Abstract The incidence of cerebral venous thrombosis (CVT) is estimated to be around three to four cases per million. Most common symptoms include headache, focal neurological deficit, seizure, mentation changes, or proptosis. Initial CT can rule out mass and hemorrhage. A combination of MR venography (MRV) with contrast and T2-weighted gradient-echo MRI has the highest specificity and sensitivity for demonstrating the absence of venous flow. Thrombophilia testing includes antithrombin, protein C and S, Factor V Leiden, Prothrombin, Antiphospholipid Syndrome, and homocysteine. We present a unique case of cavernous venous thrombosis in the setting of heparin-induced thrombocytopenia, complicated by diffused multifocal cerebral infarction. A 40-year-old Hispanic female with a history of HIV, noncompliant with medication, end-stage renal disease on peritoneal dialysis, presents with dry gangrene of the right third finger after a crush injury. Right upper extremity arteriogram with runoff showed atherectomy of the distal ulnar and palmar arch, with balloon angioplasty performed. A heparin drip was started. Seven days later, she had a precipitous drop of 80% in platelets with a nadir of 13,000/mcL. The heparin antibody test was positive, and the serotonin release assay confirmed the diagnosis of HIT. Heparin was stopped immediately and replaced with argatroban. She also developed a frontal and paranasal headache with proptosis. Focal motor neurological symptoms were observed. MRI of the brain and MRV showed diffuse intravascular venous thrombosis with multiple bilateral acute cerebral infarctions. Despite management, she developed severe cerebral edema and hemorrhagic transformation that led to brainstem herniation and death. HIT-induced CVT is rare, especially in the setting of diffuse intracerebral infarction. Management can be complex. No clear guidelines for acute ischemic stroke, nor CVT treatment, in the setting of HIT have been established. However, a systematic review of multiple clinical guidelines indicates consensus that all heparin products, including unfractionated and low-molecular-weight heparin, should be discontinued immediately. In cases of HIT with CVT or ischemic stroke, non-heparin anticoagulation should be initiated. Both the American Society of Hematology (ASH) and the American College of Chest Physicians (ACCP) endorse direct thrombin inhibitors (DTIs): argatroban, bivalirudin, or fondaparinux. In addition, vitamin K antagonists, specifically warfarin, should be avoided due to the risk of limb ischemia. This abstract is funded by: None
Yin et al. (Fri,) studied this question.