Good Outcome Following Catastrophic Cerebral Sinus Thrombosis due to Heparin-Induced Thrombocytopenia: Case Report and Review of Literature

Anudariya Dean, Stephanie Zyck, Grahame Gould, Elena Schmidt and Julius Gene Latorre

College of Medicine, SUNY Upstate Medical University Hospital, USA
Department of Neurosurgery, SUNY Upstate Medical University Hospital, USA
Department of Neurosurgery, SUNY Upstate Medical University Hospital, USA
Department of Neurology and Neurosurgery, SUNY Upstate Medical University Hospital, USA
Department of Neurology and Neurosurgery, SUNY Upstate Medical University Hospital, USA

^*Correspondance to: Julius Gene Latorre 

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Abstract:

Introduction: Systemic anticoagulation with heparin is the primary treatment of acute cerebral venous sinus thrombosis (CVT). Treatment of CVT due to heparin-induced thrombocytopenic thrombosis (HITT) is a management conundrum. In the acute phase when continuous parenteral anticoagulant is necessary, argatroban, a direct thrombin inhibitor, has been used for HITassociated thrombosis. In cases of catastrophic CVT with severe neurologic compromise or when anticoagulation does not result in clinical improvement, the safety and efficacy of combination therapy with systemic anticoagulation, directed thrombolysis and thrombectomy is unknown.Case Report: We report a patient with catastrophic CVT due to HIT presenting with unresponsiveness. CT brain showed intracranial hemorrhage, cerebral edema, cerebral herniation and extensive cerebral sinus thrombosis. She was treated initially with argatroban and subsequently had decompressive craniectomy for intracranial hypertension. Cerebral angiography showed persistent sinus thrombosis despite systemic anticoagulation, endovascular thrombolysis and mechanical thrombectomy. Continuous intra-sinus alteplase infusion was started concurrently with systemic argatroban infusion x 24 hours. The patient made a remarkable recovery and achieved a mRS=1 in 6 months.Conclusion: Aggressive multimodal therapy with systemic anticoagulation, continuous intra-sinus thrombolytic infusion, mechanical thrombectomy and neurointensive treatment is a reasonable management option for patients with catastrophic CVT who failed initial anticoagulation therapy. Argatroban is an effective alternative when heparin is contraindicated.

Keywords:

Cerebral venous thrombosis; Heparin induced thrombocytopenia; Argatroban, Intrasinus thrombolysis; Mechanical thrombectomy

Cite the Article:

Dean A, Zyck S, Gould G, Schmidt E, Latorre JG. Good Outcome Following Catastrophic Cerebral Sinus Thrombosis due to Heparin-Induced Thrombocytopenia: Case Report and Review of Literature. Ann Clin Case Rep. 2018; 3: 1517.