Search Results (79)

Infective endocarditis (IE) arises from complex interactions between microbial pathogens and host hemostasis systems, where dysregulated coagulation mediates microbial persistence and systemic thromboembolic complications. Alterations in primary, secondary, and tertiary hemostasis in the acute IE phase have direct clinical implications for vegetation formation and detachment. Staphylococcus aureus is one of the most common pathogens that causes IE, and it is capable of profoundly altering the coagulation cascade through several mechanisms, such as platelet activation, prothrombin activation through staphylocoagulase release, and plasminogen stimulation via staphylokinase production. Understanding these complex and yet unmasked mechanisms is of pivotal importance to promoting targeted therapeutic intervention aimed at reducing IE morbidity and mortality. Moreover, the management of antiplatelet and anticoagulant treatment during IE onset is a controversial issue and needs to be tailored to patient comorbidities and IE-related complications, such as cerebral embolism. This review provides a roadmap to promote clinicians’ understanding of the complex interactions between hemostasis and IE clinical manifestations and complications, discussing pathogen-specific coagulation profiles while addressing critical knowledge gaps for IE management. Full article

Background/Objectives: Thrombotic diseases (TDs), currently the number one killer worldwide, account for the highest mortality rate globally. In this study, we evaluated the antithrombotic efficacy of Velefibrinase, a marine bacteria-derived fibrinolytic enzyme, across multiple animal models. Results: The results demonstrated that Velefibrinase prolonged bleeding time (BT) and clotting time (CT), reduced mortality and thrombosis, relieved pulmonary alveolar structure degeneration in an acute pulmonary thromboembolism model, and inhibited carotid artery thrombosis and endothelial tissue damage in a rat model of FeCl₃-induced carotid arterial thrombosis. Moreover, Velefibrinase reduced cerebral ischemia volume and ameliorated neurological deficits in a cerebral ischemia/reperfusion (I/R) injury model in rats. The putative underlying mechanisms were found to involve the inhibition of platelet aggregation and coagulation, along with the modulation of oxidative stress and inflammation levels. Conclusions: These results revealed that Velefibrinase exerts a notable thrombosis-preventive effect by interacting with multiple targets, thereby breaking the vicious cycle involving inflammation, oxidative stress, and thrombosis. Full article

Direct oral anticoagulants (DOACs) have emerged as a preferred alternative to vitamin K antagonists (VKAs) for the prevention and treatment of thromboembolic disorders, offering improved safety, predictable pharmacokinetics, and ease of administration. Despite these advantages, their use in complex clinical scenarios presents significant challenges that necessitate individualized therapeutic strategies. This comprehensive review explores the efficacy, safety, and limitations of DOAC therapy in special populations, including patients with renal or hepatic impairment, obesity, cancer-associated thrombosis, and antiphospholipid syndrome. Additionally, we examine their role in uncommon thrombotic conditions such as superficial venous thrombosis, embolic stroke of undetermined source, upper extremity vein thrombosis, inferior vena cava thrombosis, pelvic vein thrombosis, and cerebral vein thrombosis. The pharmacokinetic variability of DOACs in renal and hepatic dysfunction requires caution to balance the bleeding and thrombotic risks. In obesity, altered drug distribution and metabolism raise concerns regarding appropriate dosing and therapeutic efficacy. Cancer-associated thrombosis presents a complex interplay of prothrombotic mechanisms, necessitating careful selection of anticoagulant therapy. Furthermore, the use of DOACs in antiphospholipid syndrome remains controversial due to concerns about recurrent thrombotic events. Finally, in some unusual scenarios like inferior vena cava, pelvic vein, and cerebral vein thrombosis, the use of DOACs has scarce evidence. This review aims to guide clinicians in optimizing anticoagulation management in challenging patient populations by synthesizing current evidence and providing practical recommendations. Full article

Background and purpose: Perforator stroke (PS) is a subtype of perinatal arterial ischemic stroke (PAIS), in which injuries occur in the territory of the perforator branches of the main cerebral arteries. This study aims to explore the incidence, timing, risk factors, and clinical presentation of PS in both preterm and full-term neonates. Material and methods: We retrospectively analyzed data about all the neonatal brain MRIs carried out in our hospital from March 2012 to March 2023. Criterium of inclusion was the radiologically confirmed diagnosis of perforator stroke involving one or more arterial districts. Results: A total of 1928 patients underwent brain MRIs during the period considered. PAIS was present in 50 patients, of which 19 had PS (38%). Among the patients with PS, nine were preterm babies (47%), and six suffered from perinatal asphyxia (31.5%). PS cUS diagnosis preceded MRI diagnosis in 88% of preterm babies. The mean age at cUS diagnosis was 20 ± 7 days. Preterm babies were often asymptomatic, whereas term babies showed neurological symptoms (mainly seizures). The outcome was favorable as long as PS was isolated. Conclusions: PS is surprisingly frequent among PAIS. It represents the most common form of PAIS in preterm babies and in babies suffering from birth asphyxia. Prenatal and perinatal factors suggesting a possible thromboembolic etiology leading to PAIS are rare in our population of preterm babies, in which the diagnosis was always preceded by negative cUS. These assumptions suggest a postnatal development of PS in premature babies more than a perinatal one. Full article

Background: Stent-assisted coil embolization (SACE) is a common endovascular technique for managing intracranial aneurysms. The permanent presence of a stent inside the cerebral artery necessitates the postoperative use of antiplatelets. However, a consensus about how long to continue on it remains debated. This systematic review aims to discuss and quantify the risk of ischemic complications after antiplatelet discontinuation following SACE. Methods: PubMed, Cochrane Library, Scopus, and Web of Science (WOS) were systematically searched for studies assessing the outcomes after antiplatelet discontinuation following SACE for cerebral aneurysms. The primary outcome was the odds of ischemic complications after antiplatelet discontinuation. Using a random-effects model, the pooled event rate, along with a 95% confidence interval (CI), was calculated. The Comprehensive Meta-Analysis software (CMA) software was used for the analysis. The Newcastle–Ottawa Scale (NOS) was used for the quality assessment. Results: A total of five observational cohort studies were included in this systematic review. The studies recruited cases from 2009 and 2020, predominantly in Korea and Japan. Data from 18,425 cases obtained from four studies were analyzed. The duration of antiplatelet therapy varied widely across the included studies. Additionally, most studies reported a median follow-up of 24 months or more after antiplatelet discontinuation. We extracted and analyzed the odds of thromboembolic complications occurring within 6 to 24 months after the discontinuation of antiplatelets. The pooled rate of thromboembolism after antiplatelet discontinuation in this meta-analysis was 0.01 (95% CI: 0.006 to 0.018). Conclusion: This review demonstrates that the risk of thromboembolic complications after discontinuing antiplatelet therapy post-SACE is low. However, no strong consensus exists on the ideal duration for maintaining dual- or single-antiplatelet therapy. Further prospective studies with longer follow-ups are warranted to clarify the optimal durations needed to balance thromboembolic risk with hemorrhagic complications. Full article

Introduction: The classification of antiphospholipid syndrome (APS) comprises clinical criteria (vascular thrombosis or obstetric complications throughout life) and laboratory criteria (antiphospholipid antibodies (aPLs) positivity, confirmed at least twice at 12-week interval). Methods: In 100 patients admitted to the hospital with COVID-19 pneumonia, thrombosis and pregnancy complications were recorded during the hospital stay and in personal medical history. They were tested for nine types of aPLs at four time points (admission, deterioration, discharge, and 3-month follow-up): anticardiolipin (aCL), anti-β2-glycoproteinI (anti-β2GPI), and antiphosphatidylserine/prothrombin (aPS/PT) isotypes IgM/IgG/IgA. Results: During hospitalization, aPLs were detected at least once in 51% of patients. All 7% of deceased patients tested negative for aPLs upon admission, and only one patient became aCL IgG positive as his condition worsened. In 83.3% of patients, intrahospital thrombosis was not related to aPLs. One patient with pulmonary artery and cerebral artery thrombosis was given an APS diagnosis (triple aPLs positivity on admission, double on follow-up). Personal anamnesis (PA) for thromboembolism was verified in 10 patients, all of whom tested negative for aPLs at admission; however, transition to aPLs positivity at discharge (as the disease subsided) was seen in 60% of patients: three of six with arterial thrombosis (at follow-up, two did not appear, and one was negativized) and three of four with deep vein thrombosis (one was confirmed at follow-up and diagnosed with APS, one was negativized, and one did not appear). At admission, the majority of the aPLs were of the aCL IgG class (58.8%). Unexpectedly, as the COVID-19 disease decreased, anti-β2GPI IgG antibodies (linked with thromboses) became newly positive at discharge (14.9%), as confirmed at follow-up (20.8%). Conclusion: The incidence of APS in our cohort was 2.0%, whereas in the general population, it ranges from 0.001% to 0.002%. The incidence might have increased even more if the four aPLs-positive patients with intrahospital thrombosis/history of thrombosis had attended follow-up. Recommendation: All patients with severe COVID-19 or post-COVID syndrome should be evaluated for current/previous thrombosis and tested for aPLs at least twice: at admission to the hospital and at discharge, then retested 3 months later in positive cases in order to be given the appropriate therapy. Full article

Background and Clinical Significance: Venous thromboembolism (VTE) is a severe extra-intestinal manifestation that can complicate the course of inflammatory bowel disease (IBD). Among pediatric patients, cerebral thrombosis (CT) is the most common form of VTE associated with IBD. Magnetic resonance imaging (MRI) remains the gold standard for diagnosing cerebral venous thrombosis, allowing visualization of flow absence and intraluminal thrombus. Prompt initiation of treatment with low-molecular-weight heparin (LMWH) is crucial to prevent complications. Follow-up imaging is essential to evaluate venous recanalization and guide therapy duration. However, data on cerebral thrombosis in pediatric patient with IBD remain scarce. Case Presentation: We report the case of a 12-year-old boy with a known history of ulcerative colitis who presented to the emergency room (ER) with a two-day history of headache and vomiting. One month prior to the ER visit, he experienced an IBD flare confirmed through clinical, biochemical, and endoscopic evaluation and was subsequently started on oral corticosteroids. Neurological examination was unremarkable; however, given the persistence of severe headache, a brain MRI was performed, leading to a diagnosis of cerebral venous thrombosis. Anticoagulation therapy with LMWH was initiated immediately. Follow-up imaging with contrast-enhanced MR venography four months later revealed partial resolution of the thrombosis. The patient continued long-term anticoagulation therapy for a total duration of 12 months. Conclusions: Cerebral venous thrombosis is a serious complication of IBD, particularly in pediatric patients. Clinicians should consider this diagnosis in any child with IBD presenting with persistent headache, even in the absence of focal neurological signs. Early diagnosis and prompt anticoagulation therapy are key to improving outcomes in these patients. Full article

Stroke is a devastating complication of cardiovascular interventions. Intraprocedural stroke is a well-documented and feared risk of cardiac percutaneous transcatheter procedures. If clinically significant strokes are absent, silent strokes remain the next in line to pose large concerns related to future cognitive decline, stroke risk, and overall increased morbidity and mortality. Cerebral protection devices (CPD) developed overtime aim to neutralize this risk through either a capture-based filter or a deflector mechanism. Many CPDs exist currently, each one unique, with varying degrees of evidence. The adoption of CPDs has allowed cardiac percutaneous transcatheter procedures to be carried out in patients with high thromboembolic risks who may have historically been discommended. Though skewed towards certain devices and transcatheter procedures, a large body of evidence is still present across other devices and procedures. This review will discuss clinical importance and respective stroke rates, updated evidence surrounding CPDs, differing opinions across types of CPDs, cost benefits, and what lies ahead for CPDs within the realm of procedures undertaken in cardiac catheterization laboratories. Full article

Background and Clinical Significance: Primary cardiac tumors are among the rarest types of tumor, and until the mid-20th century, they were diagnosed only post-mortem or during other surgical interventions. With the rapid evolution of cardiovascular imaging and the widespread use of echocardiography, the incidence of cardiac fibroelastoma has increased, though it remains one of the rarest primary cardiac tumors. Papillary fibroelastoma is a benign primary cardiac tumor that develops from endocardial tissue, is usually solitary, and can have multiple locations, with the pulmonary valve being one of the rarest sites. The symptoms and complications depend on the tumor’s location, ranging from asymptomatic patients to cerebral ischemic embolism or pulmonary embolism. We analyzed the electronic databases PubMed, Web of Science, and Cochrane and conducted a systematic review of pulmonary valve papillary fibroelastoma (PVPF). Additionally, we included a case from the Adult and Pediatric Cardiovascular Surgery Clinic in Targu Mures. Case Presentation: We present the case of a 58-year-old patient who complained of exertional dyspnea. A transthoracic echocardiography (TTE) revealed a tumor mass attached to the pulmonary valve and coronary angiography identified severe coronary lesions. Following discussions within the Heart Team, surgical myocardial revascularization and tumor excision were decided upon due to the thromboembolic risk. Histopathological examination confirmed the diagnosis of papillary fibroelastoma. The postoperative course was uneventful, with an improvement in dyspnea. The mean age of the patients was 60 years, with half being men (n = 26, 50%). Regarding symptoms, 34% (n = 18) of cases were incidentally identified, while over 30% (n = 17) presented with dyspnea. Pulmonary embolism (PE) was reported in only two patients, and the most common associated comorbidities included high blood pressure (HBP) in 33% (n = 16) and dyslipidemia in 18%. Tumor size ranged from 0.7 cm to 3 cm with the initial benign cardiac tumor; its occurrence in the pulmonary valve remains exceedingly rare. Due to its frequent overlap with other cardiac pathologies, the clinical presentation is often a nonspecific diagnosis or suspicion of a tumor predominantly established via transthoracic echocardiography in 62% of patients. From a surgical perspective, 63% (n = 33) underwent tumor resection with valve sparing, 25% (n = 12) required pulmonary valve repair, and three patients necessitated pulmonary valve replacement. Conclusions: Although the incidence of papillary fibroelastoma is increasing, making it the most common, there is a need to highlight the indispensable role of echocardiography in diagnosis. Although papillary fibroelastoma is benign, surgical intervention is recommended, particularly in symptomatic patients, or if the tumor exceeds 1 cm in size, exhibits increased mobility, or is present alongside other cardiac surgical procedures. Full article

Background/Objectives: Kissing aneurysms, a rare and intriguing cerebrovascular anomaly, challenge even the most advanced neurosurgical techniques. These lesions, characterized by two intimately apposed aneurysms with shared arterial walls, often masquerade as single, irregular aneurysms. This report documents a case of ruptured kissing aneurysms in the M1 segment of the right middle cerebral artery (MCA), complicated by ischemic stroke and pulmonary thromboembolism (PTE)—a convergence of severe complications rarely encountered. The case underscores the importance of precise diagnostics, innovative surgical strategies, and multidisciplinary care. Methods: A 55-year-old female presented with subarachnoid hemorrhage, confirmed by advanced imaging to arise from ruptured kissing aneurysms in the M1 segment of the right MCA. Surgical intervention via a right frontotemporal craniotomy and microsurgical clipping achieved definitive aneurysmal exclusion. Postoperatively, the patient experienced ischemic stroke and PTE, necessitating dynamic adjustments in anticoagulation therapy, intensive care, and rehabilitation protocols. Results: The dual aneurysms were successfully clipped, as confirmed by intraoperative and postoperative imaging. Despite developing significant complications, including left-sided motor deficits and PTE, a carefully orchestrated treatment strategy enabled the patient’s full recovery, with marked neurological and systemic improvement by her three-month follow-up. This favorable outcome highlights the resilience of a multidisciplinary approach in navigating such high-risk scenarios. Conclusions: This case showcases the formidable challenges of managing kissing aneurysms, particularly when compounded by stroke and PTE. It emphasizes the transformative role of cutting-edge imaging and surgical techniques in achieving successful outcomes. By illustrating how precision medicine and collaborative care can overcome rare and complex cases, this report contributes valuable insights to the evolving field of cerebrovascular surgery and postoperative management. Full article

Background/Objectives: Tranexamic acid (TXA) is a synthetic antifibrinolytic agent that inhibits plasminogen activation, thereby reducing bleeding. The aim of this systematic review was to investigate its role in aneurysmal subarachnoid hemorrhage (SAH)—a condition indicated by bleeding between two layers of brain tissue—to stop rebleeding and improve patient outcomes. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials from 1981 to 2024, focusing on the efficacy and safety of TXA in treating aneurysmal SAH (PROSPERO registration: CRD42024504834). Our comprehensive search of the PubMed and Cochrane Library databases identified studies assessing TXA at dosages of 3 to 6 g per day and examining outcomes such as rebleeding incidence, mortality, thromboembolic events, and other adverse effects. Results: From six included studies involving 2990 patients, the meta-analysis showed TXA largely lowered rebleeding risk (OR 0.54 95% CI 0.43–0.68; p < 0.00001), yet mortality rates were not largely different between the TXA group (385 out of 1201), and the control group (344 out of 1193) (OR 1.18 95% CI 0.98–1.40; p = 0.07). Likewise, there were no large differences in the occurrence of cerebral ischemia and blood clot-related events between the groups. Conclusions: TXA effectively reduces the risk of rebleeding in SAH patients, but does not significantly alter mortality or the incidence of thromboembolic complications. These findings back the careful use of TXA and demonstrate the need for further research to better its clinical use and assess long-term impacts. Full article

Silent Brain Infarction (SBI) is increasingly recognized in patients with cardiac conditions, particularly Atrial Fibrillation (AF) in elderly patients and those undergoing Transcatheter Aortic Valve Implantation (TAVI). While these infarcts often go unnoticed due to a lack of acute symptoms, they are associated with a threefold increase in stroke risk and are considered a precursor to ischemic stroke. Moreover, accumulating evidence suggests that SBI may contribute to the development of dementia, depression, and cognitive decline, particularly in the elderly population. The burden of SBI is substantial, with studies showing that up to 11 million Americans may experience a silent stroke annually. In AF patients, silent brain infarcts are common and can lead to progressive brain damage, even in those receiving anticoagulation therapy. The use of cerebral embolic protection devices (CEPDs) during TAVI has been explored to mitigate the risk of stroke; however, their efficacy remains under debate. Despite advancements in TAVI technology, cerebrovascular events, including silent brain lesions, continue to pose significant challenges, underscoring the need for improved preventive strategies and therapeutic approaches. We propose a device consisting of a strut structure placed at the base of the treated artery to model the potential risk of cerebral embolisms caused by atrial fibrillation, thromboembolism, or dislodged debris of varying potential TAVI patients. The study has been carried out in two stages. Both are based on computational fluid dynamics (CFD) coupled with the Lagrangian particle tracking method. The first stage of the work evaluates a variety of strut thicknesses and inter-strut spacings, contrasting with the device-free baseline geometry. The analysis is carried out by imposing flow rate waveforms characteristic of healthy and AF patients. Boundary conditions are calibrated to reproduce physiological flow rates and pressures in a patient’s aortic arch. In the second stage, the optimal geometric design from the first stage was employed, with the addition of lateral struts to prevent the filtration of particles and electronegatively charged strut surfaces, studying the effect of electrical forces on the clots if they are considered charged. Flowrate boundary conditions were used to emulate both healthy and AF conditions. Results from numerical simulations coming from the first stage indicate that the device blocks particles of sizes larger than the inter-strut spacing. It was found that lateral strut space had the highest impact on efficacy. Based on the results of the second stage, deploying the electronegatively charged device in all three aortic arch arteries, the number of particles entering these arteries was reduced on average by $62.6$% and $51.2$%, for the healthy and diseased models respectively, matching or surpassing current oral anticoagulant efficacy. In conclusion, the device demonstrated a two-fold mechanism for filtering emboli: (1) while the smallest particles are deflected by electrostatic repulsion, avoiding micro embolisms, which could lead to cognitive impairment, the largest ones are mechanically filtered since they cannot fit in between the struts, effectively blocking the full range of particle sizes analyzed in this study. The device presented in this manuscript offers an anticoagulant-free method to prevent stroke and SBIs, imperative given the growing population of AF and elderly patients. Full article

Ischemic stroke (IS) is a severe complication and leading cause of mortality in patients under extracorporeal membrane oxygenation (ECMO). The aim of our narrative review is to summarize the existing evidence and provide a deep examination of the diagnosis and treatment of acute ischemic stroke patients undergoing ECMO support. The incidence rate of ISs is estimated to be between 1 and 8%, while the mortality rate ranges from 44 to 76%, depending on several factors, including ECMO type, duration of support and patient characteristics. Several mechanisms leading to ISs during ECMO have been identified, with thromboembolic events and cerebral hypoperfusion being the most common causes. However, considering that most of the ECMO patients are severely ill or under sedation, stroke symptoms are often underdiagnosed. Multimodal monitoring and daily clinical assessment could be useful preventive techniques. Early recognition of neurological deficits is of paramount importance for prompt therapeutic interventions. All ECMO patients with suspected strokes should immediately receive brain computed tomography (CT) and CT angiography (CTA) for the identification of large vessel occlusion (LVO) and assessment of collateral blood flow. CT perfusion (CTP) can further assist in the detection of viable tissue (penumbra), especially in cases of strokes of unknown onset. Catheter angiography is required to confirm LVO detected on CTA. Intravenous thrombolytic therapy is usually contraindicated in ECMO as most patients are on active anticoagulation treatment. Therefore, mechanical thrombectomy is the preferred treatment option in cases where there is evidence of LVO. The choice of the arterial vascular access used to perform mechanical thrombectomy should be discussed between interventional radiologists and an ECMO team. Anticoagulation management during the acute phase of IS should be individualized after the thromboembolic risk has been carefully balanced against hemorrhagic risk. A multidisciplinary approach is essential for the optimal management of ISs in patients treated with ECMO. Full article

Cerebral venous thrombosis (CVT) is a rare type of cerebrovascular event in which the thrombosis occurs in a vein of the cerebral venous system. The diagnosis could be challenging due to the great clinical variability, but the outcome is favourable in most cases, especially in the case of early diagnosis. Anticoagulant therapy is the core of CVT management and currently consists of heparin in the acute phase followed by vitamin K antagonists (VKAs) in the long term. The ideal duration of anticoagulant therapy is still unclear, and the same criteria for the treatment of extracerebral venous thromboembolism currently apply. In this paper, we reviewed the literature regarding the use of direct oral anticoagulants (DOACs) in CVT since in recent years a considerable number of studies have been published on the use of these drugs in this specific setting. DOACs have already been shown to be equally effective with VKAs in the treatment of venous thromboembolism. In addition to efficacy, DOACs appear to have the same safety profile, being, on the other hand, more manageable, as they do not require close monitoring with continuous personalised dose adjustments. In addition, a further advantage of DOACs over VKAs is the possibility of anticoagulant prophylaxis using a reduced dosage of the drug. In conclusion, although the use of DOACs appears from preliminary studies to be effective and safe in the treatment of CVT, additional studies are needed to include these drugs in the treatment of CVT. Full article

(1) Background: The three factors within the Virchow triad play the leading role in the development of deep vein thrombosis (DVT) during pregnancy. (2) Methods: This research approaches the various risk factors associated with DVT and its most representative complications, pulmonary thromboembolism and cerebral venous thrombosis, in pregnant and postpartum women across a 15-year period (2007–2021). (3) Results: A total of 201 out of 287 patients with DVT had associated risk factors, while 86 did not present with any. Out of the 201 patients with risk factors, 47 developed pulmonary thromboembolism, while 12 experienced cerebral thrombosis. The statistical analysis of risk factors involved in DVT revealed high significance for obesity (OR 3.676; CI 2.484–5.439), gestational diabetes (OR 3.394; CI 2.101–5.483), hypertension (OR 2.325; CI 1.591–3.397), preeclampsia (OR 4.753; CI 2.342–9.645), thrombophilia (OR 12.138; CI 8.973–16.417), and varicose veins (OR 9.678; CI 7.321–12.793); for pulmonary thromboembolism, there was high significance for obesity (OR 7.867; CI 4.297–14.401), hypertension (OR 2.605; CI 1.246–5.446), preeclampsia (OR 7.483; CI 2.346–23.872), thrombophilia (OR 11.035; CI 5.910–20.602), and varicose veins (OR 6.837; CI 3.665–12.757); and for cerebral thromboembolism (CTE), the risk factors identified were obesity (OR 6.755; CI 1.954–23.347), hypertension (OR 1.167; CI 0.155–8.770), preeclampsia (OR 9.655; CI 1.283–72.672), and thrombophilia (OR 33.275; CI 12.884–85.939). (4) Conclusions: Obesity was the only significant factor found to influence DVT, pulmonary embolism and CTE risks, and hereditary thrombophilia was the main factor influencing the risk for pulmonary thromboembolism and CTE. Systemic lupus erythematosus and gestational diabetes revealed conflicting results that require further investigation. Full article