Presentation
Presents to ED with sudden right hemianopia and dysphasia on a background of 5 days of left-sided headache and tinnitus. On examination, the patient was GCS 13 and had left periorbital purpura.
Patient Data
Left temporo-parieto-occipital hematoma with intraventricular extension and likely small subdural extension, as suggested by high density material along the left side of the tentorium and the posterior falx cerebri. Subsequent rightward midline shift and early hydrocephalus, as indicated by dilated right temporal horn.
Hyperdensity of the left transverse sinus, left sigmoid sinus, and left internal jugular vein on non-contrast imaging, in conjunction with non-opacification of these structures on venogram, is consistent with cerebral venous sinus thrombosis. Hyperdensity and distension of the left superior ophthalmic vein on non-contrast imaging, with asymmetric opacification on venogram, suggests thrombosis. Non-opacification of the posterior left cavernous sinus is suspicious for further thrombosis.
Case Discussion
Blood tests revealed severe thrombocytopaenia (18 x 109/L) and significantly elevated D-Dimer (29000 ng/mL). Given a history of AstraZeneca COVID-19 vaccine 12 days prior to presentation, suspicion was raised for vaccine induced thrombotic thrombocytopaenia. Enzyme-linked immunosorbent assay (ELISA) detection of platelet factor 4 (PF4) antibodies confirmed the diagnosis.
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