Cerebral Venous Thrombosis after Autologous Stem Cell Transplantation

The incidence of venous thromboembolic events (VTE) after autologous stem cell transplantation is around 5 percent. However, in this setting the incidence of cerebral venous sinus thrombosis (CVST) is unknown.  Here we describe the first reported case of CVST after autologous stem cell transplantation in the literature. In our patient CVST greatly increased the morbidity of post-transplant care.

A 62 year old female underwent autologous stem cell transplantation for multiple myeloma, and at the time of transplant was in complete remission. On D+17, she developed acute encephalopathy.  A non-contrast computerized tomographic (CT) scan of the head revealed a thin focus of hyper attenuation along the right tentorium. Magnetic Resonance Imaging/Venography (MRI/MRV) head and brain revealed a dural sinus thrombosis involving the entire right transverse, sigmoid sinus and visible portions of right internal jugular vein, without venous infarct of the brain. CT images of chest and abdomen showed no additional clot extension and specifically, no clot on the central venous catheter. Patient was started on anticoagulation after which her mentation improved gradually over several weeks. Follow up MRI/MRV after two weeks of anticoagulation showed persistence of the dural clot, but no extension.  The patient was discharged to the outpatient environment with continued thrombosis on prolonged therapy and is currently D+145 from transplant.

Patients undergoing stem cell transplantation (SCT) have known risk factors for the development of VTE including the underlying malignancy, chemotherapy regimens, immobility during hospitalization and the use of central venous catheters.  CVST is an unusual complication following SCT and was heralded in this case by both dramatic clinical features and subtle findings on imaging. It is unclear if CVST is extremely rare or under-diagnosed post-transplant, and is a possible element in the differential diagnosis of confusion in this setting.  Once detected, the dural thrombus persisted despite prolonged anti-coagulation and steady improvement of patient's sentinel symptoms.

Fig 1: MRI/MRV head and brain with sinus thrombosis involving the right internal jugular vein (A), sigmoid sinus (B) and entire right transverse sigmoid sinus (C)