Categories
Vascular

Is dabigatran as effective as warfarin for cerebral vein thrombosis?

RE-SPECT CVT Study Group. Safety and efficacy of dabigatran etexilate vs dose-adjusted warfarin in patients with cerebral venous thrombosis: a randomized clinical trial.

Ferro JM, Coutinho JM, Dentali F, et al;

JAMA Neurol 2019 (Epub ahead of print).

Abstract

BACKGROUND:

Patients with cerebral venous thrombosis (CVT) are at risk of recurrent venous thrombotic events (VTEs). Non-vitamin K oral anticoagulants have not been evaluated in randomized controlled trials in CVT.

METHODS:

RE-SPECT CVT is an exploratory, prospective, randomized (1:1), parallel-group, open-label, multicenter clinical trial with blinded end-point adjudication (PROBE design). It was performed from December 21, 2016, to June 22, 2018, with a follow-up of 25 weeks, at 51 tertiary sites in 9 countries (France, Germany, India, Italy, the Netherlands, Poland, Portugal, Russia, and Spain). Adult consecutive patients with acute CVT, who were stable after 5 to 15 days of treatment with parenteral heparin, were screened for eligibility. Patients with CVT associated with central nervous system infection or major trauma were excluded, but those with intracranial hemorrhage from index CVT were allowed to participate. After exclusions, 120 patients were randomized. Data were analyzed following the intention-to-treat approach.

INTERVENTIONS:

Dabigatran, 150 mg twice daily, or dose-adjusted warfarin for a treatment period of 24 weeks.

RESULTS:

In total, 120 patients with CVT were randomized to the 2 treatment groups (60 to dabigatran and 60 to dose-adjusted warfarin). Of the randomized patients, the mean (SD) age was 45.2 (13.8) years, and 66 (55.0%) were women. The mean (SD) duration of exposure was 22.3 (6.16) weeks for the dabigatran group and 23.0 (5.20) weeks for the warfarin group. No recurrent VTEs were observed. One (1.7%; 95% CI, 0.0-8.9) major bleeding event (intestinal) was recorded in the dabigatran group, and 2 (3.3%; 95% CI, 0.4-11.5) (intracranial) in the warfarin group. One additional patient (1.7; 95% CI, 0.0-8.9) in the warfarin group experienced a clinically relevant non-major bleeding event. Recanalization occurred in 33 patients in the dabigatran group (60.0%; 95% CI, 45.9-73.0) and in 35 patients in the warfarin group (67.3%; 95% CI, 52.9-79.7).

CONCLUSIONS:

This trial found that patients who had cerebral vein thrombosis anticoagulated with either dabigatran or warfarin had low risk of recurrent venous thromboembolic events, and the risk of bleeding was similar with both medications, suggesting that both dabigatran and warfarin may be safe and effective for preventing recurrent VTEs in patients with CVT.

This paper is cited in the neurochecklist:

Cerebral vein thrombosis (CVT): anticoagulant treatment

By MarinaVladivostokOwn work, CC0, Link

Abstract link

 

Categories
Neurological infections

The 7 most ruthless bacterial infections of the nervous system

This is a follow up to our previous post, the 7 most devastating viral neurological infections. The list of bacteria that invade the nervous system is endless, but some stand out because of the fear they evoke, and the peril they pose. Here then are the 7 most horrifying bacterial infections that threaten the nervous system.

1. Bacterial meningitis

Klebsiella pneumonia bacterium. NIAID on Flikr. https://www.flickr.com/photos/niaid/13383468143

Many bacteria invade the covering of the brain, the meninges, without invading the brain substance. The commonest are Neisseria meningitidis, causing meningococcal meningitis, and Streptococcus pneumoniae, causing pneumococcal meningitis. Other relatively frequent meningeal intruders include Listeria monocytogenes and Haemophilus influenzae. Bacteria may get into the brain following infections elsewhere, such as sinusitis or otitis media (inner ear infection). There are many complications of bacterial meningitis such as cerebral venous thrombosis (CVT) and brain abscess.

2. Tuberculosis

Mycobacterium tuberculosis bacteria, the cause of TB. NIAID on Flikr. https://www.flickr.com/photos/niaid/5149398656

Tuberculosis (TB) is probably as old as history. It is caused by mycobacterium tuberculosis, a slow groing but pernicious organism. TB spares no part of the nervous system, and manifests often as tuberculous meningitis (TBM) or Pott’s disease of the spine. Nervous system TB may also present as an encephalopathy, tuberculoma, brain abscess, vasculopathy, arachnoiditis, radiculomyelitis, and calvarial TB.

3. Neurosyphilis

ff treponema pallidum. isis335 on Flikr. https://www.flickr.com/photos/92708411@N07/8579266595

Treponema pallidum, the bacterium behind the dreaded syphilis, is another ancient bug. It has a variety of ways it terrorises the nervous system, and the longer it inhabits the neurones, the worse the outcome. Typical manifestations of neurosyphilis are tabes dorsalis, general paresis of the insane (GPI), taboparesis, stroke, meningovascular syphilis, optic neuritis (ON), and several movement disorders.

4. Lyme neuroborreliosis

Lyme Disease Bacteria, Borrelia Burgdoferri. NIAID on Flikr. https://www.flickr.com/photos/niaid/5661846104

Lyme disease has acquired an infamy which is probably beyond its real notoriety. It is best known for its tick-borne transmission, and for its classical dermatological feature, erythema chronicum migrans. It affects the nervous system in diverse ways such as encephalomyelitislymphocytic meningitis, cranial neuropathies, spinal radiculitis, stroke, diaphragmatic paralysis, and peripheral neuropathy. Post-Lyme syndrome is a very contentious topic; you may read more on this in a post from our sister blog, The Neurology Lounge, titled ‘Why is chronic Lyme disease so frustrating to neurology.

5. Neurobrucellosis

By This media comes from the Centers for Disease Control and Prevention‘s Public Health Image Library (PHIL), with identification number #1902.Note: Not all PHIL images are public domain; be sure to check copyright status and credit authors and content providers.English | Slovenščina | +/−, Public Domain, Link

Neurobrucellosis is a rarely discussed bacterial infection but it is a significant contributor to neurological morbidity and mortality around the world. It is caused by various brucella species usually grouped under the name Brucella militensis. It has a long reach in the nervous system, causing  a variety of insults such as encephalitis, meningoencephalitis, cranial neuropathies, intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH), transverse myelitis, radiculitis, and peripheral neuropathy.

6. Leprosy

Public Domain, Link

This most distasteful of infectious diseases unfortunately has a strong affinity for the nervous system. Unlike its distant cousin, TB, leprosy favours the peripheral over the central nervous system. Its hallmark is thickening of the nerves or nerve hypertrophy. Caused by Mycobacterium leprae, leprosy has a legion of neurological manifestations such as mononeuritis, mononeuritis multiplex, cranial and peripheral neuropathy, myelitis, and leprous ganglionitis.

7. Botulism

Clostridium botulinum. Phil Moyer on Flikr. https://www.flickr.com/photos/hukuzatuna/2537594892

Botulism is the end result of damage by the toxin of Clostridium botulinum. This toxin produces a deadly paralysis by blocking neural transmission across the neuromuscular junction (NMJ). Botulinum toxin respects no borders, able to gain access to the nervous system through the gut, the skin, or the lungs. It paralyses everything, causing acute limb, ocular, and bulbar weakness. Left unchecked, botulism results in autonomic dysfunction and respiratory failure.

 

PS: For Tetanus, check out The Neurology Lounge blog post on The 13 most dreadful neurological disorders

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Explore more neurological infections in neurochecklists!

Bacteria. AJ Cann on Flikr. https://www.flickr.com/photos/ajc1/8975675759