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.