Cerebral venous sinus thrombosis associated with spontaneous heparin-induced thrombocytopenia syndrome after total knee arthroplasty

Abstract

Spontaneous heparin-induced thrombocytopenia (HIT) syndrome, characterized by clinical and serologic features of HIT despite the absence of proximate heparin exposure, can be triggered by total knee arthroplasty (TKA). A 56-year-old female receiving aspirin thromboprophylaxis post-TKA presented with aphasia and thrombocytopenia on post-operative day 11. Imaging studies revealed cerebral venous sinus thrombosis (CVST) and intravenous bivalirudin was initiated. Her serum tested strong-positive for IgG anti-PF4/polyanion complexes and serotonin-release assay in the presence and absence of heparin; strong-positive IgG-specific chemiluminescent immunoassay; and moderate-positive latex immunoturbidimetric assay. Two 65 g doses of IVIG were administered. With the improvement of her platelet count, she was transitioned from bivalirudin to warfarin. At one-year follow-up, she remained free of recurrent thrombosis and neurologically stable with a normal platelet count. Previous reports of post-TKA spontaneous HIT syndrome include venous/arterial thrombosis and adrenal hemorrhage, and this report of CVST expands the clinical spectrum of this rare complication of orthopedic surgery.

KEYWORDS:

• Heparin-induced thrombocytopenia
• Cerebral venous sinus thrombosis
• Intravenous immunoglobulin

Declaration Of Interest

TEW has received lecture honoraria from Alexion and Instrumentation Laboratory and royalties from Informa (Taylor & Francis); has provided consulting services to Aspen Global, Bayer, CSL Behring, Ergomed, Instrumentation Laboratory, and Octapharma; has received research funding from Instrumentation Laboratory; and has provided expert witness testimony relating to HIT and non-HIT thrombocytopenic and coagulopathic disorders. AP has issued patents and pending patent applications in the area of HIT diagnosis, has equity ownership in Retham Technologies, and is on the advisory board of Veralox Therapeutics. He has also served as a consultant to Terumo BCT. RKP has received honoraria for attending advisory boards from: CSL Behring, Genentech Inc, Bayer Healthcare AG, HEMA Biologics, Instrumentation Laboratory and Merck. The other authors report no conflicts of interest.