Thromboembolism Research Articles

A-166 Performance verification of a polyclonal anti-PF4 immunoassay in evaluation of Heparin Induced Thrombocytopenia (HIT)

Abstract Background Heparin-induced thrombocytopenia (HIT) is a severe complication of exposure to heparin that occurs in a small percentage of patients in anticoagulation therapy. HIT could happen regardless of the dose, exposure, schedule, or route of administration. HIT results from an autoantibody directed against endogenous platelet factor 4 (PF4) that forms complex with heparin. This antibody activates platelets and can cause life threatening arterial and venous thrombosis. Untreated HIT has a mortality rate as high as 20%. However, with appropriate screening, diagnosis and early intervention, mortality rates have been reported to be below 2%. The laboratory evidence in evaluating patients for HIT is crucial for early intervention. There are several assays available to diagnose Heparin Induced Thrombocytopenia (i.e., immunoassay and/or functional assay for HIT antibodies; serotonin release assays). The purpose of this study is to establish the measurement criteria and verify performance characteristics of a polyclonal anti-PF4 immunoassay. The test of interest (anti-PF4 immunoassay) is intended for the qualitative detection of the anti-heparin-platelet factor 4 antibodies in plasma or serum by ELISA. Methods The ASSERACHROM Assay (Diagnostica Stago, Inc. USA) was implemented in the automated Dynex DS2 ELISA Processing System (Dynex Technologies Inc USA). Two Dynex DS2 instrument comparisons along with precision, accuracy and measurement range for qualitative positive and negative results were studied. The reference method comparisons with serotonin release assay and other monoclonal anti-PF4 immunoassays were performed. To evaluate performance of the assay, we conducted precision, accuracy, and qualitative method comparison. We compared the assay of interest with two reference lab immunoassays and the gold standard reference method (serotonin release assay). The statistical analysis was carried out in EP Evaluator and GraphPad Prism. Results The negative control precision demonstrated CV of 9.2% (N=20, mean= 0.11, SD= 0.01). The analyte measurement is expressed as optical density (OD). The positive control precision characteristics showed CV of 8.1% (N=20, mean= 1.62, SD= 0.13). The threshold was defined as reference reagent absorbance (R6OD) times the variance factor divided by 100 ((R6OD* variance factor)/100= threshold (X)). This is used for positive (>the X) and negative (< the X) absorbance cut off for patient samples. The R6 reference material precision study resulted in a CV of 7.95% (N=20, mean= 2.1, SD= 0.17). The R6 variance factor per precision statistics at 3SD level was 23.85%. This is comparable to peer group variance provided in the assay package insert (23.5%). The polyclonal anti-PF4 immunoassay versus a reference monoclonal method (N=40) demonstrated agreement of 90.9% with positive agreement of 100% and negative agreement of 89.5%. When compared with gold standard serotonin release assay (N=40), the assay demonstrated agreement of 75% with positive agreement of 90% and negative agreement of 60%. The two instruments demonstrated agreement of 97.5% with positive agreement of 100% and negative agreement of 93.3% (Cohen's Kappa 94.6%; with Kappa > 75% indicates “high” agreement). Conclusions This anti-PF4 immunoassay is precise, accurate and comparable with three different reference methods. The test is best utilized when 4T score based clinical algorithm is used for evaluation of HIT.

A-168 Comparison of Two Different Lupus Anticoagulant Hexagonal Phase Phospholipid Confirmatory Assays on an Automated Coagulation Analyzer

Abstract Background Antiphospholipid syndrome (aPS) is an autoimmune disorder resulting in venous and/or arterial thrombosis, characterized by presence of lupus anticoagulants (LA) in patient plasma, also referred to as antiphospholipid antibodies. Depending on clinical history and symptoms, or if an unexpected elevated routine aPTT result is observed, LA laboratory testing would be performed, if appropriate. According to published clinical guidelines, LA tests should use aPTT-based and dRVVT-based screening (low phospholipid) and confirmatory (high phospholipid) methods, run in parallel. aPS diagnosis is confirmed from both clinical and laboratory criteria. Laboratory criteria are met if either the aPTT or dRVVT confirmatory test results are positive, and if lab positivity is confirmed following repeated testing 12 weeks following initial results. Due to the multiple tests used, and different manufacturers’ reagents, analysis of comparative performance allows users to identify the optimal tests to use. Objectives of the study were 1) compare intra-run and total precision of two different aPTT-based LA confirmatory tests on a newly available automated coagulation instrument equipped with improved pipetting methodology and preanalytical sample integrity detection and 2) correlate results from the two different aPTT-based LA confirmatory test assays. Methods CRYOcheck Hex LA (Precision BioLogic, Inc., Dartmouth, NS, Canada) and Staclot LA (Diagnostica Stago, Inc., Parsippany, NJ, USA) were run on a STA R Max3 automated coagulation analyzer (Diagnostica Stago, Inc.), using manufacturer recommended protocols. For intra-run precision and total precision analysis, replicates of 5 quality control samples were used (STA Control LA 1+2, Diagnostica Stago, Inc.). For the correlation studies, 20 different LA positive samples were used, supplied by the Specimen Access Team (SAT) from Laboratory Corporation of America Holdings, Burlington, NC, USA. LA positivity was defined as positive by CRYOcheck Hex LA delta result > 11 seconds, which was the cutoff determined at LabCorp’s facility. CRYOcheck Normal Donor Set plasmas were used for normal samples (Precision BioLogic, Inc.). Samples were run in batches containing 5 normal samples and 5 abnormal samples, with quality control run at the beginning and end of each batch. Results Intra-run precision was superior for Staclot LA compared to CRYOcheck Hex LA, with the exception of the high phospholipid “LA Correct” positive tube from CRYOcheck Hex LA. Total precision was either comparable or superior for Staclot LA compared to CRYOcheck Hex LA. In addition, correlation data showed Staclot LA recovered the same result between 3 different aliquots of the same patient mother tube, whereas CRYOcheck Hex LA recovered varying results between runs, when using manufacturer recommended cutoffs. Conclusions Analysis of intra-run and total precision, along with result correlation and recovery between multiple sample aliquots is recommended for when coagulation laboratories evaluate different manufacturers’ reagents. Our data indicate Staclot LA demonstrates superior performance to the CRYOcheck Hex LA on the STA R Max3 automated coagulation analyzer.

A 10-year cross-sectional study showed that anti-coagulation therapy was not always of value when treating paediatric cases with septic cerebral venous thrombosis.

Cerebral venous thrombosis (CVT) is a rare complication of ear, nose and throat (ENT) infections. Although recent guidelines recommend the systematic use of anti-coagulation therapy (ACT) in the treatment of these CVT, literature data are scarce. The present study's objective was to determine the value of ACT in achieving recanalisation after thrombosis and its effect on patient outcomes. All paediatric patients with CVT and a concomitant ENT infection who attended Lille University Hospital (Lille, France) between January 2012 and December 2021 were retrospectively included. We included 43 children (63% boys), with a mean age of 4 years. The most frequent infection was mastoiditis (54%). ACT was initiated in 23 patients (53%), one of whom had an intracranial haemorrhage. Partial or full recanalisation was observed in 33 (80%) of the 41 survivors. In patients with no neurological signs and symptoms on admission and in patients with mastoiditis-related CVT, the clinical and radiological outcomes were favourable and did not differ according to the administration of ACT. Likewise, ACT did not appear to influence the recanalisation rate or sequelae. ACT was not necessary for all patients with mastoiditis-related CVT and those with no neurological signs and symptoms on admission.

Mechanical Thrombectomy in Cerebral Venous Thrombosis Caused by Spontaneous Intracranial Hypotension: A Case Report with Novel Pathological Findings of Fibrin/Platelet-predominant Thrombus

This case report presents pathological findings in a rare case of cerebral venous thrombosis (CVT) caused by spontaneous intracranial hypotension (SIH) that was treated successfully with mechanical thrombectomy. The etiologies and prognosis of CVT vary, and CVT resulting from SIH is particularly uncommon and challenging to diagnose and manage. In this case, magnetic resonance imaging revealed signs consistent with both SIH and CVT, which contributed to the patient’s worsening weakness. The patient was treated with a combination of endovascular thrombectomy and epidural blood patch, followed by anticoagulation therapy, and recovered without any complications. A pathological analysis of the retrieved thrombus using hematoxylin and eosin staining showed a high proportion of fibrin and platelets, which could shed light on the mechanism of CVT induced by SIH under conditions of low blood flow due to venous engorgement.

Systematic review of ultrasound-guided central venous catheter placement-related complications in neonates and infants aged

Although ultrasound can be considered an assistant method, successful placement of a central venous catheter (CVC) in infants is still challenging. The incidence of CVC placement-related complications is still high. Therefore, this systematic review aimed to synthesize evidence to assess the effects of ultrasound-guided CVC placement on adverse outcomes in infants and neonates aged <12 months. PubMed, Ovid, EMBASE, and the Cochrane Library were searched to identify potentially relevant studies. The main outcome was the incidence of adverse events, which included inadvertent arterial puncture, hematoma, pneumothorax and hemothorax, catheter kinking, threading, and malpositioning problems, venous thrombosis, catheter-related infection, phlebitis, and cardiac tamponade. Eleven studies involving 2097 patients were included in the final analysis. The odds of inadvertent arterial puncture, and catheter kinking, threading, and malpositioning problems were lower in the ultrasound group than in the control group. No significant difference was detected in the incidence of hematoma or venous thrombosis between the control and ultrasound groups. Other complications, such as pneumothorax, hemothorax, phlebitis, and cardiac tamponade, rarely occurred. Ultrasound-guided CVC placement can improve the safety of punctures in neonates and infants. CVC punctures should be guided in real-time by ultrasound.

Assessment of the clinical and laboratory risk factors for thrombosis in neonates admitted to neonatal intensive care unit (two Egyptian tertiary centers experience)

In neonates admitted to the neonatal intensive care unit (NICU), arterial and venous thromboembolism is a major cause of morbidity and death which could be attributed to multiple risk factors exposure. This study aimed to evaluate the clinical characteristics, laboratory and radiological assessments, predisposing risk factors, and outcomes of thrombosis in neonates admitted to NICU. This prospective cohort study was conducted at NICU, Minia, and Alexandria University Children’s Hospital. Screening of 886 patients admitted to NICU over one year with different clinical presentations, patients were classified into the thrombotic and non-thrombotic groups based on the presence or absence of thrombosis. Thrombosis was diagnosed based on clinical, laboratory and different radiologic assessments. Genetic testing for factor V Leiden mutations G1691A, prothrombin mutation G20210A, protein C, protein S, and antithrombin III gene mutations were performed for patients with a family history of thrombosis. Out of a total of 886 neonatal admissions, 36 patients were diagnosed with evident thrombosis (40 per 1000 NICU admissions). The sites of venous thrombosis detection were Portal vein thrombosis in 11 patients (30.6%), superior vena cava thrombosis in 7 patients (19.4%), deep venous thrombosis in 5 patients (13.9%), central venous thrombosis in 5 patients (13.9%), intra-cardiac thrombosis in 3 patients (8.3%) and necrotic skin patches in one patient (2.8%). Only 69% of enrolled thrombosis patients showed genetic mutations the most common of which was factor V Leiden mutation (52.3%). Sepsis, central venous line (CVL) insertion, C reactive protein (CRP), and duration of NICU admission were significantly more common in the thrombotic group (p < 0.001) and were associated with a higher risk of thrombosis (ORs: 1.02, 7.7, and 1.11, respectively) (p < 0.001). Higher mortality occurred in thrombosis neonates compared with a non-thrombotic group (52.8% versus 17.4%) (p < 0.001). NICU-admitted neonates are exposed to multiple overlapped risk factors, the detection of which is important for preventing potential thrombosis and improving the patient’s outcomes. The complexity of sepsis pathogenesis and management could potentiate multiple acquired risk factors. inherited thrombophilia detection is required for prevention of further morbidities.

Features of Kidney Transplant in Pediatric Recipients: Experience of a Single Center.

Congenital abnormalities of the kidneys and the urinary tract are common reasons for endstage renal disease in children. We studied the features of postoperative management and possible complications after pediatric kidney transplant. We retrospectively analyzed 29 children aged from 9 to 18 years who underwent kidney transplants from April 2018 to December 2013 (17 boys and 12 girls). All recipients were on hemodialysis for 3 to 18 months (mean of 10.17 ± 4.52 mo). Etiology of end-stage kidney disease included chronic glomerulonephritis (n = 12 [41.4%]), urolithiasis (n = 3 [10.3%]), and congenital abnormalities of the kidneys and the urinary tract (n =14 [48.3%]), including urinary reflux (n = 5 [17.2%]). Donors were parents in 16 cases, siblings in 5, uncles in 5, and aunts in 3 cases. HLA mismatching ranged from 2 to 5 (mean of 2.93 ± 1.39). Three patients had intraoperative nephrectomy, and 2 patients had hydronephrosis and urethroplasty with megaureter to prevent urinary tract infection. Six patients (20.6%) had early postoperative complications: 2 with delayed graft function, 1 with venous anastomosis thrombosis, 2 with hematoma around the graft, and 1 with lymphocele. Venous anastomosis thrombosis was eliminated by open thrombectomy, with graft function restored on postoperative day 17. The lymphocele was eliminated by puncture and drainage. Hematomas did not require surgical correction and blood transfusion. Ten patients (34.4%) had late postoperative complications: 1 with stricture of vesicoureteral anastomosis, 3 with vesicoureteral reflux, and 5 with urinary tract infection (3 with bacterial culture). Stricture of vesicoureteral anastomosis was successfully resolved by open surgery. Vesicoureteral reflux was eliminated with hydrogel. One patient developed chronic kidney rejection within 6 months because of noncompliance with posttransplant regimen and required transplantectomy. A major factor in reducing frequency of infections after surgery is the recipient's nephrectomy.

The effects of an aggressive breast tumor on thrombosis after antithrombin downregulation in a hypercoagulable mouse model

BackgroundDespite improvements in therapy, breast cancer still contributes to high mortality rates. Survival of these patients becomes progressively worse upon diagnosis with cancer-associated thrombosis (CAT). Unfortunately, the mechanism causing CAT has remained unclear. ObjectiveSet up an acute and non-invasive hypercoagulable mouse model with an aggressive breast cancer and study the mechanism of cancer-associated thrombosis. MethodsMice were grafted with the aggressive breast cancer cell line MDA-MB-231 or sham-treated. Subsequently, an acute imbalance in coagulation was introduced by injecting a synthetic small interfering (si) RNA targeting hepatic Serpinc1 to knockdown antithrombin – a condition known to predispose to cause a hypercoagulant state in vivo. ResultsSilencing Serpinc1 with siRNA decreased plasma antithrombin levels. siRNA treatment had no short-term effects on tumor characteristics, but increased distant metastasis within the timeframe of this study. The systemic pro-inflammatory status, with elevated platelet counts and fibrinogen levels in tumor-bearing mice, was also not affected by antithrombin silencing. While elevated fibrin deposition in the liver upon Serpinc1 targeting was not significantly affected by the presence of breast cancer, knockdown of antithrombin did significantly increase intratumoral fibrin deposition and inflammation. Surprisingly, in the presence of an aggressive tumor, a protective outcome with less clinical features coinciding with venous thrombosis were observed in mice with antithrombin knockdown. ConclusionWe conclude that the presence of a breast tumor protects hypercoagulant mice from severe consumption of coagulation factors after lowering hepatic antithrombin levels, possibly due to elevated platelet counts. However, the consequences on cancer-associated thrombosis remained inconclusive.

Cerebral venous thrombosis in children an 18-year review of a Portuguese hospital

IntroductionCerebral venous thrombosis (CVT) is an uncommon and clinically heterogeneous cerebrovascular particularly in children, only a few published case series focused in the pediatric population. Patients and methodsRetrospective single-center observational and analytical study of consecutive pediatric patients admitted in a level II Portuguese hospital with a confirmed diagnosis of CVT, from 2003 to 2021. Clinical presentation, neuroimaging findings, prothrombotic factors, treatment strategies, outcome and recanalization were documented. ResultsTwelve children were included (58% female). Mean age was 7.3 years. The most frequent symptoms were vomiting, headache and behavioral alterations. Infection was the triggering factor in 50% of the cases. The diagnosis of CVT was made based on imaging evidence of thrombosis through magnetic imaging resonance (MRI) with venography and/or computed tomography (CT) with venography. In 67% of cases there were multiples sinuses involved; the transverse sinus was the most affected, followed by the sigmoid sinus. In 83% of cases anticoagulant therapy was initiated with low molecular weight heparin (LMWH) and associated prothrombotic factors were investigated, with no major prothrombotic factors identified. No deaths occurred, but 30% had long-term neurological sequelae. One patient recurred 18 years later. ConclusionThe results of this study are consistent with data from other published studies. MRI is the preferred imaging method for diagnosis in children by avoiding ionizing radiation and allowing identification of subjacent causes. Anticoagulation with LMWH is recommended and important to reduce mortality and sequelae. Infectious diseases are the most common trigger for CVT and can also be the cause for high morbidity and poor outcomes.

Predictive utility of a combination of the modified caprini risk assessment score and D-dimer for the evaluation and management of lower extremity venous thrombosis after lung cancer surgery

ObjectiveThe objective of this study was to examine the utility of a combination of the modified Caprini score and D-dimer levels for the evaluation and management of lower extremity venous thrombosis following lung cancer surgery. The purpose was to offer insights for developing clinical intervention programs.MethodsThe study sample consisted of 224 patients who underwent surgery for lung cancer at the First Central Hospital of Baoding City. General patient data and D-dimer levels on the first day post-surgery were collected. The modified Caprini risk assessment score was calculated. All patients underwent ultrasonography of the lower limb veins before and after surgery to identify venous thrombosis in the lower limb veins. Differences in lower extremity venous thrombosis and D-dimer levels among patients in various modified Caprini score groups were compared and analyzed.ResultsBased on the modified Caprini risk assessment score, all patients were categorized into three groups: the low-risk, medium-risk, and high-risk groups. The groups did not differ significantly in terms of age, but the differences in the rates of lower extremity venous thrombosis in the low, intermediate, and high-risk Caprini risk groups (16.5%, 19.2%, and 37.1%, respectively) were statistically significant. Out of the total 224 patients, 47 (21%) were diagnosed with venous thromboembolisms post-surgery, and all of them had thrombosis of the intermuscular veins of the lower extremity. The difference in the modified Caprini risk assessment score between patients with and without lower extremity venous thrombosis was statistically significant (P = 0.035), as were the postoperative D-dimer levels (1.28 ± 1.64 vs. 2.69 ± 2.77, respectively; P < 0.05) between these two groups of patients. The modified Caprini risk assessment score showed an association with lower extremity venous thrombosis (r = 0.15, P = 0.56) with an area under the receiver operating characteristic curve (AUC) of 0.59.ConclusionIn this study, we found that combining the modified Caprini risk assessment score with D-dimer measurements enhanced the accuracy of assessing the severity of deep vein thrombosis (DVT). This combination can be beneficial in evaluating thrombosis risk post-lung cancer surgery and holds significant clinical utility.

JAK2 Mutation Assessment in Thrombotic Events at Unusual Anatomical Sites: Insights from a High-Altitude Cohort.

Thrombosis stands as a significant contributor to both morbidity and mortality in individuals afflicted with myeloproliferative neoplasms. This retrospective study investigated the association between JAK2 mutations and venous thrombosis at unusual sites, and in young individuals with ischemic stroke, residing at high altitudes in the Aseer region, Saudi Arabia. Data were collected from two high-altitude referral hospitals over three years (2020-2022). Records of all JAK2 mutation tests were reviewed. Those requested as part of evaluation of thrombosis events, without known myeloproliferative neoplasms (MPNs) were analysed. Among the 208 JAK2 tests, 40 (19.2%) were linked to thrombotic event evaluations. The cohort, with a median age of 41, included 17 (42.7%) males and 23 females, with 57.5% having completely normal complete blood counts (CBC). Thrombotic events were divided between splanchnic vein thrombosis (36.6%) and cerebral thrombosis (34.1%), while the remaining cases involved unprovoked deep vein thromboses/pulmonary embolisms and portal vein thrombosis. Only 2 (5%) participants tested positive for JAK2 mutations: a 17-year-old male diagnosed concurrently with polycythemia vera after renal vein thrombosis and a 31-year-old woman with hepatic vein thrombosis and a normal CBC. This study reveals that JAK2 mutations are infrequently found in high-altitude patients with unprovoked DVT, PE, or atypical thrombosis. While JAK2 testing is notably relevant for splanchnic vein thrombosis, its routine use for other thrombotic events, particularly with normal CBC results, remains uncertain. Given the study's limitations, further prospective research with larger cohorts is needed to refine guidelines for JAK2 mutation testing in various thrombotic contexts.

Thrombosis with thrombocytopenia syndrome following adenovirus vector-based vaccines to prevent COVID-19: Epidemiology and clinical presentation in Spain

BackgroundWe describe the epidemiological and clinical characteristics of thrombosis with thrombocytopenia syndrome (TTS) cases reported in Spain. MethodsWe included all venous or arterial thrombosis with thrombocytopenia following adenovirus vector-based vaccines (AstraZeneca or Janssen) to prevent COVID-19 disease between February 1st and September 26th, 2021. We describe the crude rate and the standardized morbidity ratio. We assessed the predictors of mortality. ResultsSixty-one cases were reported and 45 fulfilled eligibility criteria, 82% women. The crude TTS rate was 4/1,000,000 doses and 14-15/1,000,000 doses between 30-49 years. The number of observed cases of cerebral venous thrombosis was 6-18 higher than the expected in patients younger than 49 years. Symptoms started 10 (interquartile range (IQR): 7-14) days after vaccination. Eighty percent (95% confidence interval (CI): 65-90%) had thrombocytopenia at the time of the emergency department visit, and 65% (95% CI: 49-78%) had D-dimer >2000 ng/mL. Patients had multiple location thrombosis in 36% and fatal outcome in 24% cases. A platelet nadir <50,000/μL (odds ratio (OR): 7.4; CI 95%: 1.2-47.5) and intracranial hemorrhage (OR: 7.9; IC95%: 1.3-47.0) were associated with fatal outcome. ConclusionTTS must be suspected in patients with symptoms 10 days after vaccination and thrombocytopenia and/or D-dimer increase.

Emphysematous Pyelonephritis as a Presentation of Delayed Venous Allograft Thrombosis

Emphysematous Pyelonephritis as a Presentation of Delayed Venous Allograft Thrombosis

Realizing the scope of venous and arterial thrombosis in cyclin-dependent kinase 4/6 inhibitors in hormone positive breast cancer

Realizing the scope of venous and arterial thrombosis in cyclin-dependent kinase 4/6 inhibitors in hormone positive breast cancer

Heritable Thrombophilia and Increased Risk for Venous Thromboembolism Despite Thromboprophylaxis After Pelvis or Acetabulum Fracture.

Individuals with pelvic and acetabular fractures are at high risk of venous thromboembolism (VTE). The purpose of this study was to determine whether serum markers for thrombophilia and rapid thromboelastography (r-TEG) values correlate with increased VTE risk among patients with pelvic and acetabular fractures. . Prospective observational study. Two urban academic level 1 trauma centers. Adult patients with isolated pelvis and/or acetabulum fractures (OTA/AO 61 and 62) treated surgically placed on a standardized VTE chemoprophylaxis regimen with enoxaparin over a 5-year period were included. Serum r-TEG, coagulation laboratory values, and markers for heritable thrombophilia were drawn postoperatively and after completion of a 6-week course of enoxaparin. The primary outcome was VTE event (either deep venous thrombosis or pulmonary embolism) diagnosed using a Duplex ultrasound, chest computed tomography angiogram, or lung ventilation-perfusion ordered based on clinical suspicion of a VTE event. Laboratory markers and values were then compared between patients who went on to have a VTE event and those who did not and patients with and without markers of thrombophilia. One hundred thirty-three adult patients with isolated operative pelvic and/or acetabular fractures were enrolled in this study. The average age of patients at time of injury was 48.3 years (range 18-91). Sixty-seven percent of patients in the study were (n = 90) males. Sixty-three percent of patients (n = 84) completed both clinical and laboratory follow-up. Forty-one percent of patients (n = 54) had 1 or more markers of heritable thrombophilia. Twelve percent (n = 10) of patients who completed follow-up were diagnosed with VTE. Age, sex, and smoking status were not associated with VTE. Patients who developed VTE had a higher body mass index (P = 0.04). Having more than 1 marker of heritable thrombophilia (P = 0.004) and an r-TEG mean amplitude greater than 72 mm postoperatively was positively associated with VTE (P = 0.02). Among patients treated surgically for isolated pelvic and acetabular fractures who received enoxaparin prophylaxis, the presence of more than 1 marker of heritable thrombophilia or r-TEG mean amplitude value greater than 72 mm postoperatively was associated with an increased risk of VTE. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A bite of death: Anaesthetic challenges in frostbite.

Frostbite is defined as tissue damage that is sustained as a result of prolonged exposures to less than 0°C resulting in ice crystallisation, microvascular occlusion and subsequently thrombosis. A 33-year-old mountaineer with cold burn over 20% of the total body surface area with eschar formation, acute renal failure, upper limb venous thrombosis and bilateral pleural effusion. We hereby report a successful anaesthetic management of this patient undergoing debridement and escharotomy for frostbite injuries and review its perioperative concerns. Frostbite injuries pose a challenge to the anaesthetic team due to the multi-systemic nature of its involvement.

Reliability of generative artificial intelligence in identifying the major risk factors for venous thrombosis

Reliability of generative artificial intelligence in identifying the major risk factors for venous thrombosis

Comment on: Outcomes and complications of patients with cerebral venous thrombosis: a retrospective study.

Comment on: Outcomes and complications of patients with cerebral venous thrombosis: a retrospective study.

DC-CRP: Deep Cerebral Venous Thrombosis, Clinicoradiological Profile, and Treatment Outcome in Indian Population-A Tertiary Care Experience.

Deep cerebral venous thrombosis (DCVT) is an uncommon cause of stroke with diverse predisposing factors, clinical presentations, imaging findings, and functional outcomes, which makes the diagnosis of DCVT even more challenging. Retrospective observational study (December 2018 to January 2023). Cases with imaging data suggestive of DCVT were included. The neuroradiological assessment was performed using multimodality imaging to determine the location of parenchymal changes and the number of deep veins involved in isolation or with the superficial dural venous system. Clinical variables were tabulated. Of the 206 cases with CVT in the study period, 27 had DCVT (13.1%), of which four (14.8%) had isolated DCVT (male-to-female ratio 13:14; mean age = 33.4 years). Hyperhomocysteinemia (n = 11) is the most common risk factor associated with it. The most common presentations were headaches (n = 27) and focal motor deficits (n = 13). Raised intracranial tension (ICT) was present in almost half of the study population (n = 14). Mean and median modified Rankins score (mRS) at the time of discharge were 2.0 and 1, respectively. The most common deep vein involved was the straight sinus (SS) (n = 25), followed by the internal cerebral vein (n = 23). The mean and median mRS after 3 months from discharge were 0.3 and 0, respectively. A knowledge of diverse clinical presentations in DCVT, its neurovascular anatomy, and imaging characteristics with prompt diagnosis and timely interventions can assist in attenuating the risk of acute complications and long-term sequelae. Extensive deep grey matter involvement in DCVT is associated with neurological manifestations like altered sensorium and motor deficits, with increased severity of illness as measured by the mRS score.

Viber Snakebite Presenting with Cerebral Venous Thrombosis: A Very Rare Case Report from Somalia

Viber Snakebite Presenting with Cerebral Venous Thrombosis: A Very Rare Case Report from Somalia