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-AzharUniversity

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 (2nd) 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 / mm3
• 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
?????

12. • 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 UMNVII 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 andA brain MRI was acquired the next day.

13. T1

14. FLAIR

15. DWI

16. ADC

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

20. FLAIR

21. • 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 / mm3
• ESR = 10 mm/h ; CRP = 5 mg/L
• D-dimer = 2800 ng/mL
• MRA and MRV
• Echocardiography: Normal
• Holter ECG (48 h): infrequent PVCs

22. MRA

23. MRV
(source
image)

24. MRV
(reconstructed)

25. • 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

30. 1. What about the culprit ofVST?
2. Diagnostic plan missing essentials?
3. What could have been done better in the management of
this case?
?!

31. Vaccine-induced ImmuneThromboticThrombocytopenia
• Simultaneous acute thrombosis and thrombocytopenia.
• Similar to heparin-induced thrombocytopenia.
• Associated mainly with the AstraZeneca and JansenCOVID-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.

34. 6

35. References:
• Kuehnen J, Schwartz A, NeffW, 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,WarkentinTE.Vaccine-induced immune
thrombotic thrombocytopenia (VITT): Update on diagnosis and management considering different
resources. JThromb 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 SputnikV vaccine. New England Journal of Medicine, 387(15), pp.1431-1432.

36. • 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