared in Fig 2. Case 2: 36-year-old man following a road traffic collision, fell from his electric scooter at a speed of 30mph, also noted to have high blood pressure on admission. He had small laceration of the liver which was managed conservatively. CT abdomen and pelvis, showed a low density 28mm right adrenal nodule, measuring 37 Hounsfield Units,(fig 3) that was completely resolved in subsequent imaging (Fig4). His biochemistry reports of dexamethasone suppression test, renin, aldosterone, 24hr metadrenaline urinary profile and urinary cortisol remained normal. Learning points: "Disappearing", adrenal mass lesions are rare, though reported, and most commonly due to adrenal hematomas, cysts or infection.