Concomitant Cerebral Venous Thrombosis and Intracranial Hemorrhages in Presentation of a Patient with Secondary Polycythemia: A Case Report

Abstract

BACKGROUND Cerebral ischemia and hemorrhages were reported to be the main complications of polycythemia vera (PV). The relationship between PV and increased risk of the cerebrovascular events has been established. Some patients with secondary polycythemia have thromboembolic events comparable to those of PV. However, secondary polycythemia that leads to cerebrovascular events is uncommon. CASE REPORT A 35-year-old man without any prior medical history presented with mild clinical acute ischemic stroke and polycythemia. The patient then showed worsening neurological deficits that were later attributed to the concurrent cerebral venous thrombosis, which led to malignant cerebral infarction with hemorrhagic transformation, and subarachnoid hemorrhage. His polycythemia appeared to be secondary to bacterial infection. The treatments for the secondary polycythemia were first phlebotomy and intravenous hydration, followed by intravenous broad-spectrum antibiotics. PV was excluded because the JAK2 V617F mutation was absent, the patient's peripheral blood smear suggested secondary polycythemia due to bacterial infection, and there were improvements in hemoglobin, erythrocyte count, and hematocrit after intravenous antibiotics. At the 1-month follow-up, he was moderately dependent, and hemoglobin, erythrocyte count, and hematocrit were within normal limits, without receiving any further phlebotomy or cytoreductive agents. CONCLUSIONS This case highlights the plausible causation of secondary polycythemia that could lead to concomitant cerebral thrombosis and hemorrhagic events. The diagnosis of cerebral venous thrombosis should be considered in a patient who presents with headache, focal neurological deficits, polycythemia, and normal head computed tomography scan.

Figure 1.

First non-contrast head CT scan. The patient’s first non-contrast head CT scan on the second day following his neurological deficits showed mild cerebral edema without any intracerebral infarction or hemorrhage, ASPECT score 10. Red arrows indicate cerebral edema.

Figure 2.

Second non-contrast head CT scan. The patient’s second non-contrast head CT scan on the 4^th day after his firs neurological deficits showing subarachnoid hemorrhage in right parietal region (green arrows), intracerebral hemorrhage in right basal ganglia (yellow arrows) that causes midline shift to the left, and cerebral infarction in right frontotemporoparietal regions (blue arrows) with ASPECT score 1.

Figure 3.

Brain MRA axial T2 showing cerebral infarction in right frontotemporoparietal regions (blue arrows) with hemorrhagic transformation in right basal ganglia (yellow arrows) without any midline shift.

Figure 4.

Brain MRA showing normal bilateral medial, anterior, and posterior cerebral arteries, vertebral arteries, anterior and posterior communicating arteries, internal carotid arteries, as well as basilar arteries, without aneurysms.

Figure 5.

Brain MRV showing non-visualization of left transverse and sigmoid sinuses with normal visualization of superior (orange arrow) and inferior sagittal sinuses (blue arrow), straight sinus (green arrow), and right transverse (red arrow) and sigmoid sinuses (yellow arrow).