Cerebral Venous Sinus Thrombosis in a Patient With Ulcerative Colitis

Abstract

Patients with inflammatory bowel disease (IBD) are at a 3 to 8-fold increased risk of venous thromboembolism (VTE), including cerebral venous sinus thrombosis (CVT). Despite this increased risk of VTE, studies report an under use of VTE prophylaxis in patients with IBD. Here we present a case of a patient with newly-diagnosed IBD who developed a CVT with subsequent cerebral infarction. A twenty-one year-old woman with past medical history including HLA-B27 reactive arthritis presented with five days of bloody diarrhea associated with subjective fevers and abdominal pain. Physical exam showed diffuse abdominal tenderness. Laboratory tests included a CRP concentration of 21.3 mg/L. Cross-sectional imaging revealed bowel wall thickening from the rectum to the transverse colon. Differential included infectious vs. inflammatory colitis. On the second hospital day, the patient developed headache, expressive aphasia and right-sided hemiparesis. Subsequent MRI and MRV demonstrated multiple cerebral venous sinus thromboses with associated left frontal lobe infarct. Routine chemoprophylaxis for VTE had not been initiated on admission due to concern for active hematochezia.The patient was started on systemic anticoagulation and underwent emergent thrombolysis and thrombectomy. Subsequent flexible sigmoidoscopy demonstrated Mayo 3 colitis to the distal transverse colon with rectal sparing. The patient was started on IV methylprednisolone for suspected ulcerative colitis (UC). She has completed a six-month course of warfarin and her UC is now in remission on adalimumab and azathioprine. Fortunately, she has made a near-complete neurologic recovery. This case highlights the risk of VTE and the need to utilize VTE prophylaxis in hospitalized patients with IBD. CVT is more common in UC than in Crohn's disease patients. Complications such as acute increases in intracranial pressure can lead to cerebral herniation and death. Management includes prevention of cerebral herniation, systemic anticoagulation, and possible endovascular intervention. Theorized reasons for under use of VTE prophylaxis in IBD patients include failure to recognize the risk of VTE and concerns regarding gastrointestinal hemorrhage, though studies suggest this is safe. Increased awareness, along with standardized guidelines, might increase utilization of VTE prophylaxis and help prevent morbidity and mortality in this high-risk population.