Hemorrhagic Venous Infarction Research Articles

Management and Outcomes of COVID – 19 Associated Cerebral Venous Sinus Thrombosis

BackgroundSystemic hyper-coagulabilty leading to micro and macro thrombosis is a known complication of Coronavirus disease – 2019(COVID -19). The postulated mechanism appears to be the viral activation of endothelium, triggering the coagulation pathways. Thrombosis of the cerebral veins and sinuses (CVT), a potentially serious condition, has been increasingly reported with COVID – 19 infection. In this clinical study we attempt to describe the clinical profile, investigations and outcomes of patients with COVID- 19 associated CVT. MethodsThis is a single center prospective observational study from South India. The study included patients (aged >18 years) with concomitant COVID infection and CVT. The clinical, laboratory, imaging characteristics, management and outcomes were described and compared with COVID negative CVT patients. ResultsOut of 97 cases of CVT treated at our center during the first and second waves of the COVID pandemic 11/97 (11%) were COVID related CVT. Among these 11 patients, 9 (81%) had presented with only CVT related symptoms and signs and were tested positive for COVID - 19 infection during the pre-hospitalization screening. Respiratory symptoms were absent in 90% of the patients. Headache (100%) and seizures (90%) were the common presenting symptoms. The median time to diagnosis was 6 hours, from presentation to the emergency department. Transverse sinus was involved 10/11 (90%) and majority of them (9/11) had Haemorrhagic Venous Infarction (HVI). Acute inflammatory markers were elevated in comparison with non COVID CVT patients, with the mean serum D-dimer being 2462.75 ng/ml and the C-reactive protein was 64.5 mg/dl. Three patients (30%) underwent decompressive hemicraniectomy (DHC) because of large hemispheric HVI. All patients survived in the COVID CVT group while the mortality in the non COVID group was 4%. At 6 months follow up excellent outcome (modified Rankin Scale (mRS) score of 0–2) was noted equally in both groups. ConclusionsSymptoms and signs of CVT may be the only presentation of COVID-19 infection. Prompt recognition and aggressive medical management including DHC offers excellent outcomes.

Simultaneous Occurrence of Cerebral Venous Sinus Thrombosis and Immune Thrombocytopenic Purpura in a Patient with a History of COVID-19 Infection.

Since the emergence of the coronavirus disease 2019 (COVID-19) pandemic, multiple but rare complications of this infection have been described, comprising cerebral venous sinus thrombosis (CVST) and immune thrombocytopenic purpura (ITP). Although these two complications have been reported as separate entities, to the best of our knowledge, their concurrent presentation has not been reported. In this case report, we present a middle-aged man with a history of COVID-19 infection who developed a sudden-onset severe occipital headache followed by right-sided blindness (right homonymous hemianopia). Upon his diagnostic workup, brain computed tomography scan with and without contrast was indicative of thrombosis of the left transverse venous sinus and hemorrhagic venous infarction. In addition, laboratory data revealed thrombocytopenia, which upon investigation confirmed a diagnosis of ITP. We postulate three pathophysiological mechanisms for this circumstance: either COVID-19 infection caused ITP and then ITP gave rise to CVST, or COVID-19 complications themselves resulted in ITP and CVST independently and simultaneously, or another plausible mechanism is immune-mediated thrombocytopenia caused by the anti-platelet 4-factor antibody, which is the proposed mechanism for CVST after the COVID-19 vaccine.

Cerebral venous sinus thrombosis with venous hemorrhagic infarct in a patient with high-grade glioma of the left thalamus

Cerebral venous sinus thrombosis (CVST) is an uncommon type of venous thromboembolism whose diagnosis is often difficult due to its vague and non-specific clinical findings. Sometimes, the diagnosis is delayed as the symptoms were considered to be attributable to the underlying etiology, especially in patients with brain tumors such as high-grade glioma (HGG). We described the case of a 60-year-old male patient who presented with headache, generalized seizures, and right hemiparesis soon after receiving brain radiation and temozolomide therapy for HGG of the left thalamus. Initially, his symptoms were considered to be due to his underlying tumor but the subsequent imaging revealed left transverse, left sigmoid, and superior sagittal sinus thrombosis with venous hemorrhagic infarct of the left occipitoparietal lobe. The patient was started on anticoagulant therapy and symptoms resolved completely within a month. Clinicians should always consider CVST in the differential diagnosis of non-specific neurological symptoms, especially in patients with underlying brain tumors.

P0020 / #1115: ASPIRATION THROMBECTOMY IN AN ADOLESCENT MALE PRESENTING WITH BILATERAL CEREBRAL VENOUS THROMBOSIS: CASE REPORT AND REVIEW OF LITERATURE FROM AN LOWER MIDDLE INCOME COUNTRY

Aims & Objectives: Bilateral Cerebral Venous Thrombosis (CVT) is a rare clinical presentation in the adolescent population and therefore offers a diagnostic challenge. The purpose of reporting this case is that the novel use of EMT in an adolescent with bilateral CVT has not been reported before and should be considered in as an emergent therapeutic adjunct in a similar case presentation. Methods: We present the case of a 17 year old boy who presented as non-traumatic coma and was found to have bilateral CVT on MRI. He subsequently underwent endovacular mechanical thrombectomy (EMT) Results: Case Presentation: We report a case of a 17 year old boy who presented as non-traumatic coma. Further imaging revealed extensive cerebral venous sinus thrombosis with hemorrhagic venous infarction in bilateral parietal lobes. Examination revealed a drowsy child. Hemodynamics were within the normal range. However, a detailed neurological examination revealed anisocoric pupils, increased tone in all four extremities and upgoing planters; He was started on Enoxaprin (1mg/kg SC Q12hourly); This was not an easy decision since the patient also had a hemorrhagic conversion in the infarct. There was no significant clinical improvement despite initiation of anticoagulation. A multidisciplinary decision led by neurology, hematology, and critical care decided on an emergent endovascular mechanical thrombectomy. Aspiration thrombectomy in the Superior sagittal sinus was performed and the enoxaparin was later switched to rivoroxaban. The patient showed dramatic clinical improvement. He regained consciousness with restoration of motor function.Conclusions: Endovascular mechanical thrombectomy is a safe therapeutic consideration of failed medical management for bilateral CVT.

Cerebral venous sinus thrombosis viewed as a postpartum complication

Cerebral venous sinus thrombosis (CVST) is a rare type of stroke caused by a clot forming in one of the cerebral sinuses and subsequent blockage in blood drainage. The clinical presentation of this disease can be atypical and diagnosis might be challenging. The patient in this case study was a 33-year-old woman admitted to the perinatology clinic at 39+5 weeks of gestation to perform a planned caesarean section, who had previously been discharged home in good condition. The patient was readmitted to the hospital because of a headache, tingling sensation, and elevated D-dimers. A performed Computed Tomography scan revealed low contrast signal in the left cerebral sinuses and the left internal jugular vein. The diagnosis was CVST, with blood clots present in all mentioned vessels. Subsequent magnetic resonance imaging revealed hemorrhagic venous infarctions in the left cerebral and cerebellar hemispheres. The patient was successfully treated with painkillers and heparin. No additional coagulation defect was detected.

Predictors of Presenting Seizures in Acute Cerebral Vein and Dural Sinus Thrombosis.

Background and PurposeRisk of seizure is significantly higher in cerebral vein and dural sinus thrombosis (CVST) compared to other stroke subtypes. There is paucity of literature on predictors of presenting seizures in CVST. This study was designed to investigate the risk and predictors of seizures in CVST at presentation.MethodsTotal 181 consecutive patients with CVST were retrospectively analyzed.ResultsTotal 181 patients with CVST were enrolled (age range, 14 to 96 years; mean age, 34.64±14.66 years). A total of 44 patients had presenting seizures. Younger age (p=0.028), involvement of superficial cortical veins (p=0.016), presence of hemorrhagic venous infarct (p≤0.001) and involvement of frontal lobe (p≤0.001) were significantly related to the presenting seizures on the univariate analysis. The hemorrhagic venous infarct (odds ratio [OR], 4.44; 95% confidence interval [CI], 1.89–10.44; p=0.001) and involvement of the frontal lobe (OR, 10.66; 95% CI, 4.02–28.29; p≤0.001) were independently associated with the presenting seizures on the multivariate analysis.ConclusionsAbout one fourth of the patients with CVST had presenting seizures. The patients with hemorrhagic venous infarct in the frontal region are more prone to have presenting seizures.

Cerebral venous sinus thrombosis complicated with haemorrhagic venous infarction and seizures, successfully treated with oral anticoagulation for one year: a case report

The AMJ is a peer-reviewed, triannual health journal published by Anuradhapura Clinical Society (ACS).The Journal strives to be a forum for all health professionals to publish original research and review articles in their area of expertise. The AMJ publishes articles in clinical medicine, public health and health promotion. Our priority is given to manuscripts on health related issues which affects the communities living in rural tropical communities. Established as a journal in 2006 as a publication parallel to ACS annual scientific sessions, the journal was relaunched as a proper journal in 2013. Anuradhapura Medical Journal is a member of COPE and is included on DOAJ.

Atypical Deep Cerebral Vein Thrombosis with Hemorrhagic Venous Infarction in a COVID-19-Positive Patient

Atypical Deep Cerebral Vein Thrombosis with Hemorrhagic Venous Infarction in a COVID-19-Positive Patient

Mechanical Thrombectomy for Cerebral Venous Sinus Thrombosis: A Case Series and Technical Note

Cerebral venous sinus thrombosis is a rare cause of acute stroke. It may lead to hemorrhagic venous infarctions, brain swelling, or raised intracranial pressure and can be associated with significant mortality and morbidity. Low-molecular-weight heparin is the mainstay of treatment. Endovascular treatment is reserved for patients who deteriorate despite medical management. Retrospective evaluation of our institutional databases from 2018-2019 revealed 7 patients who underwent aspiration thrombectomy using large-bore aspiration catheters for recanalization of the dural sinuses with or without intrasinus thrombolysis during the procedure. Their clinical, imaging findings, endovascular technique, and outcome are discussed. We treated 7 patients who did not respond to best medical management. Aspiration thrombectomy was the primary mode of endovascular treatment. Adjuvant low-dose (10 mg recombinant tissue plasminogen activator), short-duration (20-minute) intrasinus thrombolysis was used in 4 patients only during the procedure. Headache was the most common symptom, followed by seizures, focal neurologic deficits, and vomiting. There was improvement in clinical condition within 24 hours of procedure in all patients. The 30-day modified Rankin Scale score was 0 in 6 patients. One patient had residual hemiparesis and aphasia. There were no procedure-related complications. The described technique appears to be simple, safe, and effective and results in a relatively short procedure time in achieving complete or partial recanalization of the dural sinuses in patients who deteriorate despite clinical management. Endovascular thrombectomy along with conventional medical management restores the final drainage pathway of the brain with good clinical outcome.

Epidemiological, Clinical Characteristics and Evolving Profile of Cerebral Venous Thrombosis in the Far Ouest of Algeria

Cerebral venous thrombosis (CVT) is rare conditions related to occlusions of isolated dural sinuses or occlusions of cortical veins. They are characterized by their clinical and radiological polymorphism. 1.1. Methods: Our work is a descriptive (between January 2010 to December 2015). We collected 96 patients, all over the age of 18 years, for which we studied the epidemiological, clinical, and paraclinical presentations, and evolution outcomes. 1.2. Results: The average age in our study was 36.65 ± 6.1years with predominance in females (sex ratio 0,1 Clinical presentation was sub-acute in 73,9% of all cases. CIH syndrome was the most common presenting symptom (51,1% and focal symptoms in 25% of cases. Thrombosis was mainly located at the superior sagittal sinus (44,8%) followed by the lateral sinus (20,8%). Cerebral CT scan showed hemorrhagic venous infarction (73,9%). Identified causes were polymorphic and associated, dominated by post-partum (25%). Septic causes remained significant (19, 8%). The outcome was favorable in 75% of cases. 1.3. Conclusion: CTV is a thrombotic condition that is not as rare as thought, requiring early diagnosis and emergency management.

Arteriovenous Fistula After Cerebral Venous Sinus Thrombosis

Thrombosis of the deep cerebral vein is a rare entity. Thrombosis of cerebral veins or dural sinus obstructs blood drainage from brain tissue, leading to cerebral parenchymal dysfunction and increased venous and capillary pressure with disruption of the blood-brain barrier. Many conditions are associated with cerebral venous sinus thrombosis. Prothrombotic conditions, malignancy, infection and head injury has been reported as risk factors for cerebral venous sinus thrombosis (CVST). Neuroimaging features of CVST include focal areas of oedema or venous infarction, hemorrhagic venous infarction, diffuse brain edema or rarely subarachnoid haemorrhage. Magnetic resonance imaging of the brain in combination with magnetic resonance venography is the most informative technique in demonstrating the presence of dural thrombus and cortical vein thrombosis.
 Bangladesh J Medicine Jan 2019; 30(1) : 35-37

Unusual occurrence of brain hydatid disease in a patient with previous surgical intervention for hemorrhagic venous infarct

Hydatid disease is an endemic parasitic disease and can occur anywhere in the body and has a variable presentation. On imaging, thelesions have varied appearance ranging from cystic to solid appearing lesions, solitary to multiples. We present a case of 35-year-oldfemale who underwent decompression craniectomy for right temporoparietal hemorrhagic venous infarct and now presented withacute onset of right-sided weakness. Magnetic resonance imaging was suggestive of cerebral hydatid disease. The presented caseemphasizes that hydatid cyst should be considered as a possibility whenever a cystic lesion is encountered during imaging.

Anatomical Venous Variants in Children With Cerebral Sinovenous Thrombosis.

Background and Purpose- Literature is sparse on the frequency and significance of anatomical venous variants (AVVs) in pediatric cerebral sinovenous thrombosis (CSVT). Methods- We retrospectively reviewed children with CSVT and controls undergoing computed tomography/magnetic resonance venography from January 2008 to 2014. Clinical features examined included raised intracranial pressure, risk factors, and treatment. Radiological features examined included CSVT location, presence and type of AVVs, hemorrhagic venous infarction, and venous collateralization. Clinical outcome was measured by the pediatric stroke outcome measure and radiological outcome by thrombus recanalization. Results- Fifty-one children with CSVT were identified. Twenty-two (43%) had AVVs at presentation. Nineteen (86%) had hypoplasia/absence of major dural sinus, 5 (23%) had persistent fetal structures, 3 (14%) had duplications/fenestrations, and 1 (5%) had disconnected superficial and deep venous systems. Controls had a slightly higher but nonsignificant prevalence 26 (51%) of AVVs. No significant clinical and radiological differences were observed between children with CSVT and AVVs compared with those with typical venous anatomy. Conclusions- AVVs are seen in many children with and without CSVT and do not seem to alter the presentation or clinical course. The influence of these variations on the brain's ability to tolerate venous congestion because of thrombosis merits further study.

A Case of Cerebral Venous Sinus Thrombosis Presenting with Delirium.

A 73-year-old woman with no history of headache, seizure and trauma was admitted to the emergency department complaining about fever, vomiting and delirium for 3 days. She was lethargic upon admission and her blood pressure (BP) was recorded as 140/90 mm/Hg, her pulse rate (PR) as 75 beat/min and oral temperature as 38 °C. No localizing findings were observed in neurological examinations. Laboratory findings were as follows: White Blood Cell (WBC) count: 7,000/mm3, Hemoglobin: 13 g/dl, Platelet count: 300000. Lumbar CSF, blood and urine cultures were found to be negative for infections. Brain Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) were also performed. MRI showed filling defects in the left transverse sinus, the jugular bulb and the internal jugular vein. Moreover, hyper-intense signal was observed in the left temporal lobe (T1 sequence) suggesting hemorrhagic venous infarction (Figure1). The obtained results were confirmed by Magnetic Resonance Venography (MRV) of the brain (Figure2). The patient underwent anticoagulation therapy using LMWH and she was? hydrated using physiologic solution. The patient’s symptoms disappeared and she was then followed up regularly.

Cerebral venous thrombosis requiring invasive treatment for elevated intracranial pressure in women with combined hormonal contraceptive intake: risk factors, anatomical distribution, and clinical presentation.

OBJECTIVE Women taking combined hormonal contraceptives (CHCs) are generally considered to be at low risk for cerebral venous thrombosis (CVT). When it does occur, however, intensive care and neurosurgical management may, in rare cases, be needed for the control of elevated intracranial pressure (ICP). The use of nonsurgical strategies such as barbiturate coma and induced hypothermia has never been reported in this context. The objective of this study is to determine predictive factors for invasive or surgical ICP treatment and the potential complications of nonsurgical strategies in this population. METHODS The authors conducted a 2-center, retrospective chart review of 168 cases of CVT in women between 2000 and 2012. Eligible patients were classified as having had a mild or a severe clinical course, the latter category including all patients who underwent invasive or surgical ICP treatment and all who had an unfavorable outcome (modified Rankin Scale score ≥ 3 or Glasgow Outcome Scale score ≤ 3). The Mann-Whitney U-test was used for continuous parameters and Fisher's exact test for categorical parameters, and odds ratios were calculated with statistical significance set at p ≤ 0.05. RESULTS Of the 168 patients, 57 (age range 16-49 years) were determined to be eligible for the study. Six patients (10.5%) required invasive or surgical ICP treatment. Three patients (5.3%) developed refractory ICP > 30 mm Hg despite early surgical decompression; 2 of them (3.5%) were treated with barbiturate coma and induced hypothermia, with documented infectious, thromboembolic, and hemorrhagic complications. Coma on admission, thrombosis of the deep venous system with consecutive hydrocephalus, intraventricular hemorrhage, and hemorrhagic venous infarction were associated with a higher frequency of surgical intervention. Coma, quadriparesis on admission, and hydrocephalus were more commonly seen among women with unfavorable outcomes. Thrombosis of the transverse sinus was less common in patients with an unfavorable outcome, with similar distribution in patients needing invasive or surgical ICP treatment. CONCLUSIONS The need for invasive or surgical ICP treatment in women taking CHCs who have CVT is partly predictable on the basis of the clinical and radiological findings on admission. The use of nonsurgical treatments for refractory ICP, such as barbiturate coma and induced hypothermia, is associated with systemic infectious and hematological complications and may worsen morbidity in this patient population. The significance of these factors should be studied in larger multicenter cohorts.

Safety profile of superior petrosal vein (the vein of Dandy) sacrifice in neurosurgical procedures: a systematic review.

OBJECTIVE Walter E. Dandy described for the first time the anatomical course of the superior petrosal vein (SPV) and its significance during surgery for trigeminal neuralgia. The patient's safety after sacrifice of this vein is a challenging question, with conflicting views in current literature. The aim of this systematic review was to analyze the current surgical considerations regarding Dandy's vein, as well as provide a concise review of the complications after its obliteration. METHODS A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A thorough literature search was conducted on PubMed, Web of Science, and the Cochrane database; articles were selected systematically based on the PRISMA protocol and reviewed completely, and then relevant data were summarized and discussed. RESULTS A total of 35 publications pertaining to the SPV were included and reviewed. Although certain studies report almost negligible complications of SPV sectioning, there are reports demonstrating the deleterious effects of SPV obliteration when achieving adequate exposure in surgical pathologies like trigeminal neuralgia, vestibular schwannoma, and petroclival meningioma. The incidence of complications after SPV sacrifice (32/50 cases in the authors' series) is 2/32 (6.2%), and that reported in various case series varies from 0.01% to 31%. It includes hemorrhagic and nonhemorrhagic venous infarction of the cerebellum, sigmoid thrombosis, cerebellar hemorrhage, midbrain and pontine infarct, intracerebral hematoma, cerebellar and brainstem edema, acute hydrocephalus, peduncular hallucinosis, hearing loss, facial nerve palsy, coma, and even death. In many studies, the difference in incidence of complications between the SPV-sacrificed group and the SPV-preserved group was significant. CONCLUSIONS The preservation of Dandy's vein is a neurosurgical dilemma. Literature review and experiences from large series suggest that obliterating the vein of Dandy while approaching the superior cerebellopontine angle corridor may be associated with negligible complications. However, the counterview cannot be neglected in light of some series showing an up to 30% complication rate from SPV sacrifice. This review provides the insight that although the incidence of complications due to SPV obliteration is low, they can happen, and the sequelae might be worse than the natural history of the existing pathology. Therefore, SPV preservation should be attempted to optimize patient outcome.

Outcomes of Preterm Infants with a Periventricular Venous Infarction in the Neonatal Period

AbstractWe compared the neurodevelopmental outcomes of infants with and without a periventricular venous hemorrhagic infarction (PVHI). The study was designed as a case–control study. The primary outcome measure was any score of < 85 in at least one of the cognition, language, or motor domains of the Bayley Scales of Infant and Toddler Development-3rd edition (Bayley-III) at 18 to 24 months corrected age. Of 41 infants identified, 20 index infants were matched with 40 controls for analyses. No differences in the primary outcome were noted between the two groups of infants, 52.9% with PVHI compared with 62.5% without PVHI (OR: 0.68, 95% CI: 0.21–2.13; p = 0.56). Infants with a PVHI were likely to have cerebral palsy, 85% compared with 7.5%, with the majority (70%) being ambulatory. Infants with a PVHI were developmentally similar to their preterm counterparts as it related to cognition and language.

Clinical Presentation, Neuroimaging Findings, and Predictors of Brain Parenchymal Lesions in Cerebral Vein and Dural Sinus Thrombosis: A Retrospective Study.

Introduction:Cerebral venous sinus thrombosis (CVST) is an unusual cause of stroke with potentially serious consequences. This study was designed to investigate the clinical and neuroimaging features in patients with CVST and to analyze the predictors of brain parenchymal lesions.Materials and Methods:A retrospective study of 181 patients with CVST was conducted in a tertiary care hospital.Results:Of 181 patients (age range 14–96 years, mean age: 34.64 ± 14.66 years), 121 were female (66.9%). Most of the patients were in their third decade of life. Headache (47.51%) was the most common clinical presentation followed by seizures (24.31%). Transverse sinus (TS) (77.9%) was the most common site of venous sinus thrombosis. Brain parenchymal lesions were present in 63%, and each patient had subarachnoid and intraventricular hemorrhage. Hemorrhagic venous infarct was the most common brain parenchymal lesion (37.57%). Frontal region (25.4%) was the most common site of brain parenchymal lesions followed by frontoparietal region (21.9%). Women were more likely to have brain parenchymal lesions (72.4%, P = 0.034). Headache was the most common clinical presentation in patients without brain parenchymal lesions while seizures with brain parenchymal lesions. Straight sinus thrombosis was more likely to be associated with brain parenchymal lesions (P = 0.009).Conclusion:CVST presents in young and more commonly in females. TS was the most common site of venous sinus thrombosis. Female gender, seizures, altered sensorium and focal neurological deficit at presentation, and straight sinus thrombosis were more likely associated with the presence of brain parenchymal lesions.

Dabigatran in the Treatment of Extensive Cerebral Venous Thrombosis: A Case Report

Background: Cerebral venous thrombosis (CVT) is a rare type of cerebrovascular disease associated with a 15% rate of death or function dependence. The mainstay of treatment for CVT is systemic anticoagulation, despite venous hemorrhagic infarction. Vitamin K antagonists have long been the only available option for anticoagulation; however, the past few years have brought the development of many new target-specific drugs, collectively called non-vitamin K antagonist oral anticoagulants (NOACs). Although emerging evidence suggests NOACs have an acceptable safety and tolerability profile in CVT, there are limited data available and no randomized controlled trials have been performed to date. Case Presentation: This describes the case of a patient with CVT occurring during an infection who was successfully treated with a NOAC, dabigatran, after a difficult time on warfarin. Conclusions: A case of extensive and deep CVT was identified. Dabigatran 150 mg treatment twice daily in this patient resulted in no additional damage to the brain. This case study illustrates that the use of NOACs such as dabigatran can be safe and effective in patients with CVT.

Direct oral anticoagulants in patients with cervical artery dissection and cerebral venous thrombosis. A case series and review of the literature

BackgroundTo date, very little is known about the effects of direct oral anticoagulants (DOA) use in patients with cervical artery dissection (CAD) and cerebral venous thrombosis (CVT). We present our initial experience with the use of DOA for CAD and CVT and an overview of the published literature. MethodsFrom our database, we identified 4 patients who received DOA after CAD and 4 patients after CVT. Also, we analyzed the data reported for 45 patients who received DOA after CAD and 23 after CVT from review of the literature. ResultsAmong patients with CAD, resolved or improved arterial stenosis was noted in 27 (55%), and symptomatic recurrent ischemic stroke in 2 (4%). Among patients with CVT, complete or partial recanalization was noted in 25 (90%), and no significant functional disability in 26 (93%). No patient developed intracranial hemorrhage. ConclusionsAlthough no statistical conclusions can be drawn from these data, DOA could be an alternative in patients with CAD-related embolic infarct and CVT-related hemorrhagic venous infarct. A large-scale clinical trial will be needed to validate these results.