DISCUSSION:
Thrombocytopenia, one of the major blood disorders can be defined as the
level of platelets less than 1, 50,000 microliter in the blood. The
cause behind such decrease in platelet count from blood can be
categorized as either from decrease in production due to factors such as
as viral infections, vitamin deficiencies, aplastic anemia, drugs or
increase in destruction of platelets resulting from heparin-induced
thrombocytopenia, idiopathic , pregnancy, immune system. Along with it
sequestration due to splenomegaly, neonatal, gestational or pregnancy
related sequestrations are the major culprits. (10)Associated with
body’s immune system, immune thrombocytopenic purpura (ITP) is an
autoimmune disorder resulting from antibodies directed against the
platelets surface glycoprotein such as GPIIb/IIIa,GP Ib/IX complexes
along with certain role of T cell mediated cytotoxicity.(3),(4)Cerebral
venous sinus thrombosis is one the rarest entity causing cerebral
ischemia and is not mostly associated with blood disorders such as ITP.
Based upon what minimal evidence that exist in the medical literature
the cause behind the concurrent association of CVST in patient of ITP
could be due to platelet microparticles, a nano vesicle causing
increased thrombin formation,patient treated with IVIGs resulting in
increased blood viscosity and increased levels of von willebrand factor
antigen are some of the few studied fields.(11),(12)Regarding the
certain group of risk factors that could potentially result in CVST are
genetic thrombophilia, such as antithrombin deficiency, protein C
deficiency, or protein S deficiency, factor V Leiden mutation,
homocysteinemia, or acquired conditions like pregnancy and puerperium,
oral contraceptive pills, malignancy, or infections.(2)In terms of
patient presentation in cases of ITP , the patient usually presents with
bleeding diathesis from low platelet count such as petechiae , purpura
, and bleeding per mucosa along with platelet count less than
30 × 109/liter can result in fatal life threatening
bleedings.(13)In cases of CVST patient usually presents with headache of
various severity, nausea, vomiting, visual disturbances and in most
cases also the optic disc changes have been seen.(14)
The diagnosis of ITP is considered after exclusion of all other possible
secondary causes whereas the diagnosis of CVST is straightforward and
radiological imaging mostly magnetic resonance venography (MRV) and MR
imaging of the brain is the standard modality of diagnosis. Regarding
the management of ITP the primary goal is to maintain adequate level of
platelets and control the bleeding tendency. Prednisolone,
dexamethasone, and methylprednisolone is considered the baseline
management whereas in case of an emergency setting, intravenous
immunoglobulin and anti-D plays vital role in acutely raising the
platelets level and prevent patient deterioration.(15)Furthermore
American Society of Hematology recommends thrombopoetion receptor
agonist(TPO-RA) either romiplostim or eltrombopag as the second-line
therapy for people suffering from ITP who are corticosteroid-dependent
or resistant to corticosteroids for at least 3 months.(15)In case of
CVST systemic anticoagulation with low molecular weight heparin and
unfractionated heparin is considered standard modality of management
which can bring about good prognosis in symptomatic improvement and
drastic recanalization.(16),(17)In recent decade there has been rise in
the cases of venous thrombotic events such as CVST but very less number
of reports have talked about CVST in diagnosed cases of
ITP.(14),(18),(19),(20) In majority of such cases where CVST and ITP
co-exist pharmacological treatment has been prioritized but endovascular
intervention such as mechanical thrombectomy in selected patients can
also bring about fruitful prognosis.Furthermore a systematic review of
CVST described emergency mechanical thrombectomy as an effective salvage
therapy with a ratio of favorable outcomes (modified Rankin Scale
scores 0–2) of almost 80%.(21)There exist several endovascular
techniques for MT such as catheter thrombolysis, balloon-assisted
thrombectomy, stent retrievers and penumbra aspiration system with no as
such intervention guiding standard protocols to ascertain the
superiority of the different endovascular interventions. Our patient was
treated with a combination of stent retriever and direct aspiration
thrombectomy known as “Solumbra” technique.(22),(23) Patient selection
for such endovascular intervention is also a major dilemma and some of
the established indicators are failure of systemic anticoagulation,
extensive clot burden, cerebral edema, elevated intracranial pressure,
altered mental status and progressive worsening of neurological
symptoms.(21)In our case the major indicator was extensive clot burden
over multiple site and severe persisting headache. With appropriate
patient selection and timely intervention the desired prognosis was
achieved in our case.