INTRODUCTION:
Among the cerebrovascular diseases cerebral venous thrombosis is considered one of the uncommon disease which can present in any age group and accounts for only 0.5% of all stroke cases.(1) Majority of risk factors that are associated with cerebral venous sinus thrombosis mostly have a common pathophysiological ground of prothrombotic state either transient or permanent and immune thrombocytopenic purpura also falls under that category .(2) Among the several causes of isolated thrombocytopenia immune thrombocytopenic purpura ( ITP) is an autoimmune disorder resulting from either increased destruction or decreased production of platelets associated with antibodies against platelets surface glycoproteins.(3)(4)The concurrent association of cerebral venou sinus thrombosis in patient of ITP is scarcely reported in medical literature along with it there is not any robust studied mechanism that explains the cause of CVST in patients of ITP. As far as from available evidences platelets microparticles (PMPs) which are tiny vesicles measuring less than 0.5 micrometer and stems from platelets membranes which further supports the formation of thrombus hence the chances of CVST. Studies have shown that the levels of PMPs are found to be in higher ranges in patient of ITP compared to other healthy individuals.(5)Regarding the management mostly the pharmacological modality such as IVIG, steroid therapy, platelet rich growth factors, anti coagulants and treatment of underlying cause are some of the major treatment means.(6)(7)There exist some studies (8)where mechanical thrombectomy have been done in CVST patients however in such rare cases where CVST resulted from ITP, the management from endovascular intervention have not been not noted well.This case has been written in accordance with SCARE guidelines .(9)
CASE SUMMARY :
A 25-year-old Asian Male was admitted to neuroscience department for headache. His past medical history was suggestive of diagnosed case of immuno thrombocytopenic purpura (ITP) under pharmacological treatment of Tab Dexamethasone 20 mg 4 days per week every alternate week since five months.Patient was also a known case of systemic hypertension but was not under regular anti hypertensive medications. Other medical and surgical history was unremarkable. . At arrival patient complaints of severe headache since 2 days, headache was diffuse in nature and more severe over bilateral frontal region, continuous, persisting, not relieved on taking over the counter medications and associated with sever bilateral periorbital pain. Vitals at the presentation were within normal range. There was no other history of dizziness, nausea,vomiting, weakness of limbs, abnormal body movement, slurring of speech, deviation of angle of mouth, bowel and bladder incontinence and trauma. On further examination neurologically GCS of the patient was 15/15, pupils were bilateral reactive to light and no other significant systemic findings. On Laboratory tests for full blood count, coagulation profile, and C-reactive protein, D-dimer remained normal limits except his platelets count was 67,500 .Patient still complained of persisting headache hence was initially managed conservatively with IV analgesics. On further investigation magnetic resonance venography (MRV) showed features suggestive of extensive dural sinus venous thrombosis i.e complete occlusion of superior saggital sinus, right transverse sinus, right straight sinus and right jugular vein . Furthermore venous congestion was also present along with venous drainage from bilateral superficial middle cerebral vein to cavernous sinus to inferior petrosal sinus to left jugular vein. A total body CECT was not done to rule out venous thrombosis in other sites however no symptoms suggesting thrombosis of other organs were apparent. Due to the clinical suspect of CVST , dexamethasone (40 mg i.v. daily for 4 days), and INJ Enoxaparin 60 mg subcutaneously twice day was started . A subsequent brain MR imaging further confirmed the diffuse cerebral venous thrombosis . The neuroradiologist suggested a neuroendovascular treatment and after a collegial discussion, we decided to proceed after platelet transfusion. Thrombectomy was performed both with aspiration using large bore aspiration catheter and with multiple embricated stent-retrievers. At the beginning of the procedure 6 vessel angio run off was done which was followed by thromobaspiration with cat-6 under 10 F guiding. After many passages, superior saggital sinus was completely opened, right transverse sinus, right straight sinus was also completely opened.Trolard and labbe vein appear draining to superior saggital sinus and right transverse sinus. Straight sinus was partly opened.At the end of the procedure, day 0, the patient was admitted in ICU where he stayed for 2 days. Screening tests for congenital and acquired thrombophilia was suggested to the patient. In the subsequent days his platelet levels fluctuated between 70,000 to 80,000.Symptomatically the severity of headache was on decreasing trend. CT head was repeated at the time of discharge which do not showed any features of hemorrhage, infarction. Patient was discharged from our center after complete free of headache and without any neurological and motor deficits.
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