Minerva medica
-
Disseminated intravascular coagulation (DIC) has long been understood as a condition where both thrombotic and hemostatic abnormalities coexist. DIC is a difficult complication for clinicians to manage as it is due to multiple underlying complications of pathophysiologic abnormalities in diverse disease states. Ongoing research continues to define the meaning of DIC, evaluate therapeutic options, and how it presents with the complex paradigm of systemic activation of coagulation. In this review we introduce the current topics regarding this difficult situation. ⋯ DIC is recognized as a pathologically triggered and dysregulated systemic activation of coagulation in response to various noxious stimuli. DIC's phenotype and clinical manifestations can vary from prothrombotic to hemorrhagic, depending on the underlying diseases. However, the fundamental mechanisms of systemic and vascular endothelial dysfunction can be explained as different phases of the acute response, with an initial prothrombotic phase that can commonly change to hemostatic insufficiency. Thrombin is the key initiator of the pathophysiologic process along with endothelial injury and initially fibrinolysis activation followed by fibrinolysis suppression. There is no established approach for managing DIC beyond initially treating the underlying disease and replacement therapy for the management of coagulopathy. Targeting anticoagulation therapy with antithrombin concentrates and recombinant thrombomodulin for the prevention of microthrombus formation, and antifibrinolytic therapy using tranexamic acid for the coagulopathy after massive bleeding, continue to be studied as therapeutic options.
-
Cerebral venous thrombosis (CVT) is a rare form of deep venous thrombosis (DVT), yet a leading cause of stroke in young adults, with an incidence that seems to be increasing in recent years. Risk factors for CVT overlap with those of DVT in other locations, with the addition of local risk factors, such as infections, head trauma and neurosurgery. The clinical presentation is highly variable, hence the diagnosis of CVT may be delayed or overlooked. ⋯ Endovascular treatment may be suggested for selected patients who deteriorate despite anticoagulant treatment. In this review we will provide an extensive and contemporary discussion of the incidence, pathophysiology, risk factors, clinical presentation, neuroimaging and management of CVT, in accordance with recent guidelines. Additionally, we will summarize the latest data with regards to direct oral anticoagulants (DOACs) treatment in CVT.