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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