Thrombosis of the Cerebral Veins and Sinuses
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《新英格兰医药杂志》
To the Editor: The review by Stam of thrombosis of the cerebral veins and sinuses (April 28 issue)1 did not include heparin-induced thrombocytopenia as one of the causes of thrombosis. This acquired hypercoagulability state results from the presence of heparin-dependent, platelet-activating IgG antibodies. Cerebral venous or sinus thrombosis occurred in 3 (2.9 percent) of 105 patients and in 7 (1.7 percent) of 408 patients in two studies2,3 involving the clinical presentation of this adverse drug reaction. If sinus thrombosis is suspected in a patient who is currently using or has recently used heparin, heparin-induced thrombocytopenia must be ruled out, since this condition represents an absolute contraindication to further anticoagulant therapy with unfractionated or low-molecular-weight heparin (the usual treatment for sinus thrombosis). Alternative anticoagulant drugs appropriate for patients with heparin-induced thrombocytopenia include lepirudin, argatroban, and danaparoid.4 The unfavorable course of cerebral venous and sinus thrombosis associated with heparin-induced thrombocytopenia includes both the progression of cerebral ischemia and the development of noncerebral thrombosis.2,5 This suggests that the use of alternative anticoagulants should not be withheld because of the thrombocytopenia and consumption coagulopathy.
Theodore E. Warkentin, M.D.
McMaster University
Hamilton, ON L8N 3Z5, Canada
Andreas Greinacher, M.D.
Ernst-Moritz-Arndt University
D-17487 Greifswald, Germany
Drs. Warkentin and Greinacher report having received lecture fees, consulting fees, or both in relation to the alternative nonheparin anticoagulant drugs lepirudin, argatroban, and danaparoid.
References
Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med 2005;352:1791-1798.
Pohl C, Klockgether T, Greinacher A, Hanfland P, Harbrecht U. Neurological complications in heparin-induced thrombocytopenia. Lancet 1999;353:1678-1679.
Greinacher A, Farner B, Kroll H, Kohlmann T, Warkentin TE, Eichler P. Clinical features of heparin-induced thrombocytopenia including risk factors for thrombosis: retrospective analysis of 408 patients. Thromb Haemost (in press).
Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia: recognition, treatment, and prevention: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:Suppl:311S-337S.
Warkentin TE, Bernstein RA. Delayed-onset heparin-induced thrombocytopenia and cerebral thrombosis after a single administration of unfractionated heparin. N Engl J Med 2003;348:1067-1069.
To the Editor: The review of cerebral vein thrombosis by Stam was comprehensive and informative. However, given the increased use of various therapeutic agents associated with cerebral vein thrombosis, epoetin alfa1 and tamoxifen2,3 should be considered in the list of drugs related to this condition. The former causes polycythemia, and the latter a prothrombic state.
Pasquale F. Finelli, M.D.
Hartford Hospital
Hartford, CT 06102
nervline@aol.com
References
Finelli PF, Carley MD. Cerebral venous thrombosis associated with epoetin alfa therapy. Arch Neurol 2000;57:260-262.
Masjuan J, Pardo J, Callejo JM, Andres MT, Alvarez-Cermeno JC. Tamoxifen: a new risk factor for cerebral sinus thrombosis. Neurology 2004;62:334-335.
Finelli PF, Schauer PK. Cerebral sinus thrombosis with tamoxifen. Neurology 2001;56:1113-1114.
To the Editor: The excellent review by Stam does not mention the important predisposing risk factor of high altitude. Cerebral venous sinus thrombosis has been well documented at high altitudes in the Himalayas and elsewhere.1 High altitude can precipitate thrombosis because of hypobaric hypoxia and its effect on the coagulation system — in particular, increased factor VIIa activity.2,3,4 Dehydration, polycythemia, and vascular spasms may also increase a tendency toward the development of cerebral venous thrombosis at high altitude.2,3,4
Ajit Singh Kashyap, M.D.
Command Hospital (Southern Command)
Pune 411 040, India
kashyapajits@hotmail.com
Kuldip Parkash Anand, M.D.
Command Hospital (Eastern Command)
Kolkata 700 027, India
Surekha Kashyap, M.D.
Command Hospital (Southern Command)
Pune 411 040, India
References
Basnyat B, Cumbo TA, Edelman R. Acute medical problems in the Himalayas outside the setting of altitude sickness. High Alt Med Biol 2000;1:167-174.
Bendz B, Rostrup M, Sevre K, Andersen TO, Sandset PM. Association between acute hypobaric hypoxia and activation of coagulation in human beings. Lancet 2000;356:1657-1658.
Basnyat B, Graham L, Lee S-D, Lim Y. A language barrier, abdominal pain, and double vision. Lancet 2001;357:2022-2022.
Kashyap AS, Kashyap S. The clot thickens! in thin air. Arch Intern Med 2002;162:1783-1783.
Theodore E. Warkentin, M.D.
McMaster University
Hamilton, ON L8N 3Z5, Canada
Andreas Greinacher, M.D.
Ernst-Moritz-Arndt University
D-17487 Greifswald, Germany
Drs. Warkentin and Greinacher report having received lecture fees, consulting fees, or both in relation to the alternative nonheparin anticoagulant drugs lepirudin, argatroban, and danaparoid.
References
Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med 2005;352:1791-1798.
Pohl C, Klockgether T, Greinacher A, Hanfland P, Harbrecht U. Neurological complications in heparin-induced thrombocytopenia. Lancet 1999;353:1678-1679.
Greinacher A, Farner B, Kroll H, Kohlmann T, Warkentin TE, Eichler P. Clinical features of heparin-induced thrombocytopenia including risk factors for thrombosis: retrospective analysis of 408 patients. Thromb Haemost (in press).
Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia: recognition, treatment, and prevention: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:Suppl:311S-337S.
Warkentin TE, Bernstein RA. Delayed-onset heparin-induced thrombocytopenia and cerebral thrombosis after a single administration of unfractionated heparin. N Engl J Med 2003;348:1067-1069.
To the Editor: The review of cerebral vein thrombosis by Stam was comprehensive and informative. However, given the increased use of various therapeutic agents associated with cerebral vein thrombosis, epoetin alfa1 and tamoxifen2,3 should be considered in the list of drugs related to this condition. The former causes polycythemia, and the latter a prothrombic state.
Pasquale F. Finelli, M.D.
Hartford Hospital
Hartford, CT 06102
nervline@aol.com
References
Finelli PF, Carley MD. Cerebral venous thrombosis associated with epoetin alfa therapy. Arch Neurol 2000;57:260-262.
Masjuan J, Pardo J, Callejo JM, Andres MT, Alvarez-Cermeno JC. Tamoxifen: a new risk factor for cerebral sinus thrombosis. Neurology 2004;62:334-335.
Finelli PF, Schauer PK. Cerebral sinus thrombosis with tamoxifen. Neurology 2001;56:1113-1114.
To the Editor: The excellent review by Stam does not mention the important predisposing risk factor of high altitude. Cerebral venous sinus thrombosis has been well documented at high altitudes in the Himalayas and elsewhere.1 High altitude can precipitate thrombosis because of hypobaric hypoxia and its effect on the coagulation system — in particular, increased factor VIIa activity.2,3,4 Dehydration, polycythemia, and vascular spasms may also increase a tendency toward the development of cerebral venous thrombosis at high altitude.2,3,4
Ajit Singh Kashyap, M.D.
Command Hospital (Southern Command)
Pune 411 040, India
kashyapajits@hotmail.com
Kuldip Parkash Anand, M.D.
Command Hospital (Eastern Command)
Kolkata 700 027, India
Surekha Kashyap, M.D.
Command Hospital (Southern Command)
Pune 411 040, India
References
Basnyat B, Cumbo TA, Edelman R. Acute medical problems in the Himalayas outside the setting of altitude sickness. High Alt Med Biol 2000;1:167-174.
Bendz B, Rostrup M, Sevre K, Andersen TO, Sandset PM. Association between acute hypobaric hypoxia and activation of coagulation in human beings. Lancet 2000;356:1657-1658.
Basnyat B, Graham L, Lee S-D, Lim Y. A language barrier, abdominal pain, and double vision. Lancet 2001;357:2022-2022.
Kashyap AS, Kashyap S. The clot thickens! in thin air. Arch Intern Med 2002;162:1783-1783.