A 27-year-old female presents to the Emergency Department after a collapse at work that was followed by a brief tonic-clonic seizure. She is 30 weeks pregnant with no previous pregnancies or other significant medical history. She currently localises bilaterally to painful stimulus but does not open her eyes or vocalise.
Her blood pressure is 170/50 mmHg, her urine analysis is unremarkable, and the cardiotocogram (CTG) is ‘reassuring’. A CT brain scan shows a sigmoid and transverse venous sinus thrombosis, with some temporal lobe parenchymal haemorrhage.
a) List the major risk factors, other than pregnancy, for this condition. (30% marks)
b) Briefly outline the management priorities for this patient? (70% marks)
Prothrombotic conditions – genetic or acquired Oral contraceptive
Parameningeal Infection e.g. ear, sinus
Autoimmune disease e.g. SLE, antiphospholipid
Other drugs e.g. androgens
o Consider intubation
o Check gas exchange (expect slight respiratory alkalosis)
o BP currently a bit on the high side, maybe careful hydralazine to SBP 140-160?
Specific therapy for cerebral venous sinus thrombosis
o Therapeutic anticoagulation
o Can use LMWH or UFH
o Intracranial haemorrhage with CVT is not a contraindication to anticoagulation
o Continued for remainder of pregnancy and usually for further 6-12 weeks postpartum
o Aspirin – no evidence of benefit. Occasionally used as alternative if firm CI to therapeutic anticoagulation
o Potential therapies include thrombolysis (systemic or catheter-directed), mechanical clot extraction, decompressive craniectomy
o Assess for underlying cause that may require specific therapy e.g.,
o May need an anticonvulsant; consider neurology input
o Involvement of obstetric service, regular CTG, ultrasound
o ? steroids to allow for early delivery if needed
o Shielding for X-ray and CT limit as able
o Blood conservation given physiological anaemia of pregnancy
o Need to keep family up to date
The following lisk of risk factors was compiled using UpToDate and Ferro et al (2004). The latter was a multinational multicentre observational study which identified 624 patients with confirmed CVT. Of this group, the following risk factors were observed:
The major approaches to fixing this problem are anticoagulation, thrombolysis, endovascular thrombectomy and open clot retrieval.
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