Anticoagulated a bleeding patient? What?
Dr Himanshu Gul Mirani, Specialty Doctor, A&E, QMC, Nottingham
Nottingham University Hospitals, NHS Trust
Case Presentation:
Cerebral sinus thrombus is an uncommon and easily missed cause of stroke.
Approximately one third of these patients develop intracerebral hemorrhage.
A 57 year old male, with no past medical history, presented with atraumatic new right sided weakness in upper and lower limbs with aphasia. His CT scan revealed superior sagittal sinus thrombus with extensive intraparenchymal bleed with mass effect. Patient had a seizure while in the emergency department.
Extensive intraparenchymal bleed with local mass effect and hyperdense superior sagittal sinus
Management and Outcome:
He was treated with heparin for his cerebral thrombus. Levetiracetam was started as seizure prophylaxis.
Key Learning Points:
Prothrombotic conditions are the most common risk factors for cerebral venous thrombosis (CVT). It’s a common cause of stroke in the younger population. Venous stasis from the thrombus leads to increased venous and capillary pressure, leading to diapedesis of RBCs and subsequent rupture of the blood vessels, resulting in intraparenchymal hemorrhage. This hemorrhage does not conform to a particular arterial distribution. Patients with CVT without contraindications for anticoagulation should be treated with heparin. Interestingly concomitant ICH related to CVT is NOT a contraindication for heparin therapy.