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. 2023 Apr 21;21(1):46.
doi: 10.1186/s12959-023-00490-7.

Cerebral venous sinus thrombosis associated with SRA-negative heparin-induced thrombocytopenia: case report

Floyd D Silva  1 , Allison E Burnett  2 , Anand Padmanabhan  3 , Marian A Rollins-Raval  1   4 , Noah P Splinter  3 , Masoom J Desai  5   6
Affiliations

Cerebral venous sinus thrombosis associated with SRA-negative heparin-induced thrombocytopenia: case report

Floyd D Silva et al. Thromb J. .

Abstract

Background: There are very few documented reports in literature of cerebral venous sinus thrombosis (CVST) caused by immune-mediated heparin-induced thrombocytopenia (HIT). Further, there are very few reports of false negative serotonin release assays (SRAs) when testing for immune-mediated HIT.

Case presentation: We present a case of a 60- year-old male with recent unfractionated heparin administration for venous thromboembolism prophylaxis, an elevated 4T score of 5 and acute CVST in which immune-mediated HIT was suspected. The enzyme-linked immunosorbent assay (ELISA) screening assay was positive for PF4 antibodies and subsequent reflexive SRA testing was negative. However, given the clinical picture, a false-negative SRA was suspected (and eventually confirmed), prompting use of the alternative PF4-dependent p-selectin expression assay (PEA) which was confirmed to be positive. The patient was successfully managed with a bivalirudin infusion and eventually transitioned to apixaban.

Conclusion: It is uncommon for immune-mediated HIT with thrombosis to manifest as CVST. Similarly, false-negative SRA is uncommon in immune-mediated HIT. Take-away lessons from our case report include considering HIT in CVST patients with an elevated 4T score and considering the entire clinical picture and degree of suspicion for HIT when interpreting negative HIT testing results. The PEA, in conjunction with the 4Ts score, may be considered as an alternate diagnostic assay for HIT.

Keywords: Heparin-induced thrombocytopenia. Cerebral venous sinus thrombosis. Serotonin release assay. Case report. P-selectin expression assay. Anticoagulation. 4T score..

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Conflict of interest statement

AP reports pending/issued patents (Mayo Clinic, Retham Technologies, and Versiti BloodCenter of Wisconsin), equity ownership in and serving as an officer of Retham Technologies, and member of the advisory board of Veralox Therapeutics. All other authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Coronal view, sagittal view, and axial view of MR Venogram of head without contrast demonstrating non-visualization of flow related signal within the super sagittal, right sigmoid and right transverse sinuses consistent with venous sinus thrombosis (Day 22)
Fig. 2
Fig. 2
Digital Subtraction Angiogram on day 23 showing microcatheter positioned in middle 1/3rd of superior sagittal sinus and extensive occlusive clot distal to the catheter
Fig. 3
Fig. 3
Timeline of patient clinical and laboratory findings. Unfractionated heparin at 5000U TID SubQ from Day 1–23; bivalirudin 250 mg [0.13 mg/kg/hr] + NaCl 0.9% (Infusion) from Day 23–32; Apixaban 5 mg BID from Day 32. SDH: Subdural hemorrhage; AMS: Altered mental status; CVST: cerebral venous sinus thrombosis; HIT: Heparin Induced Thrombocytopenia; SRA: serotonin release assay; PEA: P-selectin expression assay; PF4: Platelet Factor 4
See this image and copyright information in PMC

References

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