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Management of a decompensated acute-on-chronic intracranial venous sinus thrombosis

A 34-year-old female patient presented during the 10th week of her second gravidity with headache, nausea and vomiting 2 weeks before admission. Her medical history was remarkable for a heterozygous factor V Leiden mutation, elevated lipoprotein A, and a cerebral venous thrombosis (CVT) after oral c...

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Autores principales: Serna Candel, Carmen, Hellstern, Victoria, Beitlich, Tania, Aguilar Pérez, Marta, Bäzner, Hansjörg, Henkes, Hans
Formato: Online Artículo Texto
Lenguaje:English
Publicado: SAGE Publications 2019
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6931136/
https://www.ncbi.nlm.nih.gov/pubmed/31903097
http://dx.doi.org/10.1177/1756286419895157
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author Serna Candel, Carmen
Hellstern, Victoria
Beitlich, Tania
Aguilar Pérez, Marta
Bäzner, Hansjörg
Henkes, Hans
author_facet Serna Candel, Carmen
Hellstern, Victoria
Beitlich, Tania
Aguilar Pérez, Marta
Bäzner, Hansjörg
Henkes, Hans
author_sort Serna Candel, Carmen
collection PubMed
description A 34-year-old female patient presented during the 10th week of her second gravidity with headache, nausea and vomiting 2 weeks before admission. Her medical history was remarkable for a heterozygous factor V Leiden mutation, elevated lipoprotein A, and a cerebral venous thrombosis (CVT) after oral contraceptive intake 15 years before. Magnetic resonance imaging (MRI) suggested acute and massive intracranial sinus thrombosis. Despite full-dose anticoagulation, the patient deteriorated clinically and eventually became comatose. Now, MRI/magnetic resonance angiography revealed vasogenic edema of both thalami, of the left frontal lobe, and of the head of the caudate nucleus, with venous stasis and frontal petechial hemorrhage. She was referred for endovascular treatment. Diagnostic angiography confirmed a complete superficial and deep venous sinus occlusion. Endovascular access to the straight and superior sagittal sinus was possible, but neither rheolysis nor balloon angioplasty resulted in recanalization of the venous sinuses. Monitored heparinization was continued and antiaggregation was initiated. The patient remained comatose for another 5 days and MRI showed progress of the cytotoxic edema. On day 6, infusion of eptifibatide at body-weight-adapted dosage was started. The following day, the patient improved and slowly regained consciousness. MRI confirmed regression of the edema. The eptifibatide infusion was continued for a total of 14 days. Thereafter two doses of 180 mg ticagrelor per os (PO) daily were started. The patient remained on acetylsalicylic acid (ASA), ticagrelor, and enoxaparin on an unchanged dosage regimen. She was discharged home 26 days after the endovascular treatment without serious neurological deficit, with the pregnancy intact. At the 30th week of pregnancy the dosage of ASA was reduced to 300 mg once PO daily. Cesarian delivery was carried out at the 38th week of pregnancy. The newborn was completely healthy. Ultima ratio therapeutic options for severe intracranial venous sinus thrombosis refractory to anticoagulation are discussed, with an emphasis on platelet-function inhibition.
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spelling pubmed-69311362020-01-03 Management of a decompensated acute-on-chronic intracranial venous sinus thrombosis Serna Candel, Carmen Hellstern, Victoria Beitlich, Tania Aguilar Pérez, Marta Bäzner, Hansjörg Henkes, Hans Ther Adv Neurol Disord Case Report A 34-year-old female patient presented during the 10th week of her second gravidity with headache, nausea and vomiting 2 weeks before admission. Her medical history was remarkable for a heterozygous factor V Leiden mutation, elevated lipoprotein A, and a cerebral venous thrombosis (CVT) after oral contraceptive intake 15 years before. Magnetic resonance imaging (MRI) suggested acute and massive intracranial sinus thrombosis. Despite full-dose anticoagulation, the patient deteriorated clinically and eventually became comatose. Now, MRI/magnetic resonance angiography revealed vasogenic edema of both thalami, of the left frontal lobe, and of the head of the caudate nucleus, with venous stasis and frontal petechial hemorrhage. She was referred for endovascular treatment. Diagnostic angiography confirmed a complete superficial and deep venous sinus occlusion. Endovascular access to the straight and superior sagittal sinus was possible, but neither rheolysis nor balloon angioplasty resulted in recanalization of the venous sinuses. Monitored heparinization was continued and antiaggregation was initiated. The patient remained comatose for another 5 days and MRI showed progress of the cytotoxic edema. On day 6, infusion of eptifibatide at body-weight-adapted dosage was started. The following day, the patient improved and slowly regained consciousness. MRI confirmed regression of the edema. The eptifibatide infusion was continued for a total of 14 days. Thereafter two doses of 180 mg ticagrelor per os (PO) daily were started. The patient remained on acetylsalicylic acid (ASA), ticagrelor, and enoxaparin on an unchanged dosage regimen. She was discharged home 26 days after the endovascular treatment without serious neurological deficit, with the pregnancy intact. At the 30th week of pregnancy the dosage of ASA was reduced to 300 mg once PO daily. Cesarian delivery was carried out at the 38th week of pregnancy. The newborn was completely healthy. Ultima ratio therapeutic options for severe intracranial venous sinus thrombosis refractory to anticoagulation are discussed, with an emphasis on platelet-function inhibition. SAGE Publications 2019-12-24 /pmc/articles/PMC6931136/ /pubmed/31903097 http://dx.doi.org/10.1177/1756286419895157 Text en © The Author(s), 2019 https://creativecommons.org/licenses/by-nc/4.0/ This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
spellingShingle Case Report
Serna Candel, Carmen
Hellstern, Victoria
Beitlich, Tania
Aguilar Pérez, Marta
Bäzner, Hansjörg
Henkes, Hans
Management of a decompensated acute-on-chronic intracranial venous sinus thrombosis
title Management of a decompensated acute-on-chronic intracranial venous sinus thrombosis
title_full Management of a decompensated acute-on-chronic intracranial venous sinus thrombosis
title_fullStr Management of a decompensated acute-on-chronic intracranial venous sinus thrombosis
title_full_unstemmed Management of a decompensated acute-on-chronic intracranial venous sinus thrombosis
title_short Management of a decompensated acute-on-chronic intracranial venous sinus thrombosis
title_sort management of a decompensated acute-on-chronic intracranial venous sinus thrombosis
topic Case Report
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6931136/
https://www.ncbi.nlm.nih.gov/pubmed/31903097
http://dx.doi.org/10.1177/1756286419895157
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