Management of a decompensated acute-on-chronic intracranial venous sinus thrombosis

Abstract

A 34-year-old female patient presented during the 10th week of her second gravidity with headache, nausea and vomiting 2 weeks before admission. Her medical history was remarkable for a heterozygous factor V Leiden mutation, elevated lipoprotein A, and a cerebral venous thrombosis (CVT) after oral contraceptive intake 15 years before. Magnetic resonance imaging (MRI) suggested acute and massive intracranial sinus thrombosis. Despite full-dose anticoagulation, the patient deteriorated clinically and eventually became comatose. Now, MRI/magnetic resonance angiography revealed vasogenic edema of both thalami, of the left frontal lobe, and of the head of the caudate nucleus, with venous stasis and frontal petechial hemorrhage. She was referred for endovascular treatment. Diagnostic angiography confirmed a complete superficial and deep venous sinus occlusion. Endovascular access to the straight and superior sagittal sinus was possible, but neither rheolysis nor balloon angioplasty resulted in recanalization of the venous sinuses. Monitored heparinization was continued and antiaggregation was initiated. The patient remained comatose for another 5 days and MRI showed progress of the cytotoxic edema. On day 6, infusion of eptifibatide at body-weight-adapted dosage was started. The following day, the patient improved and slowly regained consciousness. MRI confirmed regression of the edema. The eptifibatide infusion was continued for a total of 14 days. Thereafter two doses of 180 mg ticagrelor per os (PO) daily were started. The patient remained on acetylsalicylic acid (ASA), ticagrelor, and enoxaparin on an unchanged dosage regimen. She was discharged home 26 days after the endovascular treatment without serious neurological deficit, with the pregnancy intact. At the 30th week of pregnancy the dosage of ASA was reduced to 300 mg once PO daily. Cesarian delivery was carried out at the 38th week of pregnancy. The newborn was completely healthy. Ultima ratio therapeutic options for severe intracranial venous sinus thrombosis refractory to anticoagulation are discussed, with an emphasis on platelet-function inhibition.

Cerebral Venous Thrombosis Presenting in Early Pregnancy Complicated with Nausea and Vomiting: A Single-Institute Consecutive Case series and Literature Review

“…Our ndings are consistent with previous reports. Thrombosis of the deep venous cerebral system veins, internal cerebral veins, vein of Galen, or the straight sinus occurs in approximately 16% of patients with CVT and is considered a risk factor for poor clinical outcome [15]. Thalamic edema is the imaging hallmark of this condition.…”

“…Larger patient series with a longer follow-up are warranted to draw more de nitive conclusions on the subject. [9] 34 G3P2 8 N HG→headache,diplopia MRI/MRV RTS,SSS intravenous heparin→LMW Yam 2013 [10] 32 N/A 9 N head dullness→headache,fever→seizure CT MRI SSS,RTS, vein of Galen,SS dehydration Nie 2015 [11] 27 G2P1 5 N Headache, slurred speech CT,MRI/MRV,DSA LTS,LSS LMWH→warf Mae 2017 [12] 35 G5P1 8 N Seizures MRI/MRV SSS,RTS intravenous heparin→LMW Fen 2018 [13] 32 G2P1 10 N headache→Seizures→unconsciousness CT, MRI/MRV RTS,RSS LMWH Zha 2018 [14] 22 G1P0 10 migraine NVP,headache CT, MRI/MRV SSS,RTS LMWH→warf Ser 2019 [15] 34 G2P1…”

Cerebral venous thrombosis as a rare cause of nausea and vomiting in early pregnancy: Case series in a single referral center and literature review

“…We searched the Medline, Embase, and Google Scholar databases to identify all English literature published using the keywords "cerebral venous thrombosis", "intracranial venous thrombosis", "first-trimester pregnancy", "early pregnancy", alone or in combination. We reviewed all articles (including case reports, case series, and review articles), and this resulted in the inclusion of fourteen case reports with a total of 15 patients (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18).…”