Argatroban Resistance and Successful Adjunctive Anticoagulation for Cerebral Venous Sinus Thrombosis With Mutation: A Case Report.

OBJECTIVES

Anticoagulation therapy for cerebral venous sinus thrombosis (CVST) with antithrombin (AT) deficiency due to mutation does not often yield the expected outcomes. Argatroban may be effective for thrombophilia caused by mutation. However, argatroban resistance deserves attention.

METHODS

We report a case of a 19-year-old man who was admitted to the hospital with sudden headache, nausea, vomiting, and eye swelling for 3 days. Brain MRI on admission showed multifocal CVST.

RESULTS

mutation (exon1, c.40delA: [p.R14Gfs*17]) combined with hereditary AT deficiency (AT activity was 50% [reference range: 80%-120%]) was detected in this patient. A high dose of anticoagulation treatment with argatroban did not improve the activated partial thromboplastin time (APTT) level to the target range (1.5-3 times over the initial baseline level) for this case. We chose adjunctive anticoagulation (argatroban-combined low-molecular-weight heparin), and the APTT gradually reached the target level. At 3-month follow-up, no recurrence of headache or any systemic hemorrhage was found and the ultrasonography of the optic nerve sheath showed normal. Magnetic resonance black blood thrombosis imaging suggested thrombus absorption.

DISCUSSION

Argatroban resistance may be associated with thrombin receptor saturation and deserves attention. The use of adjunctive anticoagulants may be the optimum strategy during acute and subacute phases of CVST with AT deficiency due to mutation.