Don't put a ring on it! cerebral venous thrombosis with the combined hormonal contraceptive NuvaRing

Abstract

Combined Hormonal Contraceptive (CHC) vaginal rings are used as an alternative to oral contraceptives with theoretical advantage of lower risk of thromboembolism. However, recent studies have shown that CHC vaginal rings may be as thrombogenic as oral forms. We present a case of complicated cerebral venous thrombosis (CVT) in a 29 year old using a vaginal contraceptive ring. A 29 year old woman presented to the emergency department with generalized seizure preceded by worsening headaches and left upper extremity weakness and numbness. Non-contrast CT revealed subarachnoid hemorrhage in bilateral frontal lobes. CT angiography revealed an occlusive thrombus within the superior sagittal sinus extending into the bilateral cerebral veins. MRI revealed infarcts in the adjacent cortices. The patient did not smoke and there was no history of prior vaso-occlusive events, hypercoagulable state, malignancy, infection or head trauma. Evaluation for inherited or acquired thrombophilia was negative. The patient was identified to have an etonogestrel/ethinyl estradiol vaginal ring (NuvaRing) for abnormal uterine bleeding. She was treated with intravenous heparin and later transitioned to Apixaban. The vaginal ring was removed. She was maintained on anti-convulsant medication and had no further seizures. At discharge, the patient had marked improvement with mild residual weakness and was ambulating independently. Combined Hormonal Contraceptive NuvaRing devices likely have prothrombotic potential comparable to oral contraceptives and increased recognition may promote earlier venous imaging and result in better clinical care and outcomes of stroke patients.