Spontaneous Epidural Hematomas due to Cerebral Venous Thrombosis in a Patient with Immune Thrombocytopenic Purpura

Cerebral venous sinus thrombosis in patient of immune thrombocytopenic purpura managed with mechanical thrombectomy: An anecdotal endovascular experience from lower middle income country

Cerebral venous sinus thrombosis in itself is rarely encountered clinical entity and its association with immune thrombocytopenic purpura (ITP) makes it more unusual presentation. No any as such standard guidelines exist that guides the prompt evidence based management in such concurrent cases but neuroendovascular modality can play a pivotal role.

Primary Cerebral Venous Thrombosis in a Patient with Immune Thrombocytopenic Purpura

Introduction

Immune thrombocytopenic purpura is an autoimmune hematological disorder characterized by low platelet level due to its destruction through autoimmune antibodies. Cerebral venous thrombosis is a serious condition defined by a thrombosis in the cerebral venous sinuses that occurs mostly in the presence of a hypercoagulable state. Hemorrhage and thrombosis are processes with a paradoxical etiology; thus, the association between these two conditions seems to be extremely rare. Case Presentation. We herein report a case of a 19-year-old female with a chief compliant of generalized tonic-clonic episode, severe headache, and blurred vision. Physical examination was significant for a bilateral Babinski's sign and severe bilateral papilledema. Laboratory workup, computed tomography, and magnetic resonance imaging were normal except for severe thrombocytopenia. Magnetic resonance venography was diagnostic for cerebral venous thrombosis. Her past medical history was significant for immune thrombocytopenic purpura that was treated with prednisolone 40 mg per day which posed a therapeutic challenge. High-dose prednisolone and platelet transfusion were initiated; enoxaparin was administrated and switched to warfarin after stabilization of platelet count. The patient was neurologically intact after 14 days of appropriate treatment and was on follow-up. Many hypotheses were suggested to explain the unexpected thrombotic events in a patient with immune thrombocytopenic purpura which were related to the disease etiology or treatment, taking into account common risk factors (such as age, obesity, smoking, hypertension, diabetes mellitus, dyslipidemia, splenectomy, and oral contraceptive agents).

Conclusion

The association between immune thrombocytopenic purpura (which is a major risk factor for bleeding) and cerebral venous thrombosis ( which is caused by a thromboembolic event )has carried a major challenge to the management plan. We believe that immune thrombocytopenic purpura and its treatment methods should be taken into consideration as risk factors for thromboembolic phenomenon.

Cerebral venous sinus thrombosis in immune thrombocytopenia patients treated with thrombopoietin receptor agonist: Case reports and literature review

Introduction and importance

Cerebral venous sinus thrombosis is an uncommon adverse event in immune thrombocytopenia (ITP) patients treated with thrombopoietin receptor agonists (TPO-RAs).

Case presentation

We reported two cases of cerebral venous sinus thrombosis after eltrombopag administration. The first case is a 29-year-old ITP woman who recently initiated eltrombopag one month before admission. She presented with progressive headache, visual disturbance, and nausea for six days with unremarkable physical examination except for bilateral optic disc edema. She was treated with enoxaparin and switched to edoxaban when discharged. The second case is a 75-year-old man with a history of vaccine-induced ITP. He was initially treated with dexamethasone and eltrombopag. One month later, he developed acute cerebral venous thrombosis with hemorrhagic infarction in the bilateral frontal lobes. Even though he was treated with intravenous heparin, his status was not improved. He received the best supportive care.

Discussion

The pathophysiology of TPO-RAs-associated cerebral venous sinus thrombosis remained unclear but might associate with platelet activation. Most cases of cerebral venous sinus thrombosis occur within two months, thus closed platelet monitoring is important.

Conclusion

Careful use and closed monitoring might prevent this event. Indications of initiation and tapering must be considered before TPO-RAs administration. Off-label use may enhance TPO-RA side effects.

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The rate of TPO-RA-associated CVT is increasing after the widespread use of TPO-RAs.

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Abnormal platelet activation may be the crucial factor for TPO-RA-associated CVT.

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Most cases of CVT occur within two months, thus closed monitoring is important.

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Before giving TPO-RAs, consider initiation and tapering indications.

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Off-label usage may unnecessarily increase the incidence of TPO-RAs adverse events.