The challenge of anticoagulation in sinus venos thrombosis: case report

*Correspondence: [e-mail].

Abstract

Case Presentation: P.H.S, 14 years old, previously healthy, with acute headache and hypotension. Progressed with right dimidium hemiparesis within 24 hours. Neuroimaging-cranial tomography was performed, suggesting the hypothesis of ischemic stroke. Subsequent nuclear magnetic resonance imaging of the skull identified venous sinus thrombosis (CSVT) with hemorrhagic venous infarcts, and anticoagulant treatment was initiated with enoxaparin 1mg/kg/dose 12/12 hours. Three days later, he started with chest pain, a chest image showed pulmonary thromboembolism. Anticoagulation has been maintained since the onset of the condition. In the etiological investigative process, alteration in antiphospholipid antibody was identified with the hypothesis of antiphospholipid antibody syndrome.

Discussion: CSVT is a rare form of stroke with a high mortality rate. The incidence is higher in women of reproductive age. After the occurrence of a CSVT event, there is an increase in venular pressure and liquor absorption, culminating in an increase intracranial pressure, cytotoxic and vasogenic edema, generating local hemorrhagic infarction. Diagnosis is through neuroimaging, with angiography being the gold standard. As our case, the signs and symptoms are diverse, headache predominating. Early recognition and treatment improve outcome in these patients. Anticoagulation with low molecular weight heparin (LMWH) is the treatment and endovascular thrombolysis is still controversial. Intracranial hemorrhage is not considered a contraindication to the use of anticoagulants. The literature recommends anticoagulation with LMWH for at least 5-10 days, followed by warfarin or LMWH for a minimum of 3 to 6 months for children. The etiological screening must be carried out in search of infectious, cardiac, neoplastic, rheumatological diseases, exogenous intoxication, and hematological conditions in the acute phase of the condition have no investigative value. In the reported case, anticoagulation with LMWH was initiated from diagnosis and maintained for 3 months. A transition to oral warfarin was attempted, without success. Regarding prophylactic antiepileptic therapy, although controversial, the literature claims to be beneficial and levetiracetam was used in this case. Surveillance of these patients is recommended due to the increased risk of recurrence of thrombotic conditions.

Final Comments: CSVT is rare. The clinical presentation is variable, the diagnosis is based on neuroimaging and anticoagulation should be started as soon as possible.

Publication History

Article published online:
12 May 2025