Screening for proximal deep vein thrombosis after acute ischemic stroke: a prospective study using clinical factors and plasma d‐dimers

Kelly, James; Rudd, Anthony; Lewis, Richard Kurt; Coshall, Catherine; Parmar, Kiran; Moody, A.R.; Hunt, Beverley J.

doi:10.1111/j.1538-7836.2004.00843.x

Cited by 31 publications

(34 citation statements)

References 20 publications

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“…The VIDAS assay has already been recently shown to be of potential clinical value in prediction of a high-risk group for proximal deep vein thrombosis among patients with acute stroke. 8 We also provide information on the performance of the 3 assays at different cutoff values. It appears that the MDA and VIDAS D-dimer assays may perform marginally better than the Biopool assay as predictors of progressing ischemic stroke.…”

Section: Discussionmentioning

confidence: 99%

d -Dimer Predicts Early Clinical Progression in Ischemic Stroke

Barber

Langhorne

Rumley

et al. 2006

Stroke

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Background and Purpose-Plasma D-dimer levels, measured using a research laboratory assay, independently predict progressing ischemic stroke. We wished to confirm these findings using commercially available assays and to provide data to allow the design of intervention studies. Methods-We studied 219 consecutive acute ischemic stroke admissions of whom 54 (25%) met criteria for progressing stroke. Results-There were strong correlations between D-dimer results as measured by the Biopool AB, MDA and VIDAS assays; correlation coefficients rϭ0.91 to 0.94; all PϽ0.001. In binary logistic regression analyses, D-dimer, as measured by the 3 different assays, was an independent predictor of progressing stroke (odds ratios, 1.87 to 2.45; all PϽ0.001). This confirms the results of our original analysis (Biopool AB) using 2 commercial D-dimer assays, demonstrating the potential usefulness of D-dimer in providing early prognostic information after ischemic stroke in different clinical settings. We also provide information on the performance of the 3 assays in predicting progressing stroke at a variety of cutoff values. Conclusions-Ischemic stroke patients at high risk of early progression can be identified using commercial D-dimer measurements. This could allow selection of high-risk patients for inclusion in randomized trials of early antithrombotic treatments. Key Words:arly clinical progression of ischemic stroke is common and is associated with poor prognosis. 1 D-dimer levels are elevated in the acute phase of stroke and subsequently fall. [2][3][4] We previously demonstrated that plasma D-dimer levels (along with mean arterial blood pressure) independently predict progressing ischemic stroke. 5 This measurement of D-dimer was performed with a commercially available ELISA from Biopool AB used in our research laboratory. We wished to confirm our findings using other commercially available assays commonly used by hospital laboratories, particularly the MDA and VIDAS D-dimer assays. Materials and MethodsWe studied consecutive ischemic stroke admissions. 5 Progressing stroke was defined using a modification of the European Progressing Stroke Study definition. 6 This requires deterioration in conscious level, arm or leg weakness, or speech over 72 hours following admission. Blood was taken within 24 hours of symptom onset, and plasma samples were stored at Ϫ80°C before analysis. The MDA D-dimer assay is an automated latex particle-based immunoassay, and the VIDAS D-dimer assay is an automated enzyme-linked fluorescent assay. 7 Univariate analysis of D-dimer levels used unpaired t tests of natural log-transformed levels. Correlations between the different assays were calculated using the Spearman rank method. Multivariate analysis was performed using a stepwise binary logistic regression procedure including variables when significance was found to be PϽ0.10 in univariate analysis. ResultsFifty-four (25%) of the 219 patients recruited met the criteria for progressing stroke. Table 2 shows the sensitivity, specificity, and po...

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Section: Discussionmentioning

confidence: 99%

d -Dimer Predicts Early Clinical Progression in Ischemic Stroke

Barber

Langhorne

Rumley

et al. 2006

Stroke

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“…Nevertheless, the limited number of our patients does not permit us to propose prognostic values. The diagnostic value of D -dimers among unselected stroke patients had been previously suggested [11] . Larger cohorts may validate these markers to identify a subgroup with a high risk of DVP/PE.…”

Section: Discussionmentioning

confidence: 99%

Diagnostic Yield of Venous Thrombosis and Pulmonary Embolism by Combined CT Venography and Pulmonary Angiography in Patients with Cryptogenic Stroke and Patent Foramen Ovale

et al. 2015

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Background: Paradoxical embolism via a patent foramen ovale (PFO) has been suggested as a potential stroke mechanism. Combined CT venography and pulmonary angiography (CVPA) is a simple, validated and accurate technique to diagnose deep venous thrombosis (DVT) or pulmonary embolism (PE). We sought to assess the prevalence of DVT or PE among patients with PFO and cryptogenic stroke (CS) by CVPA. Methods: Patients were identified retrospectively from a clinical registry of consecutive patients with stroke admitted to our Stroke Unit. The following criteria were required for inclusion in this study: CS, PFO identified by transthoracic echography using contrast medium and CVPA performed during the hospitalization following stroke. Results: A total of 114 patients with PFO underwent a CVPA within 7 days (interquartile range 4-9) from stroke symptom onset. On cerebral imaging, 11% had multiple infarcts. CVPA documented deep vein thrombosis (DVT) in 10 patients (8.8%) and PE in 5 patients (4.4%), that is, a total of 12 patients with prevalence of 10.5% (95% CI 5.5-17.7). Patients with PE-DVT had higher D-dimers and C reactive protein level than patients without PE-DVT (p < 0.05). Conclusion: CVPA may be used by the stroke team in the work-up of suspected paradoxical embolism among cryptogenic ischemic stroke patients with PFO.

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“…So the clinician's index of suspicion must be high and there should be awareness of subtle signs such as slight increases in calf diameter and tension, a raised respiratory rate and/or heart rate, and minor changes in oxygen saturation. It has to be said these clinical signs may only have moderate predictive value, for instance in the MRDTI study of severe ischemic stroke patients a calf diameter change of 1 cm had a sensitivity of 44 % and positive predictive value of 53 %, whilst using 2 cm change had a greater positive predictive value of 78 % but sensitivity fell to 28 % [ 99 ]. Nevertheless, under current processes of care, relying on clinical signs are the mainstay of diagnosis, and knowing the greater risks associated with clinical VTE, it is better to investigate any suspicion and not dismiss them or presume infection or oedema.…”

Section: Diagnosis Of Vtementioning

confidence: 97%

“…Various things, including the older batch assay and the rehabilitation setting with recruitment 3 months after stroke, probably means this d -dimer level is not applicable for use for acute stroke today. The more recent MRDTI study found the VIDAS ELISA test of 2,096 ng/ml and the IL agglutination test of 1,174 ng/ml had a sensitivity of 78 % and 83 % for proximal DVT, but at the cost of imaging 30 % of the patients [ 99 ].…”

Section: -Dimermentioning

confidence: 97%

Venous Thromboembolism

Pathansali¹

2015

Management of Post-Stroke Complications

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Venous thromboembolism after acute stroke has long been a diagnostic and management problem. From the realisation in the 1970s that the incidence of deep-vein thrombosis could be as great as 75 % because of a high unrecognised subclinical element, and silent pulmonary embolism may be the cause of a high proportion of post-stroke deaths, the concern has been on how to prevent this potentially deadly complication. The use of subcutaneous low-dose anticoagulation successful in other groups of high-risk patients has been fraught with the fear of causing intracranial haemorrhage in ischaemic stroke and extending bleeding in intracranial haemorrhage. Some have felt that the benefi ts of anticoagulation outweigh the risk, especially when using low-molecular-weight heparin, others have opted for mechanical prophylaxis which until recently had scant evidence in acute stroke. Meanwhile, improvements in acute stroke care appears, in itself, to have led to a fall in the incidence of venous thromboembolism, making the case for benefi t over risk of prophylactic anticoagulation less clear. Recent large trials have also both clarifi ed and strengthened the case for mechanical thromboprophylaxis, showing clearly that graduated compression stockings were not benefi cial, but intermittent pneumatic compression did prevent deep-vein thrombosis and reduce mortality. Venous thromboembolism when it occurs should be treated as a matter of urgency with anticoagulation or an inferior vena cava fi lter if the risk of bleeding is high. Keywords Key Messages• Occurs early after stroke and presents a diagnostic and management challenge.• Risk factors include severity of the stroke, immobility, and dehydration.

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Screening for proximal deep vein thrombosis after acute ischemic stroke: a prospective study using clinical factors and plasma d‐dimers

Cited by 31 publications

References 20 publications

d -Dimer Predicts Early Clinical Progression in Ischemic Stroke

d -Dimer Predicts Early Clinical Progression in Ischemic Stroke

Diagnostic Yield of Venous Thrombosis and Pulmonary Embolism by Combined CT Venography and Pulmonary Angiography in Patients with Cryptogenic Stroke and Patent Foramen Ovale

Venous Thromboembolism

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