Abstract
Background
Heparin-induced thrombocytopenia (HIT)-related cerebral venous sinus thrombosis (CVST) has been described in 10 prior case reports in the English language medical literature. We report the first case of low molecular weight HIT-related CVST with detailed clinical course and novel therapeutic approach.
Methods
A 69-year-old woman presented with a focal seizure after total hip replacement. Enoxaparin for venous thromboembolism prophylaxis had been initiated 8 days prior to the seizure.
Results
The patient experienced progressive neurologic deterioration, and MRI and CT angiography were consistent with cerebral sinus thrombosis (CVST). The new onset of thrombocytopenia, thrombosis, and positive heparin ELISA (enzyme-linked immunosorbent assay) and SRA (serotonin release assay) assays confirmed HIT. In spite of aggressive management of HIT-related CVST, including argatroban therapy and endovascular mechanical thrombolysis, the patient expired.
Conclusions
A review of the previous 10 case reports in the literature confirms that HIT-related CVST is often a fatal condition, particularly when diagnosed in comatose patients. Because the diagnosis is rare and often delayed relative to initial presentation, prevention is the key to improve patient outcomes. Newer anticoagulants with different mechanism of action than heparin are currently under review by the FDA; they will facilitate prevention of HIT-related CVST and other HIT-related neurological complications.
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References
Stevenson MM. Thrombocytopenia during heparin therapy. N Engl J Med. 1976;295(21):1200–1.
Van der Weyden M, Hunt H, McGrath K, et al. Delayed-onset heparin-induced thrombocytopenia. A potentially malignant syndrome. Med J Aust. 1983;2(3):132–5.
Calhoun BC, Hesser JW. Heparin-associated antibody with pregnancy: discussion of two cases. Am J Obstet Gynecol. 1987;156(4):964–6.
Kyritsis AP, Williams EC, Schutta HS. Cerebral venous thrombosis due to heparin-induced thrombocytopenia. Stroke. 1990;21(10):1503–5.
Meyer-Lindenberg A, Quenzel EM, Bierhoff E, et al. Fatal cerebral venous sinus thrombosis in heparin-induced thrombotic thrombocytopenia. Eur Neurol. 1997;37:191–2.
Pohl C, Klockgether T, Greinacher A, et al. Neurological complications in heparin-induced thrombocytopenia. Lancet. 1999;353:1678–9.
Warkentin TE, Bernstein RA. Delayed-onset heparin-induced thrombocytopenia and cerebral thrombosis after a single administration of unfractionated heparin. N Engl J Med. 2003;348(11):1067–9.
Refaai MA, Warkentin TE, Axelson M, Matevosyan K, Sarode R. Delayed-onset heparin-induced thrombocytopenia, venous thromboembolism, and cerebral venous thrombosis: a consequence of heparin flushes. Thromb Haemost. 2007;98:1139–40.
Fountas KN, Faircloth LR, Hope T, Grigorian AA. Spontaneous superior sagittal sinus thrombosis secondary to type II heparin-induced thrombocytopenia presenting as an acute subarachnoid hemorrhage. J Clin Neurosci. 2007;14(9):890–5.
Warkentin TE, Sheppard JI, Horsewood P, Simpson PJ, Moore JC, Kelton JG. Impact of the patient population on the risk for heparin-induced thrombocytopenia. Blood. 2000;96(5):1703–8.
Warkentin TE. Platelet count monitoring and laboratory testing for heparin-induced thrombocytopenia. Arch Pathol Lab Med. 2002;126:1415–23.
Warkentin TE. Clinical presentation of heparin-induced thrombocytopenia. Semin Hematol. 1998;35(suppl 5):9–16.
Sztajzel R, Coeytaux A, Dehdashti AR, Delavelle J, Sinnreich M. Subarachnoid hemorrhage: a rare presentation of cerebral venous thrombosis. Headache. 2001;41:889–92.
Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med. 2005;352(17):1791–8.
Baker MD, Opatowsky MJ, Wilson JA, et al. Rheolytic catheter and thrombolysis of dural venous sinus thrombosis: a case series. Neurosurgery. 2001;48(3):487–93.
Bauer KA, Eriksson BI, Lassen MR, Turpie A, Steering Committee of the Pentasaccharide in Major Knee Surgery Study. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after elective major knee surgery. N Engl J Med. 2001;345(18):1305–10.
Warkentin TE, Greinacher A, Koster A, Lincoff AM, American College of Chest Physicians. Treatment and prevention of heparin-induced thrombocytopenia: American college of chest physicians evidence-based clinical practice guidelines (8th Edition). Chest. 2008;133(6 Suppl):340S–80S.
Warkentin TE, Maurer BT, Aster RH. Heparin-induced thrombocytopenia associated with fondaparinux. N Engl J Med. 2007;356(25):2653–5.
Rota E, Bazzan M, Fantino G. Fondaparinux-related thrombocytopenia in a previous low-molecular-weight heparin (LMWH) induced heparin-induced thrombocytopenia (HIT). Thromb Haemost. 2008;99(4):779–81.
RE-MOBILIZE Writing Committee, Ginsberg JS, Davidson BL, Comp PC, Francis CW, Friedman RJ, et al. Oral Thrombin Inhibitor Dabigatran Etexilate vs North American Enoxaparin Regimen for Prevention of Venous Thromboembolism After Knee Arthroplasty Surgery. J Arthroplasty. 2009; 24(1):1–9.
Eriksson BI, Borris LC, Friedman RJ, et al. Rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty. N Engl J Med. 2008;358(26):2765–75.
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Fesler, M.J., Creer, M.H., Richart, J.M. et al. Heparin-Induced Thrombocytopenia and Cerebral Venous Sinus Thrombosis: Case Report and Literature Review. Neurocrit Care 15, 161–165 (2011). https://doi.org/10.1007/s12028-009-9320-y
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DOI: https://doi.org/10.1007/s12028-009-9320-y