Cerebral venous sinus thrombosis secondary to heparin-induced thrombocytopenia: a complex presentation managed with endovascular treatment (5143)

Objective: NA

Background: Heparin-induced thrombocytopenia (HIT) is a well-known phenomenon with potentially fatal side-effects caused by the immune system creating antibodies that activate platelets in the presence of heparin. This results in a prothrombotic state that can involve both the arterial and venous systems. A rare presentation of this includes cerebral venous sinus thrombosis (CVST). We report on this unique presentation and subsequent complicated treatment course in a patient who presented with an acute intractable headache found to be a HIT-associated CVST and ultimately underwent multiple rounds of endovascular treatment (EVT).

Design/Methods: NA

Results: A 44-year old male presented with a thunderclap headache, photophobia, dizziness, and decreased visual acuity. Five days prior to presentation, the patient had a percutaneous nephrolithotomy for a renal calculus and received heparin products for percutaneous nephrostomy (PCN) placement. CT imaging revealed an extensive clot in the sagittal system from the right sigmoid and transverse sinus extending to the right internal jugular. Blood test demonstrated a drop-in platelet count from 115,000 to 45,000. A heparin induced antibody with reflex serotonin release assay (SRA) came back positive, confirming HIT. Despite continuous infusion of bivalirudin, a subtherapeutic INR and persistent thrombocytopenia complicated the anticoagulation course. The patient underwent venous thrombectomy, however re-thrombosis of the venous sinuses occurred twice more, requiring venous thrombectomy a total of three times. He is currently maintained on warfarin and doing well.

Conclusions: CVST secondary to HIT is a rare presentation with a mortality rate of up to 4.39%. The non-specific clinical picture requires a high index of suspicion to diagnose and treat in a timely manner. Though EVT is not the first line of management for CVST, it could play an important role in improving the overall outcomes in a situation where standard medical management is subtherapeutic.

Disclosure: Miss Rana has nothing to disclose. Dr. Edwards has nothing to disclose. Miss Memon has nothing to disclose. Terri Yeager has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Portola Pharmaceuticals. Dr. Jovin has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Cerenovus. Dr. Jovin has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Contego Medical. Dr. Jovin has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Several law firms. Dr. Jovin has received stock or an ownership interest from Corindus. Dr. Jovin has received stock or an ownership interest from Methinks. Dr. Jovin has received stock or an ownership interest from Viz.ai. The institution of Dr. Jovin has received research support from Stryker. The institution of Dr. Jovin has received research support from Medtronic.