The appearance of cerebral venous sinus thrombosis (CVST) in childhood acute lymphocytic leukemia (ALL) is a rare life-threatening disease that can cause significant morbidity, neurological sequelae, and potentially poor outcomes.
We present the case of a 13-year-old boy with ALL who developed CVST and intrinsic hemorrhage approximately 30 days after receiving chemotherapy with vincristine, dexamethasone, daunorubicin, and pegylated-asparaginase (PEG-Asp). He complained of a severe headache and then developed a generalized seizure at night. T1- and T2-weighted magnetic resonance imaging (MRI) and cerebral magnetic resonance venography sequences revealed superior sagittal sinus thrombosis and intrinsic hemorrhagic changes in the bilateral frontoparietal lobes. He received nadroparin calcium as the anticoagulant treatment and was switched to Erwinia asparaginase (Erwinia Asp) rather than PEG-Asp. Oxcarbazepine and clonazepam were started with good seizure control. Intrathecal treatment was delayed until 1 month later. Anticoagulation treatment was stopped for 24 h before and 6 h after lumbar puncture. Platelet transfusion was administered to ensure the platelet count remained at >50 × 109/L. Oral acetazolamide (500–1,000 mg, daily) was administered to relieve headache and reduce intracranial pressure. Three months later, brain MRI showed a complete resolution of or significant improvement in the filling defect. Nadroparin calcium was administered for 1 week after switching to Erwinia Asp to prevent clot recurrence. He completed the 6-month chemotherapy and is doing well with no neurological sequelae and no recurrence of bleeding or thrombosis.
Nadroparin calcium therapy appears to be safe and effective for pediatric CVST with ALL. The reintroduction of Erwinia Asp should be accompanied by anticoagulant therapy with nadroparin calcium