CVT in Mexico

1. 54
55
56
1 Cerebral Venous Thrombosis in a Mexican Multicenter Registry 57
2
3
of Acute Cerebrovascular Disease: The RENAMEVASC Study 58
59
4 60
5 61
6 Jos L. Ruiz-Sandoval, MD,*† Erwin Chiquete, MD, PhD,*
e 62
7 ~ 63
L. Jacqueline Banuelos-Becerra, MD,‡ Carolina Torres-Anguiano, MD,‡
8 64
9 Christian Gonzlez-Padilla, MD,‡ Antonio Arauz, MD,x
a 65
10
Carolina Leon-Jimnez, MD,k Luis M. Murillo-Bonilla, MD, MSc,**
e 66
11 67
12 Jorge Villarreal-Careaga, MD,†† Fernando Barinagarrementer MD,‡‡
ıa, 68
13
Q2 Carlos Cant -Brito, MD, PhD xx and the RENAMEVASC investigatorskk
u 69
14 70
15 71
16 72
17 73
18 74
19 Background: Cerebral venous thrombosis (CVT) is a rare form of cerebrovascular 75
20 disease that is usually not mentioned in multicenter registries on all-type acute
76
21 stroke. We aimed to describe the experience on hospitalized patients with CVT in
77
22 a Mexican multicenter registry on acute cerebrovascular disease. Methods: CVT
patients were selected from the RENAMEVASC registry, which was conducted 78
23 79
between 2002 and 2004 in 25 Mexican hospitals. Risk factors, neuroimaging,
24 80
and 30-day outcome as assessed by the modified Rankin scale (mRS) were analyzed.
25 81
Results: Among 2000 all-type acute stroke patients, 59 (3%; 95% CI, 2.3-3.8%) had
26 CVT (50 women; female:male ratio, 5:1; median age, 31 years). Puerperium (42%), 82
27 contraceptive use (18%), and pregnancy (12%) were the main risk factors in women. 83
28 In 67% of men, CVT was registered as idiopathic, but thrombophilia assessment was 84
29 suboptimal. Longitudinal superior sinus was the most frequent thrombosis location 85
30 (78%). Extensive (.5 cm) venous infarction occurred in 36% of patients. Only 81% of 86
31 patients received anticoagulation since the acute phase, and 3% needed decompres- 87
32 sive craniectomy. Systemic venous thromboembolism (8.5%), pneumonia (10.2%),
88
33 and mechanical ventilation (13.6%) were the main in-hospital complications. The
89
34 30-day case fatality rate was 3% (2 patients; 95% CI, 0.23-12.2%). In a Cox propor-
tional hazards model, only age ,40 years was associated with a mRs score of 0 to 90
35 91
2 (functional independence; rate ratio, 3.46; 95% CI, 1.34-8.92). Conclusions: The rel-
36 92
ative frequency of CVT and the associated in-hospital complications were higher
37 than in other registries. Thrombophilia assessment and acute treatment was subop- 93
38 timal. Young age is the main determinant of a good short-term outcome. Key Words: 94
39 Cerebral veins—cerebral venous thrombosis—cerebrovascular disease—cranial 95
40 sinuses—outcome—stroke. 96
41 Ó 2011 by National Stroke Association 97
42 98
43 99
44 From the *Department of Neurology, Hospital Civil de Guadalajara 100
Zubirn,’’ Mexico City, Mexico; and kkRENAMEVASC investigators
a
45 ‘‘Fray Antonio Alcalde,’’, †Department of Neurosciences, Centro Uni-
are listed in the Appendix. 101
46 versitario de Ciencias de la Salud, Universidad de Guadalajara,
Received May 2, 2010; revision received December 23, 2010; 102
‡Department of Internal Medicine, Hospital Civil de Guadalajara
47 accepted January 13, 2011.
103
‘‘Fray Antonio Alcalde,’’ Guadalajara, Mexico, xStroke Clinic, Insti-
48 tuto Nacional de Neurolog y Neurociruga, Mexico City, Mexico,
ıa ı
Address correspondence to Jos L. Ruiz-Sandoval, MD, Servicio de
e
104
Neurologa y Neurocirug Hospital Civil ‘‘Fray Antonio Alcalde,’’
ı ıa,
49 kDepartment of Neurology, Hospital Valentn Gmez Far Zapo-
ı o ıas, 105
Hospital 278, 44280 Guadalajara, Jalisco, Mexico. E-mail:
50 pan, Mexico, **Endovascular Therapy, Instituto Panvascular de Occi-
jorulej-1nj@prodigy.net.mx. 106
51 dente and Universidad Autnoma de Guadalajara, Guadalajara,
o
1052-3057/$ - see front matter 107
Mexico, ††Departments of Neurology at the Hospital General de
52
Ó 2011 by National Stroke Association
108
Culiacn, Culiacn, ‡‡Hospital Angeles Quertaro, Quertaro,
a a e e
53 xxInstituto Nacional de Ciencias Mdicas y Nutricin ‘‘Salvador
e o
doi:10.1016/j.jstrokecerebrovasdis.2011.01.001
109
Journal of Stroke and Cerebrovascular Diseases, Vol. -, No. - (---), 2011: pp 1-6 1
FLA 5.1.0 DTD Š YJSCD733_proof Š 8 February 2011 Š 12:10 pm Š ce

2. 2 J.L. RUIZ-SANDOVAL ET AL.
110 Cerebral venous thrombosis (CVT) is the least common Wald method. Pearson Chi-square or Fisher exact tests 165
111 form of acute cerebrovascular disease,1 accounting for were used to assess proportions in nominal variables for 166
112 about 0.5% among all types of strokes.2 Depending on bivariate analyses. To compare quantitative variables be- 167
113 the population and methodology, the estimated annual in- tween 2 groups, the Student t and Mann–Whitney U tests 168
114 cidence ranges from 1 to 12 cases per million adults per were performed in distributions of parametric and non- 169
115 year,3-6 and about 7 cases per million children (especially parametric variables, respectively. A Cox proportional 170
116 neonates) per year.7 Although generally considered a con- hazards model was constructed to find independent pre- 171
117 dition with a very good outcome in developed countries, dictors of 30-day functional independence (mRS, 0-2). 172
118 the case fatality rate during the hospitalization period Competing variables were chosen with a P set at , .1 in 173
119 may surpass 15% in low-income nations, especially associ- the bivariate selection process. Adjusted rate ratios (RRs) 174
120 ated with a delay in diagnosis and with low anticoagula- with the respective 95% CIs are provided. A Kaplan–Meier 175
121 tion practice.6,8-10 actuarial analysis was performed to evaluate the associa- 176
122 In Mexico, information regarding CVT has mainly de- tion of the independent predictors with a good functional 177
123 rived from single-center reports, with a relative frequency outcome (mRS, 0-2) during the follow-up. P values are 178
124 among all forms of acute cerebrovascular disease ranging 2-sided and considered significant when P , .05. SPSS 179
125 from 0.43% to 8%.11-13 There is a paucity of international for Windows (version 17.0; SPSS, Chicago, IL) was used 180
126 epidemiologic data on incidence, prevalence, or relative in all calculations. 181
127 frequency among hospitalized stroke patients, and 182
128 hospital registers on all-type acute stroke cases rarely refer 183
Results
129 specifically to CVT.14,15 The National Mexican Registry 184
130 of Cerebral Vascular Disease (RENAMEVASC) was a The RENAMEVASC registry included 2000 hospital- 185
131 multicenter stroke surveillance system that included ized patients with all types of acute cerebrovascular dis- 186
132 2000 consecutive patients with all types of acute ease. In all, 59 (2.97%; 95% CI, 2.3-3.8%) had CVT. There 187
133 cerebrovascular disease,16,17 of whom 59 were identified were 50 (85%) women and 9 (15%) men (female:male ra- 188
134 with CVT. The aim of this report on CVT is to describe tio, 5:1), with a median age of 31 years (interquartile 189
135 the risk factors, neuroimaging features, acute range, 22-39 years). A total of 45 (76%) patients were 190
136 management, in-hospital complications, and the 30-day younger than 40 years of age. The median time from neu- 191
137 outcomes of CVT patients hospitalized in Mexico. rologic symptoms to hospital presentation was 48 hours 192
138 (interquartile range, 15-96 hrs). Only 1 case of CVT was 193
139 Methods identified during hospital stay for another cause. Table 1 194
140 shows the main risk factors and clinical presentation asso- 195
Patients
141 ciated with CVT, stratified by gender and age. Puerpe- 196
142 This prospective, hospital-based multicenter registry rium and oral contraceptives use were the most 197
143 was conducted between November 2002 and October frequent etiologies (in the female gender separately, 42% 198
144 2004 in 25 referral centers from 14 states of Mexico. All in- and 18%, respectively). Only 1 of 21 (4.7%) women in pu- 199
145 vestigators were neurologists trained in cerebrovascular erperium had severe concomitant anemia (hemoglobin 200
146 disease. The complete methodology of the RENAME- concentration ,7 g/dl), and only one patient (a 57-year- 201
147 VASC study has been reported elsewhere.16,17 Briefly, old woman) had this factor as the unique etiology of 202
148 consecutive patients were registered if a suspected acute CVT. As expected, puerperium was more frequent among 203
149 cerebrovascular disease was confirmed and accurately young women than their older counterparts (51.2% v 0%); 204
150 classified by computed tomographic (CT) or magnetic however, no differences on contraceptive use were ob- 205
151 resonance imaging (MRI) scanning in all patients. A served when comparing women aged ,40 years of age 206
152 standardized case report form was used to collect with older females (17.1% v 22.2%; P 5 .66). CVT was as- 207
153 clinical data from the patient or primary guardian. The sociated with pregnancy in 6 (14.5%) women. Among all 208
154 patient’s functional status was classified by the patients, a previous major surgery in the last 15 days was 209
155 modified Rankin scale (mRS). For the purpose of this more frequently observed in people $40 years of age than 210
156 report, patients with CVT confirmed by MRI, MRI in younger patients (P 5 .009). No cases associated with 211
157 venography, or four-vessel angiography were included. malignancy were identified. There were no assessments 212
158 The coordinating office performed the case ascertain- for hereditary thrombophilia in this cohort. 213
159 ments. The internal committee of ethics of every partici- At hospital arrival, 33 (56%) patients were alert, 21 214
160 pating center approved the present study. Informed (36%) drowsy, 3 (5%) stuporous, and 2 (3%) in coma. 215
161 consent was obtained from the patient or the legal proxy. The mean Glasgow coma score at hospital presentation 216
162 was 13.5 points (range, 3-15 points; median, 14; interquar- 217
Data Analysis
163 tile range, 13-15 points). Headache and nausea/vomiting 218
164 For the main relative frequencies reported, 95% confi- were more frequent in women than in men, whereas mo- 219
dence intervals (CIs) were calculated using the adjusted tor deficit was more common in the male gender (Table 1). 220
FLA 5.1.0 DTD Š YJSCD733_proof Š 8 February 2011 Š 12:10 pm Š ce

3. CEREBRAL VENOUS THROMBOSIS IN MEXICO 3
221 Table 1. Analysis of risk factors and clinical presentation of cerebral venous thrombosis 276
222 277
Gender, n (%) Age, n (%) 278
223
224 279
All patients Male Female ,40 y $40 y
225 Variables (n 5 59) (n 5 9) (n 5 50) Py (n 5 45) (n 5 14) Pz 280
226 281
227 Risk factors,* n (%) 282
228 Puerperium 21 (35.6) 0 21 (42.0) .01 21 (46.7) 0 .001 283
229
Oral contraceptives 9 (15.3) 0 9 (18.0) .17 7 (15.6) 2 (14.3) .90 284
Major surgery in the last 15 days 6 (10.2) 2 (22.2) 4 (8.0) .20 2 (4.4) 4 (28.6) .009 285
230
Pregnancy 6 (10.2) 0 6 (12.0) .27 6 (13.3) 0 .15 286
231 Current smoking 5 (8.5) 1 (11.1) 4 (8.0) .76 3 (6.7) 2 (14.3) .37
232 287
Severe anemia 4 (6.9) 1 (11.1) 3 (6.1) .50 2 (4.5) 2 (14.3) .21
233 288
Migraine 2 (3.4) 0 2 (4.0) .99 2 (4.4) 0 .99
234 Clinical presentation, n (%) 289
235 Headache 54 (91.5) 6 (66.7) 48 (96.0) .02 43 (95.6) 11 (78.6) .08 290
236 Seizures 12 (20.3) 0 12 (24.0) .18 10 (22.2) 2 (14.3) .71 291
237 Nausea/vomiting 34 (57.6) 1 (11.1) 33 (66.0) .003 27 (60.0) 7 (50.0) .51 292
238 Altered mental status 28 (47.5) 4 (44.4) 24 (48.0) .99 20 (44.4) 8 (57.9) .41 293
239 Focal motor deficit 10 (16.9) 4 (44.4) 6 (12.0) .04 7 (15.6) 3 (21.4) .69 294
240
Impaired speech 12 (20.3) 0 12 (24.0) .18 1 (2.2) 3 (21.4) .04 295
241 296
*No risk factors were identified in 6 (66.7%) male patients.
242 297
yP value for differences between men and women; Chi-square or Fisher exact test as appropriate.
243 zP value for differences between persons $40 years of age or younger; Chi-square or Fisher exact test as appropriate. 298
244 299
245 300
246 Brain imaging studies showed extensive venous infarc- that systemic thromboembolism occurred during hospital 301
247 tion (length .5 cm) or edema in 21 (36%) patients and stay in 8% of cases (1 case resulting in death) without 302
248 bihemispheric infarction in 13 (22%; Table 2). Longitudi- differences between genders or age groups. A total of 303
249 nal superior sinus was the most frequent location of 48 (81%) patients received anticoagulation in the acute 304
250 CVT (78% of patients), followed by the lateral sinus in 9 stage, with intravenous heparin being the most frequent 305
251 (15%) cases. No differences were observed according to method (46%) followed by low-molecular-weight heparin 306
252 gender or age groups with respect to CVT location, exten- (LMWH; 31%) and oral coumarins (5%). Two (3%) patients 307
253 sion, or in-hospital complications. underwent craniectomy (Table 2). 308
254 Mean in-hospital stay was 16.8 days (range, 3-57 days); In all, 37 (63%) patients attained functional indepen- 309
255 being significantly higher among older patients than in dence (mRS, 0-2) at hospital discharge, 20 (34%) were de- 310
256 younger individuals (24.1 v 14.6 days, respectively; P 5 pendent, and 2 (3%; 95% CI, 0.23-12.2%) died (Table 4). 311
257 .005). Mechanical ventilation and hospital-acquired pneu- Of the 2 fatalities registered, 1 was attributed to a neuro- 312
258 monia were more frequent in patients $40 years of age logic etiology (a women in puerperium with longitudinal 313
259 than in younger individuals (Table 3). It is noteworthy sinus thrombosis, severe hemorrhagic venous infarction, 314
260 315
261 316
262 Table 2. Radiologic features of patients with cerebral venous thrombosis 317
263 318
Gender, n (%) Age, n (%) 319
264
265 All patients Male Female ,40 y $40 y 320
266 Variables (n 5 59) (n 5 9) (n 5 50) P* (n 5 45) (n 5 14) Py 321
267 322
268 Radiologic features, n (%) 323
269
Extensive venous infarction (.5 cm) 21 (35.6) 3 (33.3) 18 (36.0) .88 16 (35.6) 5 (35.7) .99 324
Bihemispheric venous infarction 13 (22.0) 2 (22.2) 11 (22.0) .99 10 (22.2) 3 (21.4) .95 325
270
Longitudinal superior 46 (78.0) 6 (66.7) 40 (80.0) .37 34 (75.6) 12 (85.7) .42 326
271 Lateral 9 (15.3) 3 (33.3) 6 (12.0) .10 8 (17.8) 1 (7.1) .33
272 327
Straight sinus 2 (3.4) 0 2 (4.0) .99 2 (4.4) 0 .99
273 328
Cortical veins 2 (3.4) 2 (4.0) 0 .99 1 (2.2) 1 (7.1) .42
274 329
275 *P value for differences between men and women; Chi-square or Fisher exact test as appropriate. 330
yP value for differences between persons $40 years of age or younger; Chi-square or Fisher exact test as appropriate. 331
FLA 5.1.0 DTD Š YJSCD733_proof Š 8 February 2011 Š 12:10 pm Š ce

4. 4 J.L. RUIZ-SANDOVAL ET AL.
332 Table 3. In-hospital management and complications in patients with cerebral venous thrombosis 387
333 388
Gender, n (%) Age, n (%) 389
334
335 390
All patients Male Female ,40 y $40 y
336 Variables (n 5 59) (n 5 9) (n 5 50) P* (n 5 45) (n 5 14) Py 391
337 392
338 Complications, n (%) 393
339 Mechanical ventilation 8 (13.6) 2 (22.2) 6 (12.0) .41 3 (6.7) 5 (35.7) .006 394
340
Hospital-acquired pneumonia 6 (10.2) 2 (22.2) 4 (8.0) .19 1 (2.2) 5 (35.7) .001 395
DVT/pulmonary embolism 5 (8.5) 1 (11.1) 4 (8.0) .76 4 (8.9) 1 (7.1) .84 396
341
Urinary tract infections 2 (3.4) 0 2 (4.0) 1 1 (2.2) 1(7.1) .42 397
342 Acute management, n (%) 57 (96.6) 8 (88.9) 49 (98.0) .28 45 (100) 12 (85.7) .05
343 398
Intravenous heparin 27 (45.8) 3 (33.3) 24 (48.0) .42 24 (53.3) 3 (21.4) .04
344 399
LMWH at therapeutic dosage 11 (18.6) 2 (22.2) 9 (18.0) .76 7 (15.6) 4 (28.6) .27
345 LMWH at prophylactic dosage 7 (11.9) 1 (11.1) 6 (12.0) .94 5 (11.1) 2 (14.3) .74 400
346 Oral anticoagulant therapy 3 (5.1) 0 3 (6.0) .99 2 (4.4) 1 (7.1) .56 401
347 Antiplatelets 7 (11.9) 2 (22.2) 5 (10.0) .29 6 (13.3) 1 (7.1) .99 402
348 Steroids 1 (1.7) 0 1 (2.0) .99 0 1 (7.1) .24 403
349 Craniectomy 2 (3.4) 0 2 (4.0) .99 1 (2.2) 1 (7.1) .42 404
350 405
Abbreviations: DVT, deep vein thrombosis; LMWH, low-molecular-weight heparin. 406
351 *P value for differences between men and women; Chi-square or Fisher exact test as appropriate.
352 407
yP value for differences between persons $40 years of age or younger; Chi-square or Fisher exact test as appropriate.
353 408
354 409
355
and coma at hospital presentation) and the other as of sys- Discussion 410
356
temic cause (a women with hypothyroidism who develop 411
The RENAMEVASC study is the first collaborative,
357
massive pulmonary thromboembolism, is spite of anticoa- 412
gulation with LMWH). At 30 days of follow-up, 43 (73%) nongovernmental, non–industry sponsored registry on
358 413
patients were independent and 14 (24%) remained patients hospitalized with all-type acute cerebrovascular
359 414
disease. In this registry, we observed 3% of cases with
360
functionally dependent for activities of daily living. No 415
CVT among all stroke types. In other countries, the rela-
361
further deaths were registered at 30 days (Table 4). In 416
tive frequency ranges from 0.5% to 2%.2,5,9,10 However,
362
a Cox proportional hazards model adjusted for gender, 417
in autopsy studies, CVT has been observed in a relative
363
Glasgow coma scale at admission, in-hospital pneumonia, 418
and systemic thromboembolism, only age , 40 years was frequency of as much as 10%,19 which suggests that
364 419
CVT is often clinically overlooked. Here we observed
365
independently associated with a good 30-day outcome 420
(RR, 3.46; 95% CI, 1.34-8.92; Fig 1). Time from CVT onset a very high female:male ratio, possibly because of
366 421
to hospital presentation was not independently associated selection bias and to a high proportion of gender-
367 422
specific risk factors. For comparison, in the ISCVT
368
with a good or adverse outcome. 423
369 424
370 425
371 Table 4. Outcome at hospital discharge and at 30-day follow-up in patients with cerebral venous thrombosis 426
372 427
373 Gender, n (%) Age, n (%) 428
374 429
All patients Male Female ,40 y $40 y
375 430
Variables (n 5 59) (n 5 9) (n 5 50) P* (n 5 45) (n 5 14) Py
376 431
377 mRS at discharge, n (%) 432
378 0-2 37 (62.7) 3 (33.3) 34 (68.0) .05 34 (75.6) 3 (21.4) ,.001 433
379 3-5 20 (33.9) 6 (66.7) 14 (28.0) .02 10 (22.2) 10 (71.4) .001 434
380 6 2 (3.4) 0 2 (4.0) .99 1 (2.2) 1 (7.1) .42 435
381
mRS at 30-day follow-up 436
0-2 43 (72.9) 6 (66.7) 37 (74.0) .65 38 (84.4) 5 (35.7) ,.001 437
382
3-5 14 (23.7) 3 (33.3) 11 (22.0) .46 6 (13.3) 8 (57.1) .001 438
383 6 2 (3.4) 0 2 (4.0) .99 1 (2.2) 1 (7.1) .42
384 439
385 Abbreviations: mRs, modified Rankin score. 440
386 *P value for differences between men and women; Chi-square or Fisher exact test as appropriate. 441
yP value for differences between persons $40 years of age or younger; Chi-square or Fisher exact test as appropriate. 442
FLA 5.1.0 DTD Š YJSCD733_proof Š 8 February 2011 Š 12:10 pm Š ce

5. CEREBRAL VENOUS THROMBOSIS IN MEXICO 5
443 This important finding emphasizes the need for anticoagu- 498
444 lation at therapeutic doses as soon as CVT is identified.1,32 499
445 The main limitation of this report is the small sample 500
446 size, which prevents an accurate detection of small, but 501
447 clinically meaningful differences, especially in outcome 502
448 analyses. Long-term follow-up was not registered, and 503
449 as a consequence, other important complications, such as 504
450 neuropsychological impairment and CVT recurrence, 505
451 could not be analyzed. Nevertheless, this study may pro- 506
452 vide important information for comparative epidemiology 507
453 that may potentially improve deliver of care in Mexico. 508
454 In conclusion, this multicenter registry showed that the 509
455 relative frequency of CVT in hospitalized cerebrovascular 510
456 patients in Mexico is higher than expected. Acute case 511
457 fatality rate is relatively low, but numerous in-hospital 512
458 short-term complications occurred. Acute management 513
459 Figure 1. Kaplan–Meier actuarial analyses on the probability of achieving
with therapeutic anticoagulation was suboptimal and 514
460 a modified Rankin scale score of 0 to 2 (functional independence) during the may potentially account for the high rate of systemic 515
461 follow-up period, as a function of age , 40 years (n 5 45) or older (n 5 14). thromboembolism observed in this registry. 516
462 517
463 registry, roughly 75% of patients were women (a 3:1 518
464 female:male ratio).20 In most international studies, the References 519
465 main risk factors for CVT are thrombophilia, oral contra- 520
1. Einh€upl K, Stam J, Bousser MG, et al. EFNS guideline on
a
466 ceptive use, infections, pregnancy, puerperium, and ma- the treatment of cerebral venous and sinus thrombosis in 521
467 lignancy.9,10,18,20-24 In our study, gender-specific risk adult patients. Eur J Neurol 2010;17:1229-1235. 522
468 factors explained the majority of cases. This differs greatly 2. Filippidis A, Kapsalaki E, Patramani G, Fountas KN. 523
469 from registries conducted in developed countries,20,23 Cerebral venous sinus thrombosis: Review of the demo- 524
where a systematic search for thrombophilia and an graphics, pathophysiology, current diagnosis, and treat- 525
470 ment. Neurosurg Focus 2009;27:E3.
471 active seeking of patients from the oncology and 3. Saadatnia M, Mousavi SA, Haghighi S, Aminorroaya A. 526
472 hematology wards is performed. CVT is a consequence Cerebral vein and sinus thrombosis in Isfahan-Iran: A 527
473 of multiple factors, and the identification of one of them changing profile. Can J Neurol Sci 2004;31:474-477. 528
474 should not prevent the intentional search for coexisting 4. Janghorbani M, Zare M, Saadatnia M, et al. Cerebral vein 529
causes1 that may potentially increase the probability of re- and dural sinus thrombosis in adults in Isfahan, Iran: 530
475 Frequency and seasonal variation. Acta Neurol Scand
476 currence.25-27 In the ISCVTregistry, 44% of the patients had 2008;117:117-121. 531
477 .1 risk factor, and congenital or genetic thrombophilia 5. Siddiqui FM, Kamal AK. Incidence and epidemiology of 532
478 was present in 22% of patients.20 A gender-specific risk fac- cerebral venous thrombosis. J Pak Med Assoc 2006; 533
479 tor was present in 65% women.20 56:485-487. 534
A case fatality rate of 3% was observed in our 6. Ferro JM, Correia M, Pontes C, et al. Cerebral vein and 535
480 dural sinus thrombosis in Portugal: 1980-1998. Cerebro-
481 registry, considerably lower than other studies that vasc Dis 2001;11:177-182. 536
482 report rates from about 6% to as high as 27% in elderly 7. deVeber G, Andrew M, Adams C, et al. Cerebral sinove- 537
483 patients.8-10,20,29,30 Indeed, this could represent a survival nous thrombosis in children. N Engl J Med 2001;345: 538
484 bias of our study; nevertheless, this low case fatality rate 417-423. 539
occurred at expense of a relatively high frequency of 8. Dentali F, Gianni M, Crowther MA, Ageno W. Natural 540
485 history of cerebral vein thrombosis: A systematic review.
486 cases with severe disabilities and numerous short-term Blood 2006;108:1129-1134. 541
487 (mainly in-hospital) complications. In-hospital systemic 9. Daif A, Awada A, al-Rajeh S, et al. Cerebral venous 542
488 thromboembolism was observed in 8% of our cases. An thrombosis in adults. A study of 40 cases from Saudi 543
489 early literature review (1942-1990) performed by Diaz Arabia. Stroke 1995;26:1193-1195. 544
et al.28 revealed that 11% of CVT cases were associated 10. Khealani BA, Wasay M, Saadah M, et al. Cerebral venous 545
490 thrombosis: A descriptive multicenter study of patients
491 with pulmonary embolism, and among these patients, in Pakistan and Middle East. Stroke 2008;39:2707-2011. Q1 546
492 the overall mortality rate was 96%. In a recent report on the 11. Nieto de-Pascual RH, G€ izar-Berm dez C, Ort
u u ız-Trejo JF. 547
493 ISCVT cohort, 6% of cases had systemic thromboembo- Epidemiolog de la enfermedad vascular cerebral en el
ıa 548
494 lism.31 This discrepancy between ours and the ISCVT reg- Hospital General de Mxico [in Spanish]. Rev Med
e 549
istry with respect to systemic venous thromboembolism Hosp Gen Mex 2003;66:7-12. 550
495 12. Rodr ıguez-Rubio LR, Medina-Crdova LL, Andrade-
o
496 parallels the different frequency of full anticoagulation in Ramos MA, et al. Trombosis venosa cerebral en el Hospi- 551
497 the acute phase of management (64% v 83% in the tal Civil de Guadalajara ‘‘Fray Antonio Alcalde’’ [in 552
RENAMEVASC and ISCVT registries, respectively).20 Spanish]. Rev Mex Neuroci 2009;10:177-183. 553
FLA 5.1.0 DTD Š YJSCD733_proof Š 8 February 2011 Š 12:10 pm Š ce

6. 6 J.L. RUIZ-SANDOVAL ET AL.
554 13. Ruiz-Sandoval JL, Chiquete E, Navarro-Bonnet J, et al. functionally independent patients. J Stroke Cerebrovasc 609
555
Isolated vein thrombosis of the posterior fossa presenting Dis 2009;18:198-202. 610
as localized cerebellar venous infarctions or hemor- 31. Miranda B, Ferro JM, Canh~o P, et al. Venous thromboem-
a 611
556 rhages. Stroke 2010;41:2358-2361. bolic events after cerebral vein thrombosis. Stroke 2010;
557 14. Lavados PM, Sacks C, Prina L, et al. Incidence, 30-day 41:1901-1906. 612
558 case-fatality rate, and prognosis of stroke in Iquique, 32. Bousser MG. Cerebral venous thrombosis: Nothing, hep- 613
559 Chile: A 2-year community-based prospective study arin, or local thrombolysis? Stroke 1999;30:481-483. 614
560
(PISCIS project). Lancet 2005;365:2206-2215. 615
15. Cantu-Brito C, Majersik JJ, Snchez BN, et al. Hospital-
a 616
561 ized stroke surveillance in the community of Durango,
Appendix
562 Mexico: The brain attack surveillance in Durango study. 617
563 Stroke 2010;41:878-884. 618
564 16. Ruiz-Sandoval JL, Cant C, Chiquete E, et al. Aneurys-
u The RENAMEVASC Investigators 619
565
mal subarachnoid hemorrhage in a Mexican multicenter
Steering committee: C. Cant -Brito, A. Arauz-Gngora, J.L.
u o 620
registry of cerebrovascular disease: The RENAMEVASC 621
566 study. J Stroke Cerebrovasc Dis 2009;18:48-55. Ruiz-Sandoval, J. Villarreal-Careaga, L. Murillo-Bonilla,
567 17. Arauz A, Cantu C, Ruiz-Sandoval JL, et al. Short-term R. Rangel-Guerra, and F. Barinagarrementeria. 622
568 prognosis of transient ischemic attacks: Mexican multi- Coordinating office: C. Cant -Brito and L. Murillo-Bonilla.
u 623
569 center stroke registry. Rev Invest Clin 2006;58:530-539. Participants: The following centers and investigators par- 624
570
18. Bousser MG, Ferro JM. Cerebral venous thrombosis: An
ticipated in the RENAMEVASC study: C. Cant -Brito u 625
update. Lancet Neurol 2007;6:162-170. 626
571 19. Banerjee AK, Varma M, Vasista RK, et al. Cerebrovascular (Instituto Nacional de Ciencias Mdicas y Nutricin Salva-
e o
572 disease in north-west India: A study of necropsy mate- dor Zubirn, Ciudad de Mxico); A. Arauz-Gngora,
a e o 627
573 rial. J Neurol Neurosurg Psychiatry 1989;52:512-515. L. Murillo-Bonilla, and L. Hoyos (Instituto Nacional de 628
574 20. Ferro JM, Canh~o P, Stam J, et al. Prognosis of cerebral
a Neurolog y Neurocirug Ciudad de Mxico). J.L.
ıa ıa, e 629
575
vein and dural sinus thrombosis: Results of the Interna-
Ruiz-Sandoval and E. Chiquete (Hospital Civil de Guada- 630
tional Study on Cerebral Vein and Dural Sinus Thrombo- 631
576 sis (ISCVT). Stroke 2004;35:664-670. lajara, Jalisco); J. Villarreal-Careaga and F. Guzmn-Reyes
a
577 21. Ferro JM, Canh~o P, Stam J, et al. Delay in the diagnosis of
a (Hospital General de Culiacn, Sinaloa); F. Barinagarre-
a 632
578 cerebral vein and dural sinus thrombosis: Influence on menteria (Hospital Angeles de Quertaro, Quertaro);
e e 633
579 outcome. Stroke 2009;40:3133-3138. J.A. Fernndez (Hospital Jurez, Ciudad de Mxico);
a a e 634
580
22. Stam J. Thrombosis of the cerebral veins and sinuses.
B. Torres (Hospital General de Len, Guanajuato);
o 635
N Engl J Med 2005;352:1791-1798. 636
581 23. Wasay M, Bakshi R, Bobustuc G, et al. Cerebral venous C. Len-Jimnez (Hospital General ISSSTE, Zapopan,
o e
582 thrombosis: Analysis of a multicenter cohort from the Jalisco); I. Rodr ıguez-Leyva (Hospital General de San 637
583 United States. J Stroke Cerebrovasc Dis 2008;17:49-54. Luis Potos San Luis Potosi): R. Rangel-Guerra (Hospital
ı, 638
584 24. Cant C, Barinagarrementeria F. Cerebral venous throm-
u Universitario de Nuevo Len, Monterrey, Nuevo Len);
o o 639
585
bosis associated with pregnancy and puerperium.
M. Ba~ os (Hospital General de Balbuena, Ciudad de
n 640
Review of 67 cases. Stroke 1993;24:1880-1884. 641
586 25. Maqueda VM, Thijs V. Risk of thromboembolism after ce- Mxico); L. Espinosa and M. de la Maza, Hospital San
e
587 rebral venous thrombosis. Eur J Neurol 2006;13:302-305. Jos de Monterrey, Nuevo Len); H. Colorado (Hospital
e o 642
588 26. Jukic I, Titlic M, Tonkic A, Rosenzweig D. Cerebral ve- General ISSSTE, Veracruz, Veracruz); M.C. Loy-Gerala 643
589 nous sinus thrombosis as a recurrent thrombotic event (Hospital General de Puebla, Puebla); J. Huebe-Rafool 644
590
in a patient with heterozygous prothrombin G20210A
(Hospital General de Pachuca, Hidalgo); G. Aguayo Leytte 645
genotype after discontinuation of oral anticoagulation 646
591 therapy: How long should we treat these patients with (Hospital General de Aguascalientes, Aguascalientes);
592 warfarin? J Thromb Thrombolysis 2007;24:77-80. G. Tavera-Guittings (Hospital General ISSSTE, Campeche, 647
593 27. Chen CM, Lee-Chen GJ, Wu YR, et al. Recurrent cerebral Campeche); V. Garcia-Talavera (Hospital IMSS ‘‘La Raza,’’ 648
594 venous thrombosis: An Arg359X mutation in the anti- Ciudad de Mxico); O. Ibarra and M. Segura (Hospital
e 649
595
thrombin gene in a Taiwanese family. Thromb Res 2006;
General de Morelia, Morelia); J.L. Sosa (Hospital General 650
118:235-240. 651
596 28. Diaz JM, Schiffman JS, Urban ES, et al. Superior sagittal de Villahermosa, Tabasco); O. Talams-Murra (Hospital
a
597 sinus thrombosis and pulmonary embolism: A syndrome General ISSSTE, Torren, Coahuila); M. Alanis-Quirga
o o 652
598 rediscovered. Acta Neurol Scand 1992;86:390-396. (Hospital Universitario de Torren, Coahuila); J.M. Esca-
o 653
599 29. Ferro JM, Canh~o P, Bousser MG, et al. Cerebral vein and
a milla (Hospital de la Marina Nacional, Ciudad de Mxico);
e 654
600
dural sinus thrombosis in elderly patients. Stroke 2005;
M.A. Alegr (Hospital Central Militar, Ciudad de
ıa 655
36:1927-1932. 656
601 30. Koopman K, Uyttenboogaart M, Vroomen PC, et al. Mxico); and J.C. Angulo (Hospital General, Veracruz,
e
602 Long-term sequelae after cerebral venous thrombosis in Veracruz). 657
603 658
604 659
605 660
606 661
607 662
608 663
664
FLA 5.1.0 DTD Š YJSCD733_proof Š 8 February 2011 Š 12:10 pm Š ce

7. Our reference: YJSCD 733 P-authorquery-v9
AUTHOR QUERY FORM
Journal: YJSCD Please e-mail or fax your responses and any corrections to:
E-mail: elsjmYJSCD@cadmus.com
Article Number: 733 Fax: 717-738-9478
Dear Author,
Please check your proof carefully and mark all corrections at the appropriate place in the proof (e.g., by using on-screen
annotation in the PDF file) or compile them in a separate list. To ensure fast publication of your paper please return your
corrections within 48 hours.
For correction or revision of any artwork, please consult http://www.elsevier.com/artworkinstructions.
Any queries or remarks that have arisen during the processing of your manuscript are listed below and highlighted by flags in
the proof.
Location Query / Remark: Click on the Q link to find the query’s location in text
in article Please insert your reply or correction at the corresponding line in the proof
Q1 Please check the page range provided.
Q2 Author affiliations will appear differently in the print and online versions of your paper. The PDF shows
how the affiliations will present following journal style, whereas the searchable online version will present
as follows in order to provide complete unabridged affiliations. Please check the accuracy of the affiliation
(s) of each author and make changes as appropriate.
*Department of Neurology, Hospital Civil de Guadalajara “Fray Antonio Alcalde,”, Guadalajara, Mexico
yDepartment of Neurosciences, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara,
Guadalajara, Mexico
zDepartment of Internal Medicine, Hospital Civil de Guadalajara “Fray Antonio Alcalde,” Guadalajara,
Mexico
xStroke Clinic, Instituto Nacional de Neurologıa y Neurocirugıa, Mexico City, Mexico
´ ´
kDepartment of Neurology, Hospital Valentın Gomez Farıas, Zapopan, Mexico
´ ´ ´
´
**Endovascular Therapy, Instituto Panvascular de Occidente and Universidad Autonoma de Guadalajara,
Guadalajara, Mexico
yyDepartment of Neurology at the Hospital General de Culiacan, Culiacan, Mexico City, Mexico
´ ´
zzDepartment of Neurology at the Hospital Angeles Queretaro, Queretaro, Mexico City, Mexico
´ ´ ´
xxDepartment of Neurology, Instituto Nacional de Ciencias Medicas y Nutricion “Salvador Zubiran,”
´ ´ ´
Mexico City, Mexico
kkRENAMEVASC investigators are listed in the Appendix
Thank you for your assistance.