Hello!

Perhaps D-dimer can give a little help.

The sinus thrombosis is one of the most disguised illnesses.

Best regards!

Hello Andrew,  our everyday experience tells us how difficult it is to diagnose CVS on MR: you need a lot of experience to avoid disapointments...  Non contrast CT is the work-horse for this pathology, especially in the early time-window (first days or hours after initial clinical symptoms when MR is so difficult to read for junior radiologists or in the middle of the night...), but be sure to check and COMPARE (and measure if necessary) the density of superior sinus, straight sinus, lateral sinuses. Sagittal and coronal reformats can be a great help (providing you have access to 1mm non-contrast CT). If ALL sinuses are dense, confront with hematocrit. Otherwise be highly suspicious of CVT, and compare the anomalous sinuses with the same post IV-contrast.   Deep venous thrombosis (straight sinus and internal cerebral veins) can be challenging and misleading before a hemorrhage occurs...  Hope this is helpful!

Best regards,

Marc BINTNER, Neuroradiologist 

Reunion island

In 30 years and having placed many thousands of ports (the word 'Port a Cath' was a trade name of a device from the US not used as far as I am aware for decades) I have seen many develop a fibrin sheath which is managed with small dose of local strptokinase.

Vessel thrombosis is rarer and in practice many of my colleagues get worried when arm oedema occurs but again I have never seen a case of embolism and it always resolves on line removal even in a few cases where the patient has been travelling and clearly had thrombosis for months

What is clear is inserting a new system even in the other arm rapidly leads to similar fibrin / thrombosis issues.

I also suspect a degree of thrombosis is almost universal but in most cases not symptomatic and not identified.

In summary I try never to remove these systems. Peer pressure and patient fear sometimes forces my hand and then I resist a new system for at least six weeks.

One should extract the catheter to prevent thrombosis extension and further damage to the vein , also consider other puncturing and maybe a dissection of other site .

Dear Camille Bernard, Yes, more viscous blood is more likely to clot or thrombose. This is because it slows intravascular flow. Rudolph Virchow, the father of pathology, was the first to identify that sluggish blood flow was a cause of thrombosis. Sluggish blood flow is a manifestation of increased blood viscosity. Sluggish blood flow is part of Virchow's triad.

Honestly these are not vaccines in the strict sense of the term. They were not sufficiently proved to be effective and they obviously cause undesirable and severe effects, which are hidden by the press and medical authorities. No other vaccine in history is linked to so serious and frequent effects, such as myocarditis, thrombosis, heart attack, Guillain-Barré syndrome, cancers and others due to the spike protein, lipid nanoparticles and IgG4 antibody.  Never were so often observed athletes and children sudden deaths, those  receiving the second or third dosis. I have been all my life  totally for vaccines, I myself received all of them, but these products are gene therapy, not immunogenic agents. Sorry if you consider me antivax. These are real facts.

Paraneoplastic complications should be looked for,  principally pancreas adenocarcinoma. It’s not rare deep vein thrombosis and pâncreas câncer. Otherwise, thrombophilia is a good possibility too.  S and C protein, Antithrombin III, MTHFR, Homocystein, Leiden, Prothrombin mutation, Beta2GP1, Lupus anticoagulante and Antiphosphilipid, should be ordered. Don’t think Apixaban as the responsible for de Hemorragic Adrenal Insufficiency…

Covid Infection may cause a multitude of coagulation disorders and (auto-)immune phenomena including thrombosis, immune thrombocytopenia (ITP) and thrombotic microangiopathy (TMA). ITP after/during covid infection is more common than TMA - but when Thrombocytopenia occours at the same time with anemia TMAs have to be ruled out (as well as bleeding, leukemia, DIC, hemophagocytosis...).

Evaluation of a blood smear for neoplastic cells as well as fragmentocytes (= schistocytes, "helmet cells") will be helpfull; furthermore ADAMTS13, haptoglobin, ferritin, sIL2R, fibrinogen, D-Dimer, ANA etc. and abdominal Sonography

Are you sure you are dosing UFH adequately?  It's been a while since I used UFH -- I'm retired -- but from memory it could take 1500 unit/hr or more, continuous i.v. infusion to anticoagulate a big man.  What you are giving is just at the upper end of what would be prophylaxis against DVT in surgical patients, and that dose doesn't prolong the aPTT, not into therapeutic range anyway.  Once daily is likely not often enough to avoid long intervals below therapeutic range.  There is (or was) a role for outpatient UFH:  it used to be the only treatment for DVT/PE in pregnancy, q8h dosing with aPTT checked just before a dose.

aPTT isn't always the best lab to monitor heparin but if that's what your hospital offers that's what you use.  At the dose you are giving, I'm not surprised it's normal.  INR isn't useful for heparin.  I found that INR didn't prolong on heparin so expect it to be normal until/unless warfarin is started.  Yes, some patients you can't get aPTT into therapeutic range despite large doses of heparin -- I can't remember how large but larger than you are giving here -- so be cautious about pushing the aPTT.as this would lead to overdose and bleeding.  In that case a direct measure of heparin level (anti-Xa activity) would be better.  (Of course if he has pre-existing anti-thrombin III deficiency, the effect of heparin is attenuated.)  Lots of things to consider but from what you say here, dose of heparin looks too small.  Was aPTT ever in therapeutic range when he was in hospital? 

Is it usual practice where you are to follow D-dimer levels?  What do you do with the results?  Here, we used it just for diagnosis, but only if we thought PE was very low likelihood and were planning not to image if it was negative.  If we were going to image anyway (scinti, CT, U/S of legs, whatever) we didn't bother doing D-dimer for diagnosis.  

Is lipoprotein A a risk factor for venous thrombophilia that contraindicates DOAC??  I know it as a risk factor for arterial atherosclerosis, not for venous thrombosis.  Am I confused here?

Attached is a paper that reviews the pathophysiology of nitrous oxide abuse https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5925601/#:~:text=Nitrous%20oxide%20irreversibly%20oxidizes%20and,vascular%20endothelial%20injury%20and%20thrombosis.

It negatively affects Vitamin B12 levels.  “Nitrous oxide irreversibly oxidizes and inactivates vitamin B12, which in turn leads to demyelination, megaloblastic anemia, etc. In addition, the accumulation of homocysteine is closely related to vascular endothelial injury and thrombosis”

the paper includes a very thorough case study 

the case study states the following:  patient’s examination upon admission revealed poor mental status, however he was alert and cooperative during the exam and his vital signs were all normal. His proximal and distal limb muscle strength was grade 4 and 3, respectively, with extensor muscle tension being greater. He could not complete the finger-to-nose test, rapid alternating movement test and heel-knee-tibia test. He had systemic hyperalgesia in a glove and stocking pattern, slightly diminished perception of rough touch below T12 plane and diminished perception of position and fine touch. He had diminished bilateral tendon reflexes and lower abdominal reflexes, as well as bilateral Babinski sign (+). The patient’s psychiatric examination revealed that he was conscious, had inappropriate deportment and normal orientation. His answers to questions were on point. Perceptual disorders including hallucinations were not present. He had illogical thinking, presented with suspicion, relational persecutory delusions, stable emotions, occasional negative ideation, diminished consciousness, as well as partial insight loss. Laboratory tests revealed RBC count: 4.94X1012/L [(4.09-5.74)X1012/L], HB: 157 g/L (131-172 g/L), WBC count: 10.37X109/L, ALT: 164 U/L (0-50U/L) and B12: 602.1 pmol/L. The rest of his blood routine, biochemical, ECG and EEG results were normal. Spinal cord MRI examination revealed an inverted V-shaped long T2 signal shadow in the posterior segment of the cervical spinal cord C2-C6

hope you’re find this helpful

Is that compared to previous variants or to a control group? I'm not aware of an official control group.

I'm also not convinced that the risk benefit ratio is addressed? I will certainly not risk myocarditis/pericarditis or venous sinus thrombosis for a minor respiratory tract infection. 

I think the associations of high temperature and air pollution with myocardial infarction can be explained by increased blood viscosity. High ambient temperatures can increase insensible fluid loss and hemoconcentration. These will increase blood viscosity.  Increased blood viscosity will reduce myocardial perfusion and predispose to a type 2 myocardial infarction. It can also predispose to arterial thrombosis. When particles are small enough, they can enter the bloodstream and increase blood viscosity. Perhaps the weak effect of cold air may be due to increased sympathetic activity and platelet aggregation. A classic scenario for myocardial infarction is the elderly, out-of-shape male who shovels snow in the morning. When ambient temperature is high, it is imperative to maintain hydration. Exercise also improves cardiovascular health.

Fully agree with Dr. Luca Puccetti. His management is exactly mine and this is how I would act in every suspected case of DVT, Deep venous THROMBOSIS, Wells score respected.  No doubt, D-dimers can be elevated by various processes, for example, by a tumor event - but even then heparin would be correct: Heparin counteracts metastasis of most tumors. I also use Doppler and sonography - but heparin ensures immediate safety and my statistics justify this approach.                         Addendum: Three weeks ago one of my patients developed DVT - D-Dimers extremely high - 87 years old, lean and on APIXABAN, Factor Xa-Inhibitor, because of AF. So Heparin was not an option there. His DVT  subsided significantly under temporary doubling of APIXABAN-Administration for about ten days  - kidney compliant - and stomach protected by PPI Pantoprazole.

Very good question. Thank you. Patients with IgM paraproteinemia are at increased risk of thrombosis, both arterial and venous. In this patient, the anemia is compensation for the hyperviscosity, mediated by the systemic vascular resistance response (SVRR). Once the response is complete and anemia develops, the risk of thrombosis is reduced because whole blood viscosity (as compared to serum viscsoity) approaches normal. However, if hydration is not maintained for some reason, hyperviscosity may ensue and thrombosis can develop. I would recommend that the patient be diligent about hydration and not start an anticoagulant.  .

Viscosity testing must be ordered separately. Plasma and serum are the most common specimens. Elevated blood viscosity can be caused by inflammation and dehydration. Suspect hyperviscsoity in patients with thrombosis or extremely high erythrocyte sedimentation rates, Hyperviscosity can also cause viscual or hearing loss. Because elevated blood viscosity reduces blood flow,to all organs, hyperviscosity can cause reduced function of any organ, particualrly the brain or heart. I have seen hyperviscosity cause altered level of consciousness and arrhythmia. 

Dear colleagues,

I found a a list of possible contraindications for diving - not complete, but long enough (in German, the List was published by colleague Dr. Gregor Dietze on http://www.tauchtauglichkeitsuntersuchungen.de/kontraindikationen/; I attemped a translation): 

RespiratoryAbsolute contraindications:acute lung diseases in generalacute respiratory infections, obstructive changesLung diseases with relevant respiratory insufficiencySpontaneous pneumothorax in history, pneumothorax with known cause after 3 monthsknown cavities, emphysema, cysts, bronchiectasissevere bronchial asthma with permanent medication of cortisone or bronchodilatorslung and pleural diseases with restriction (fibrosis, pneumoconiosis)Directly after surgical intervention of the lungRelative contraindications:Chronic obstructive pulmonary disease (COPD) with mild pulmonary function impairment.healed sarcoidosis (radiologically) with normal lung functionpneumothorax due to accident / barotrauma after 3 monthstreated lung injury or lung surgery, at the earliest 3 months postoperativelyBronchial asthma with normal lung function, or in attack-free interval, or only mild activityvery heavy nicotine use with suspected morphological changesCardiovascularAbsolute contraindications:Coronary artery disease with stable or unstable angina pectorisexisting cardiac symptoms after dilatation or bypass surgery, or abnormal ECGAfter a large myocardial infarction, continuing cardiac symptoms, or continuing increased cardio-vascular riskHeart failure or markedly impaired ventricular function on cardiac echo.Cardiac arrhythmias: Sick sinus syndrome, complex ventricular dysfunction, supraventricular dysfunction with loss of consciousness, conduction disorders with paroxysmal tachycardia, block patterns of grade II or higher , left bundle branch block patterns with underlying morphologic diseaseall valve diseases with hemodynamic relevanceafter valve replacement, impaired performance, relevant cardiac arrhythmias or impaired hemodynamicsknown aortic aneurysmatrial or ventricular septal defects with hemodynamic relevancepacemaker with overall impaired performance and depending on the pacemaker typeMyocarditis (at least also 6 months after symptoms cease)Pulmonary embolism, thereafter 3 monthsPulmonary hypertension, cor pulmonaleArterial hypertension permanently > 160/100 mmHgSymptomatic peripheral circulatory disordersDeep vein thrombosis, until full mobilizationopen leg ulcerRelative contraindications:Myocardial infarction or cardiac surgery after 12 months with no symptoms, unremarkable exercise ECG and good exercise capacity and ventricular function.Grade I valve disease or 12 months or older after valve replacement with normal hemodynamics and valve function (echo + long-term ECG)Atrial or ventricular septal defects without hemodynamically effective shunt (echo / TEE)Functionally patent foramen ovale with diving restrictions and recommendationsafter overall assessment cardiac arrhythmias like AV block II°b, extrasystoles, ventricular arrhythmias, left bundle branch block, normofrequency atrial fibrillationpacemaker depending on type and underlying diseasemyocarditis after 6 months if well healedPulmonary embolism after 3 months with good lung functionLeg vein thrombosis in healing up to 6 monthsAnticoagulation / blood thinning is not a contraindication for diving.ENTAbsolute contraindications:lack of or severely limited pressure equalizationperforation of the tympanic membrane or a tube in the ear, atelectasisacute and chronic inflammation of the auditory canal, middle ear, inner ear and tubeatresia or non-evaluability of the tympanic membrane in case of occlusion of the auditory canalpersistent tube dysfunction after successful surgery of the tympanic membraneextensive radical surgery of the middle ear and mastoidacute and chronic balance disorders at rest or light exertionnasal septal deformity with disturbed tubal functionInability to hold and seal the mouthpiece (e.g., stroke or jaw injury)Functionally limiting and relevant laryngeal diseasesacute dental diseasesRelative contraindications:mild ear canal irritation or changes after surgerygood tubal function after successful treatment of pressure equalization disorder, healing of tympanic membrane perforation, relevant scars, atrophic changes, tubal catarrh, after middle ear infection, surgery, etc.after operations of the nose, larynx or eardrum with good overall function from 3 months onwardshearing improving operations individuallychronic vestibular disorders only under severe stress, normal provocation test or absence of symptoms after vestibular disordersdeafness, severe hearing loss, tinnitus or after hearing lossLaryngeal diseases without functional impairment with complaintschronic dental diseases, insufficient fillings and dentures

Mental state

Absolute contraindications:repeated hyperventilation syndrome with clear disposition to recurrencepanic and anxiety disorder confirmed and also already with justified suspicion or unstable mental situationacute psychoses (schizophrenic or manic-depressive) of psychological or organic originacute aggressive statesacute depression or medication of antidepressants, suicide attemptsanorexia nervosa and bulemiaphysical or psychological addictions (drugs, medication, alcohol)Relative contraindications:one-time hyperventilation syndrome with a known triggerafter psychotic disorder of any kind with stable conditions and no need for medicationovercome depression without medication or suicide riskafter anorexia nervosa with reintegration and normal eating behaviorafter addictions from 12 months depending on the remaining organic or psychological damage.Internal organsAbsolute contraindications:decompensating metabolic diseases, all relevant inflammatory diseasesall acute diseases with danger of collapseacute diarrhea or symptomatic colitisflorid ulcer, or after multiple gastrointestinal bleedingsacute anemia of unclear origin, thallasemia major in generaldiabetes mellitus 1 and 2 with poor control, hypoglycemia in the last 2 yearsknown intestinal obstruction in history, operationssevere flatulence or other intestinal gasinguinal hernia not reducible or painfulacute symptomatic stone disease, ureteral stones in generalprostate disease with recurrent urinary retentionclear renal insufficiency, hemodialysisoperations without sufficient wound healinginadequately treated disorders of increased coagulation, cryoglobinemia in generalRelative contraindications:stable mild metabolic diseases without risk potentialall stable chronic diseases with good performanceAdiposits, severe overweight with high fat mass due to increased inert gas accumulation !clear micturition disorders of any kindknown urological malformations even with good function, symptom-free kidney stones, after kidney transplantationrenal insufficiency (KreaClearance > 20) and good functionnon-symptomatic inguinal hernias, or after surgeryintestinal obstruction with adhesiolysis and absence of symptomsat most mild flatulence or other intestinal gashealed or treated ulcer disease without symptomsknown diabetes mellitus in experienced and disciplined sport divers with reliable and good adjustment, known signal signs of hypoglycemiasurgery with sufficient healing and good performanceknown acute anemia with good performanceMusculoskeletal system - Traumatology - OrthopedicsAbsolute contraindications:Degenerative, inflammatory or post-traumatic changes without sufficient self-control, efficiency or coordinationinsufficient self-controlled swimming ability or breathing safetyrehabilitation phase after operations or repositions, orthoseschest deformities with limited lung function ( < 70% )acute bone necrosis of any kindRelative contraindications:assured independence or experienced and assistive companionship, overall sufficient performance with assistive devicesrecurrent or habitual dislocations with persistent instabilitycompleted rehabilitation after trauma or surgerysignificant thoracic deformities without restriction of lung functionsubacute bone necrosis and absence of symptomsEyesAbsolute contraindications:angle-closure glaucoma or traumatic narrow-angle glaucoma after known glaucoma attackintraocular surgery (e.g. cataract) up to 1 monthcorneal operations 3-12 months depending on type of operationsevere ocular vascular diseases or after ocular hemorrhagesignificant visual field limitations e.g. after loss of one eye 4 months due to missing stereopsisnot compensated or corrected hyperopia > 4 dioptersRelative contraindications:unhealed ocular inflammationprimary open angle glaucoma also with functional impairmentknown narrow but asymptomatic chamber angleintraocular surgery (e.g. cataract) up to 3 monthsvisual field loss > 80% horizontal and > 50% vertical depending on underlying disease, diving candidates first in handicapped divingloss of one eye 4-12 months due to development of pseudostereopsis, experienced diving partnerlimited visual acuity < 0,5, possibly lower depending on instrumentsContact lenses, soft ones recommended because of better adhesionVariousAbsolute contraindications:mind-altering medication such as antidepressants, cytostatics or also Lariam with dizziness symptomsPregnancy (even without reliable evidence of a risk)Relative contraindications:Skin diseases e.g. eczema or cold urticaria or with risk of infectionafter pregnancy 4-6 weeks, 6-10 weeks after sectioexternal bowel outlet with good independent care - self-interest and actually also no contraindicationperformance-limiting medicationanticoagulation or risk of bleedingBoastful fearlessness, presentation without diving licenseFear with diving reluctance

Based on an old Lancet study back in the 1990s more than 60% of apoplexy in post partum Sheehan syndrome were associated with an underlying pituitary adenoma. There could be an undiagnosed pituitary adenoma who's prevalence is about 10-15% of adult population. On top of that you have someone on thrombosis prophylaxis which increases the risk. 

The anticoagulant theraphy has to be mantain until chemotherapy treatment is done and the cáncer has been fully cure, becaouse paraneoplasic syndrome and hypercoagulable condición due to chemotherapy could be the couse of the aortic thrombosis