Coexistent ipsilateral venous sinus thrombosis and arterial stroke in iron deficiency anemia

Abstract

Concomitant ipsilateral cerebral venous sinus thrombosis and arterial infarction are exceedingly rare clinical entity. We suggest that iron deficiency anemia caused the simultaneous affection of the two arterial beds. We report a 34-year-old right-handed male who presented with headache, vomiting, left hemiplegia and drowsiness. On arrival to ER, he had hypotension and sinus bradycardia necessitating inotropic support. He was drowsy and had signs of right middle cerebral artery involvement confirmed by unenhanced CT brain showing acute right temporo-parietal ischemic infarction. The investigations revealed anemia (Hb 8.8 g/dL, MCV 57.7fL), hypoferritinemia (<5 ng/mL) and hypochromic microcytic anemia suggesting iron deficiency anemia. Other investigations including inflammatory markers, bacterial cultures, anticoagulation profile, lipids, glycemic indices, Hb Electrophoresis, autoimmune markers including antiphospholipid syndrome, cryoglobulins, thrombophilia screen, viral markers for hepatitis B and C as well as HIV were negative. The echocardiogram and a pan CT abdomen and chest were unremarkable. A repeat CT brain on the same day revealed right middle cerebral artery territory infarction with hyperdense right transverse and sigmoid sinuses. CT cerebral angio- and venogram showed dural sinus thrombosis involving the right transverse and sigmoid sinuses, jugular bulb and proximal jugular vein along with linear filling defect at the origin of the right internal carotid artery. Later, he underwent decompressive hemicraniectomy. He received blood transfusions, iron supplementations and therapeutic anticoagulation. Inotropic support was weaned off gradually. Neurologically, residual hemiplegia prevailed.