Creeping Stroke - Venous thrombosis presenting with pc-stroke.pptx

A Case study of a patient with pc-stroke presentation that was found to be due to venous sinus thrombosis

1. Creeping Stroke Yasser A. Alzainy MSc. Assistant Lecturer of Neurology Al-Azhar University

2. I do not have any disclosures.

3. A 75-year-old man, hypertensive , compliant on treatment, presented to our emergency department with acute onset vertigo and blurry vision that persisted over the past 2 days. He reported receiving the booster dose (2 nd ) of Sputnik vaccine 1 week earlier. His examination revealed right horizontal nystagmus , normal head impulse test (central vertigo) and minimal ataxia on tandem gait. He was admitted to stroke unit after acquiring a brain CT with possible pc-stroke, started on DAPT and statin in addition to prophylactic anticoagulation . MRI brain was acquired the next day.

4. T1 T2 FLAIR

5. DWI ADC ?????

6. Gaillard F, Cerebral vascular territories (illustration). Case study, Radiopaedia.org (Accessed on 07 May 2024) https://doi.org/10.53347/rID-10814

7. He remained a total of 3 days at the hospital, during which he was vitally stable and his stroke workup was done: HbA1C = 5.8 LDL = 112 mg/dL ; TG = 78 mg/dL Chemistry = NL CBC = w/n NL except for mild decrease in PLT count = 146,000 / mm 3 ESR = 12 mm/h ; CRP = 4 mg/L Echocardiography : Normal Carotid duplex : Unremarkable PA U/S = enlarged prostate He was then discharged to home on DAPT , high dose statin and anti-vertiginous medication.

8. Six weeks later, he developed acute worsening of the previous symptoms in addition to numbness involving the left side of his face. He consulted a private physician who ordered another brain MRI and started the patient on ASA and neurotonics in addition to a 5-day course of Enoxaparin 60 IU qd . The patient reported gradual improvement of symptoms over the following few days.

9. T1 FLAIR

10. DWI ADC ?????

11. Four weeks later, the patient developed right side weakness associated with dysarthria , diplopia , facial asymmetry in addition to headache and vertigo . He presented to our hospital on days 3 and His examination revealed: Mildly elevated BP = 130/85, normal temperature and HR (ECG: NSR) Mid dysarthria (slurred speech) Right UMN VII and XII Right horizontal and upbeat nystagmus Right side weakness grade 0-1 Crossed hemihypesthesia (left face; right body) Left appendicular ataxia He was admitted and A brain MRI was acquired the next day.

12. T1

13. FLAIR

14. DWI

15. ADC

16. What would be your differential diagnosis for this case? What would be your diagnostic plan ? Imaging? Labs? Scarcity-Limited medical practice What treatment plan would you have this patient started on until you get your results? Why are the lesions strictly unilateral? ?!

17. FLAIR

18. The following workup was done: HbA1C = 5.9 LDL = 83 mg/dL ; TG = 62 mg/dL Chemistry = NL CBC = w/n NL except for mild decrease in PLT count = 137,000 / mm 3 ESR = 10 mm/h ; CRP = 5 mg/L D-dimer = 2800 ng/mL MRA and MRV Echocardiography: Normal Holter ECG (48 h): infrequent PVCs

19. MRA

20. MRV (source image)

21. MRV (reconstructed)

22. After the Imaging results, our working diagnosis was left transverse sinus thrombosis, and we started the patient on therapeutic anticoagulation and physiotherapy . After 5 days the patient has improved partially : Resolution of headache and vertigo Right side weakness improved to grade 3 His mRS was 4 He was discharged to home on Apixaban 5mg bid with gradual improvement over the following weeks. His mRS on 3-month f/u was 2

23. What about the culprit of VST? Diagnostic plan missing essentials? What could have been done better in the management of this case? ?!

24. Vaccine-induced Immune Thrombotic Thrombocytopenia Simultaneous acute thrombosis and thrombocytopenia . Similar to heparin-induced thrombocytopenia . Associated mainly with the AstraZeneca and Jansen COVID-19 vaccines. Usually 5-28 days post vaccination . VITT is extremely rare . 1.2-3.6 per million people after the AstraZeneca COVID-19 vaccine ~0.9 per million people after Johnson & Johnson vaccine. Diagnosis require testing for PF-4 antibodies. Main line of treatment is therapeutic anticoagulation and IVIG .

25. 6

26. References: Kuehnen J, Schwartz A, Neff W, Hennerici M. Cranial nerve syndrome in thrombosis of the transverse/sigmoid sinuses. Brain. 1998 Feb;121 ( Pt 2):381-8. doi : 10.1093/brain/121.2.381. PMID: 9549513. Greinacher A, Langer F, Makris M, Pai M, Pavord S, Tran H, Warkentin TE. Vaccine-induced immune thrombotic thrombocytopenia (VITT): Update on diagnosis and management considering different resources. J Thromb Haemost . 2022 Jan;20(1):149-156. doi : 10.1111/jth.15572. Epub 2021 Nov 10. PMID: 34693641; PMCID: PMC8646430. Herrera- Comoglio , R. and Lane, S., 2022. Vaccine-induced immune thrombocytopenia and thrombosis after the Sputnik V vaccine. New England Journal of Medicine, 387(15), pp.1431-1432.

27. Cerebral venous thrombosis can present with PC-syndrome . Suspect if there’s Patient with high risk for thrombosis Early neurological deterioration despite optical medical treatment Poor response on APT Imaging inconsistent with timing of symptoms or arterial vascular territories ? Utilization of anticoagulation in pc-stroke