Cerebral vein and dural sinus thrombosis in elderly patients

Backgound and Purpose - The clinical features and prognosis of cerebral vein and dural sinus thrombosis (CVT) in elderly patients have not been previously described. Methods - In a multicenter prospective observational study, we compared clinical and imaging features, risk factors, and outcome of adult patients aged = 65 years (elderly patients). Results - A total of 624 adult patients with CVT were registered and followed-up for a median of 16 months. Fifty-one (8.2%) were aged >= 65 years. Presentation as an isolated intracranial hypertension syndrome was less frequent in elderly patients (4/51 versus 139/573, P=0.008), whereas depressed consciousness (17 versus 97, P=0.005), and mental status changes (22 versus 115, P=0.001) were more frequent in the elderly. The prognosis of elderly patients was considerably worse than that of younger patients, as only 49% of elderly patients made a complete recovery (versus 82% in younger patients), whereas 27% died and 22% were dependent at the end of follow-up (versus 7 and 2% respectively in younger patients). Carcinoma (5 cases) was more frequent as a risk factor for CVT in elderly patients (P=0.017). During follow-up, elderly patients were more likely to experience thrombotic events (HR=4.8, 95% CI=1.9 to 11.9) and were less likely to experience severe headaches (HR=0.2, 95% CI=0.02, 0.97). Conclusions - Elderly patients with CVT have a distinctive clinical presentation: isolated intracranial hypertension is uncommon, whereas mental status and alertness disturbances are common. The prognosis of CVT is worse in elderly patient

Prognosis of cerebral vein and dural sinus thrombosis - Results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT)

Background and Purpose - The natural history and long-term prognosis of cerebral vein and dural sinus thrombosis (CVT) have not been examined previously by adequately powered prospective studies. Methods - We performed a multinational ( 21 countries), multicenter ( 89 centers), prospective observational study. Patients were followed up at 6 months and yearly thereafter. Primary outcome was death or dependence as assessed by modified Rankin Scale ( mRS) score > 2 at the end of follow-up. Results - From May 1998 to May 2001, 624 adult patients with CVT were registered. At the end of follow-up ( median 16 months), 356 patients (57.1%) had no symptom or signs ( mRS = 0), 137 (22%) had minor residual symptoms ( mRS = 1), and 47 (7.5%) had mild impairments ( mRS = 2). Eighteen (2.9%) were moderately impaired ( mRS = 3), 14 (2.2%) were severely handicapped ( mRS = 4 or 5), and 52 (8.3%) had died. Multivariate predictors of death or dependence were age > 37 years ( hazard ratio [HR] = 2.0), male sex ( HR = 1.6), coma ( HR = 2.7), mental status disorder ( HR = 2.0), hemorrhage on admission CT scan ( HR = 1.9), thrombosis of the deep cerebral venous system ( HR = 2.9), central nervous system infection ( HR = 3.3), and cancer ( HR = 2.9). Fourteen patients ( 2.2%) had a recurrent sinus thrombosis, 27 (4.3%) had other thrombotic events, and 66 (10.6%) had seizures. Conclusions - The prognosis of CVT is better than reported previously. A subgroup (13%) of clinically identifiable CVT patients is at increased risk of bad outcome. These high-risk patients may benefit from more aggressive therapeutic interventions, to be studied in randomized clinical trial

Unfractionated or Low-Molecular Weight Heparin for the Treatment of Cerebral Venous Thrombosis

Background and Purpose-There is no consensus whether to use unfractionated heparin or low-molecular weight heparin for the treatment of cerebral venous thrombosis. We examined the effect on clinical outcome of each type of heparin. Methods-A nonrandomized comparison of a prospective cohort study (the International Study on Cerebral Vein and Dural Sinus Thrombosis) of 624 patients with cerebral venous thrombosis. Patients not treated with heparin (n=107) and those who sequentially received both types of heparin (n=99) were excluded from the primary analysis. The latter were included in a secondary analysis, allocated according to the type of heparin given first. The primary end point was functional independency at 6 months (modified Rankin scale score <= 2). Secondary end points were complete recovery (modified Rankin scale score 0 to 1), mortality, and new intracranial hemorrhages. Results-A total of 119 patients received low-molecular weight heparin (28%) and 302 received unfractionated heparin (72%). Significantly more patients treated with low-molecular weight heparin were functionally independent after 6 months, both in univariate analysis (odds ratio, 2.1; CI, 1.0 to 4.2) and after adjustment for prognostic factors and imbalances (odds ratio, 2.4; CI, 1.0 to 5.7). In the secondary analysis, there was a similar, nonsignificant trend (odds ratio, 1.7; CI, 0.80 to 3.6). Low-molecular weight heparin was associated with less new intracerebral hemorrhages (adjusted odds ratio, 0.29; CI, 0.07 to 1.3), especially in patients with intracerebral lesions at baseline (adjusted odds ratio, 0.19; CI, 0.04 to 0.99). There was no difference in complete recovery and mortality. Conclusions-This nonrandomized study in patients with cerebral venous thrombosis suggests a better efficacy and safety of low-molecular weight heparin over unfractionated heparin. Low-molecular weight heparin seems preferable above unfractionated heparin for the initial treatment of cerebral venous thrombosis. (Stroke. 2010;41:2575-2580.

Factores de riesgo cardiovascular y aterosclerosis carotídea detectada por ultrasonografía

OBJETIVO: Evaluar la frecuencia y los factores determinantes de aterosclerosis carotídea en una comunidad de la ciudad de México. MATERIAL Y MÉTODOS: Se realizó, de julio de 1993 a enero de 1996, una ultrasonografía carotídea en 145 participantes del proyecto CUPA, que consiste en un estudio de vigilancia epidemiológica. Se investigó la presencia de aterosclerosis carotídea y su relación con factores de riesgo cardiovascular. RESULTADOS: La prevalencia de aterosclerosis carotídea detectada por ultrasonografía fue de 64.8%. En 64 personas (44.1%) se documentó engrosamiento del complejo íntima-media de la pared aterial y en 82 sujetos (56.5%) se observaron placas de ateroma (concomitantes con engrosamiento íntima-media en 52 individuos). En sólo ocho personas (5.5%) las placas de ateroma se asociaron a estenosis hemidámicamente significativa. No se encontraron diferencias en la prevalencia de aterosclerosis en relación con el sexo (hombres, 61.9% y mujeres, 66.0%). Los factores de riesgo asociados con aterosclerosis fueron: edad (p<0.0001), hipertensión arterial sistémica (p<0.001), hipertensión sistólica aislada (p=0.01), hipercolesterolemia (p=0.04) y diabetes mellitus (p=0.06). La prevalencia de aterosclerosis carotídea aumentó progresivamente al incrementarse el número de factores de riesgo vascular. CONCLUSIONES: La prevalencia de aterosclerosis carotídea fue elevada en una comunidad de edad avanzada de la ciudad de México y similar a la observada en países occidentales. Se asoció principalmente con la edad, la hipertensión arterial, la hipercolesterolemia y la diabetes mellitus