Safety of thrombolysis in cerebral venous thrombosis: A systematic review of the literature
Internal Medicine, Department of Clinical Medicine, University of Insubria Ospedale di Circolo, Varese, Italy. Thrombosis and Haemostasis
(Impact Factor: 4.98).
09/2010; 104(5):1055-62. DOI: 10.1160/TH10-05-0311
Several small series have suggested the efficacy of thrombolysis in patients with cerebral vein thrombosis (CVT). However, since no randomised controlled trials have compared the use of thrombolysis with anticoagulant treatment in these patients, the risk to benefit ratio of this approach remains uncertain. The aim of this study is therefore to assess the safety of thrombolysis in CVT estimating mortality and major bleeding complications. MEDLINE and EMBASE databases were searched up to June 2010. Two reviewers performed study selection independently. Studies providing data on mortality and/or on the incidence of major bleeding complications were potentially eligible for the study. Two reviewers independently extracted data on study and population characteristics, type, dose and administration route of thrombolytic treatment; use and dose of concomitant heparin. Weighted mean proportion of the mortality rate and of the rate of major and non-major bleeding complications were calculated. Fifteen studies for a total of 156 patients were included. Twelve patients died after thrombolysis (weighted mean 9.2%; 95% CI 4.3, 15.7%) and 15 patients had a major bleeding complication (weighted mean 9.8%; 95% CI 5.3, 15.6%). Twelve haemorrhages were intracranial (weighted mean 7.6%; 95% CI 3.5, 13.1%), and seven of these patients died (58.3%; 95% CI 32.0, 80.7%). Our results suggest that thrombolysis is associated with a non-negligible incidence of major bleeding complications, including intracranial bleeding potentially affecting patients outcome. Future studies are necessary to evaluate the safety of thrombolysis in comparison to more conservative strategies.
Available from: Henri Bounameaux
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ABSTRACT: Bounameaux H (Division of Angiology and Hemostasis, Department of Internal Medicine, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland). Contemporary management of pulmonary embolism: the answers to ten questions (Review). J Intern Med 2010; 268: 218–231.
Pulmonary embolism (PE) cannot be diagnosed solely on a clinical basis, because of the lack of sensitivity and specificity of clinical signs and symptoms. Pulmonary angiography is invasive and resource demanding. Because the prevalence of PE is relatively low (20% or less) amongst individuals who are clinically suspected of having the disease, submitting all of them to imaging (multi-detector CT angiography or ventilation/perfusion lung scintigraphy) would not be cost-effective. Therefore, diagnostic algorithms have been developed that include clinical probability assessment and D-dimer measurement to select the patients who require noninvasive imaging. Once the diagnosis is suspected or confirmed, therapy must be started to avoid potentially fatal recurrence. Treatment starts for an initial 3-month period with a 5-day course of parenteral unfractionated or low-molecular-weight heparin or fondaparinux overlapping with and followed by oral vitamin K antagonists monitored to maintain an international normalized ratio of 2–3. This initial period of 3 months may then be followed by a long-term secondary prevention period in patients who experience an idiopathic thromboembolic event and are at low risk of bleeding. New oral anticoagulants that do require patient monitoring and might exhibit a more favourable benefit–risk balance are currently under extensive clinical testing and might change the situation in the near future. A critical appraisal of the contemporary management of suspected PE is given in this overview with the discussion of 10 practical questions.
Journal of Internal Medicine 09/2010; 268(3):218-31. DOI:10.1111/j.1365-2796.2010.02254.x · 6.06 Impact Factor
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ABSTRACT: Physiological platelet activation and thrombus formation are essential to stop bleeding in case of vascular injury, whereas inadequate triggering of the same process in diseased vessels can lead to fatal thromboembolism and tissue ischemia of vital organs. A central step in platelet activation is agonist-induced elevation of the intracellular Ca(2+) concentration. This happens on the one hand through the release of Ca(2+) from intracellular stores and on the other hand through Ca(2+) influx from the extracellular space. In platelets, the major Ca(2+) influx pathway is the so-called store operated Ca(2+) entry (SOCE), induced by store depletion. Studies in the last five years discovered the molecular background of platelet SOCE. Stromal interaction molecule 1 (STIM1) and Orai1, two so far unknown molecules, got in the focus of research. STIM1 was found to be the Ca(2+) sensor in the endoplasmic reticulum (ER) membrane, whereas Orai1 was identified as the major store operated Ca(2+) (SOC) channel in the plasma membrane. These two molecules and their role in platelet function and thrombus formation are the topic of the present review with a special focus on apoptosis and apoptosis-like processes in platelet physiology.
Cell calcium 05/2011; 50(3):270-8. DOI:10.1016/j.ceca.2011.04.002 · 3.51 Impact Factor
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ABSTRACT: Venous thromboses in unusual sites are rare and heterogenous manifestations of venous thromboembolism (VTE). These uncommon diseases are each characterized by peculiar pathophysiological and clinical features, mainly reflecting the different characteristics of the organs of origin. Moreover, the relative frequency and importance of risk factors associated with their development may be different compared to those of the classical manifestations of VTE, such as deep vein thrombosis of the lower limbs or pulmonary embolism. The need for anticoagulant therapy for unusual site thrombosis (UST) is generally accepted. However, several questions remain unanswered: what is the best therapeutic agent, is it safe, and for how long should it be used? These questions persist mainly due to the low level of available evidence given the rarity of these diseases. The short- and long-term prognoses, and in particular the risk of recurrence and mortality, are quite heterogenous among the different manifestations of UST and even within each of them, depending mainly on the predisposing causes.
Seminars in Hematology 10/2011; 48(4):264-70. DOI:10.1053/j.seminhematol.2011.08.005 · 3.27 Impact Factor
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