Trombosis venosa cerebral puerperal: implicaciones neurocríticas de un caso clínico

CRITICAL CARE & EMERGENGY MEDICINE VOL. 6

Puerperal cerebral venous thrombosis: neurocritical implications of a clinical case

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www.doi.org/10.58281/ccem.v6i2.10

Omar Mendoza 1, 2 , Vanessa Campozano 1, 2 , Ralph Naranjo 1, 2 , Xavier Montenegro 4 , Oswaldo Bolaños 2, 3 .

1 Unidad de terapia intensiva, Hospital General Guasmo Sur, Guayaquil-Ecuador.
2 Universidad de Especialidades Espíritu Santo, Guayaquil, Ecuador
3 Unidad de terapia intensiva, Hospital Clínica San Francisco, Guayaquil-Ecuador.
4 Médico radiólogo, Cerid, Guayaquil-Ecuador.

Abstract

Background: Cerebral venous thrombosis (CVT) is an uncommon cerebrovascular emergency with heterogeneous clinical expression. During pregnancy and the puerperium, early recognition is challenging because neurologic symptoms overlap with obstetric and neurocritical differential diagnoses.

Case presentation: We report a 30-year-old woman in the immediate puerperium after emergency cesarean delivery complicated by placenta accreta, hypovolemic shock and hysterectomy, who developed akinetic mutism and bilateral brachial paresis during intensive care unit hospitalization. Brain computed tomography, magnetic resonance imaging and venous magnetic resonance angiography demonstrated bilateral frontoparietal cortico-subcortical lesions consistent with venous infarction and involvement of cortical venous branches.

Intervention and outcome: Neurocritical support, electroencephalographic evaluation and anticoagulation were implemented, initially with enoxaparin and subsequently with apixaban after individualized thrombotic and hemorrhagic risk assessment. The patient improved progressively, reaching Glasgow Coma Scale 13/15 at discharge and complete functional recovery at follow-up.

Conclusion: Puerperal CVT should be suspected in critically ill postpartum patients with unexplained neurologic deterioration. Early neuroimaging confirmation and multidisciplinary management may be associated with favorable neurologic outcome.

Introducción: La trombosis venosa cerebral (TVC) es una emergencia cerebrovascular infrecuente, de presentación clínica heterogénea, cuyo reconocimiento en el embarazo y puerperio exige alta sospecha clínica por la coexistencia de cefalea, crisis epilépticas, alteración del sensorio o déficits focales con diagnósticos diferenciales obstétricos y neurocríticos.

Presentación del caso: Se presenta el caso de una mujer de 30 años en puerperio inmediato poscesárea complicada por placenta acreta, choque hipovolémico e histerectomía, quien durante la estancia en unidad de cuidados intensivos desarrolló mutismo acinético y paresia braquial bilateral. La tomografía cerebral, la resonancia magnética y la angiorresonancia documentaron lesiones cortico-subcorticales frontoparietales bilaterales compatibles con infarto venoso y compromiso de ramas venosas corticales de la convexidad cerebral.

Intervención y evolución: El abordaje integró soporte neurocrítico, evaluación electroencefalográfica y anticoagulación, inicialmente con enoxaparina y posteriormente con anticoagulación oral directa con apixabán según balance clínico de riesgo trombótico y hemorrágico. La paciente presentó recuperación progresiva, con Glasgow 13/15 al alta y recuperación funcional completa en el seguimiento ambulatorio.

Conclusión: El caso subraya que la TVC puerperal debe considerarse ante deterioro neurológico no explicado en pacientes obstétricas críticas. La sospecha temprana, la confirmación por neuroimagen y el manejo multidisciplinario se asociaron con evolución neurológica favorable.

Cerebral venous thrombosis; postpartum period; pregnancy;
neurocritical care; anticoagulation.

Omar Mendoza  
Unidad de terapia intensiva, Hospital General Guasmo Sur, Guayaquil-Ecuador.
Universidad de Especialidades Espíritu Santo, Guayaquil, Ecuador

 Vanessa Campozano   
Unidad de terapia intensiva, Hospital General Guasmo Sur, Guayaquil-Ecuador.
Universidad de Especialidades Espíritu Santo, Guayaquil, Ecuador

Ralph Naranjo  
Unidad de terapia intensiva, Hospital General Guasmo Sur, Guayaquil-Ecuador.
Universidad de Especialidades Espíritu Santo, Guayaquil, Ecuador

Xavier Montenegro  
Médico radiólogo, Cerid, Guayaquil-Ecuador.

Oswaldo Bolaños  
Universidad de Especialidades Espíritu Santo, Guayaquil, Ecuador
Unidad de terapia intensiva, Hospital Clínica San Francisco, Guayaquil-Ecuador.

  1. Herrera-Salgado J, et al. Cerebral venous thrombosis in obstetrics: literature review and clinical case reports. Rev. med. Hosp. Gen. Méx. 2024; 87(2).

  2. Hussein A, et al. Cerebral venous sinus thrombosis in pregnancy and puerperium A comprehensive review. Brain Circulation. 2022; 8(4).

  3. Gazioglu S, et al. Cerebral venous sinus thrombosis in pregnancy and puerperium. Acta Neurol Belg. 2021; 121(967–72).

  4. Gokey R, et al. Venous Sinus Thrombosis StatPearls. Treasure Island (FL) StatPearls Publishing. 2022; 1.

  5. Roeder H, et al. Ischemic stroke and cerebral venous sinus thrombosis in pregnancy. Handb Clin Neurol. 2020; 172(3–31).

  6. Ferro J, et al. Cerebral venous thrombosis: An update. Curr Neurol Neurosci Rep. 2019; 19(74).

  7. Silvis S, et al. Postpartum period is a risk factor for cerebral venous thrombosis. Stroke. 2019; 50(501–3).

  8. Idiculla P, et al. Cerebral venous thrombosis: A comprehensive review. Eur Neurol. 2020; 83(369–79).

  9. Coutinho J, et al. Effect of endovascular treatment with medical management versus standard care on severe cerebral venous thrombosis: The TO-ACT randomized clinical trial. JAMA Neurol. 2020; 77(966–73).

  10. Bajko Z, et al. Postpartum Cerebral Venous Thrombosis A Single-Center Experience. Brain Sci. 2021; 11(3).

  11. Kashkoush A, et al. Cerebral venous sinus thrombosis in pregnancy and puerperium: A pooled, systematic review. J. Clin. Neurosci. 2017; 39(9–15).

  12. Cantú C, et al. Cerebral venous thrombosis associated with pregnancy and puerperium. Stroke. 1993; 24(1880–1884).

  13. Dmytriw A, et al. Cerebral venous thrombosis: State of the art diagnosis and management. Neuroradiology. 2018; 60(669–685).

  14. Feher G, et al. Do we have to anticoagulate patients with cerebral venous thrombosis? Int. Angiol. 2016; 35(369–373).

  15. Ferro J, et al. RE-SPECT CVT Study Group. Safety and Efficacy of Dabigatran Etexilate vs. Dose-Adjusted Warfarin in Patients with Cerebral Venous Thrombosis: A Randomized Clinical Trial. JAMA Neurol. 2019; 76(1457–1465).

  16. Ferro J, et al. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis-endorsed by the European Academy of Neurology. European Stroke Organization. Eur. J. Neurol. 2017; 24(1203–1213).

  17. Ghoneim A, et al. Imaging of cerebral venous thrombosis. Clin Radiol. 2020; 75(4).

[1] Mendoza, O. Campozano V, Naranjo R, Montenegro X, Bolaños O. Trombosis venosa cerebral puerperal: implicaciones neurocríticas de un caso clínico. Critical Care & Emergency Medicine, 6(2).
https://doi.org/10.58281/ccem.v6i2.10
PDF

Licencia

© 2025 Critical Care & Emergency Medicine by Ediciones Prado. This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0) .

Licencia Creative Commons CC BY 4.0

The copyrights of the articles published in Critical Care & Emergency Medicine belong to Ediciones Prado. The contents of the articles that appear in the Journal are exclusively the responsibility of the authors and do not necessarily reflect the opinions of the Editorial Committee of the Journal. It is allowed to reproduce the material published in Critical Care & Emergency Medicine without prior authorization for non-commercial use.

ISSN

2992-6785

eISSN: 2992-6785
DOI: 10.3989/ccem

Indexación

Patrocinadores

www.doi.org/10.58281/ccem.v6i2.10

Omar Mendoza 1, 2 , Vanessa Campozano 1, 2 , Ralph Naranjo 1, 2 , Xavier Montenegro 4 , Oswaldo Bolaños 2, 3 .

1 Unidad de terapia intensiva, Hospital General Guasmo Sur, Guayaquil-Ecuador.
2 Universidad de Especialidades Espíritu Santo, Guayaquil, Ecuador
3 Unidad de terapia intensiva, Hospital Clínica San Francisco, Guayaquil-Ecuador.
4 Médico radiólogo, Cerid, Guayaquil-Ecuador.

Abstract

Background: Cerebral venous thrombosis (CVT) is an uncommon cerebrovascular emergency with heterogeneous clinical expression. During pregnancy and the puerperium, early recognition is challenging because neurologic symptoms overlap with obstetric and neurocritical differential diagnoses.

Case presentation: We report a 30-year-old woman in the immediate puerperium after emergency cesarean delivery complicated by placenta accreta, hypovolemic shock and hysterectomy, who developed akinetic mutism and bilateral brachial paresis during intensive care unit hospitalization. Brain computed tomography, magnetic resonance imaging and venous magnetic resonance angiography demonstrated bilateral frontoparietal cortico-subcortical lesions consistent with venous infarction and involvement of cortical venous branches.

Intervention and outcome: Neurocritical support, electroencephalographic evaluation and anticoagulation were implemented, initially with enoxaparin and subsequently with apixaban after individualized thrombotic and hemorrhagic risk assessment. The patient improved progressively, reaching Glasgow Coma Scale 13/15 at discharge and complete functional recovery at follow-up.

Conclusion: Puerperal CVT should be suspected in critically ill postpartum patients with unexplained neurologic deterioration. Early neuroimaging confirmation and multidisciplinary management may be associated with favorable neurologic outcome.

Introducción: La trombosis venosa cerebral (TVC) es una emergencia cerebrovascular infrecuente, de presentación clínica heterogénea, cuyo reconocimiento en el embarazo y puerperio exige alta sospecha clínica por la coexistencia de cefalea, crisis epilépticas, alteración del sensorio o déficits focales con diagnósticos diferenciales obstétricos y neurocríticos.

Presentación del caso: Se presenta el caso de una mujer de 30 años en puerperio inmediato poscesárea complicada por placenta acreta, choque hipovolémico e histerectomía, quien durante la estancia en unidad de cuidados intensivos desarrolló mutismo acinético y paresia braquial bilateral. La tomografía cerebral, la resonancia magnética y la angiorresonancia documentaron lesiones cortico-subcorticales frontoparietales bilaterales compatibles con infarto venoso y compromiso de ramas venosas corticales de la convexidad cerebral.

Intervención y evolución: El abordaje integró soporte neurocrítico, evaluación electroencefalográfica y anticoagulación, inicialmente con enoxaparina y posteriormente con anticoagulación oral directa con apixabán según balance clínico de riesgo trombótico y hemorrágico. La paciente presentó recuperación progresiva, con Glasgow 13/15 al alta y recuperación funcional completa en el seguimiento ambulatorio.

Conclusión: El caso subraya que la TVC puerperal debe considerarse ante deterioro neurológico no explicado en pacientes obstétricas críticas. La sospecha temprana, la confirmación por neuroimagen y el manejo multidisciplinario se asociaron con evolución neurológica favorable.

Cerebral venous thrombosis; postpartum period; pregnancy;
neurocritical care; anticoagulation.

Omar Mendoza  
Unidad de terapia intensiva, Hospital General Guasmo Sur, Guayaquil-Ecuador.
Universidad de Especialidades Espíritu Santo, Guayaquil, Ecuador

 Vanessa Campozano   
Unidad de terapia intensiva, Hospital General Guasmo Sur, Guayaquil-Ecuador.
Universidad de Especialidades Espíritu Santo, Guayaquil, Ecuador

Ralph Naranjo  
Unidad de terapia intensiva, Hospital General Guasmo Sur, Guayaquil-Ecuador.
Universidad de Especialidades Espíritu Santo, Guayaquil, Ecuador

Xavier Montenegro  
Médico radiólogo, Cerid, Guayaquil-Ecuador.

Oswaldo Bolaños  
Universidad de Especialidades Espíritu Santo, Guayaquil, Ecuador
Unidad de terapia intensiva, Hospital Clínica San Francisco, Guayaquil-Ecuador.

  1. Herrera-Salgado J, et al. Cerebral venous thrombosis in obstetrics: literature review and clinical case reports. Rev. med. Hosp. Gen. Méx. 2024; 87(2).

  2. Hussein A, et al. Cerebral venous sinus thrombosis in pregnancy and puerperium A comprehensive review. Brain Circulation. 2022; 8(4).

  3. Gazioglu S, et al. Cerebral venous sinus thrombosis in pregnancy and puerperium. Acta Neurol Belg. 2021; 121(967–72).

  4. Gokey R, et al. Venous Sinus Thrombosis StatPearls. Treasure Island (FL) StatPearls Publishing. 2022; 1.

  5. Roeder H, et al. Ischemic stroke and cerebral venous sinus thrombosis in pregnancy. Handb Clin Neurol. 2020; 172(3–31).

  6. Ferro J, et al. Cerebral venous thrombosis: An update. Curr Neurol Neurosci Rep. 2019; 19(74).

  7. Silvis S, et al. Postpartum period is a risk factor for cerebral venous thrombosis. Stroke. 2019; 50(501–3).

  8. Idiculla P, et al. Cerebral venous thrombosis: A comprehensive review. Eur Neurol. 2020; 83(369–79).

  9. Coutinho J, et al. Effect of endovascular treatment with medical management versus standard care on severe cerebral venous thrombosis: The TO-ACT randomized clinical trial. JAMA Neurol. 2020; 77(966–73).

  10. Bajko Z, et al. Postpartum Cerebral Venous Thrombosis A Single-Center Experience. Brain Sci. 2021; 11(3).

  11. Kashkoush A, et al. Cerebral venous sinus thrombosis in pregnancy and puerperium: A pooled, systematic review. J. Clin. Neurosci. 2017; 39(9–15).

  12. Cantú C, et al. Cerebral venous thrombosis associated with pregnancy and puerperium. Stroke. 1993; 24(1880–1884).

  13. Dmytriw A, et al. Cerebral venous thrombosis: State of the art diagnosis and management. Neuroradiology. 2018; 60(669–685).

  14. Feher G, et al. Do we have to anticoagulate patients with cerebral venous thrombosis? Int. Angiol. 2016; 35(369–373).

  15. Ferro J, et al. RE-SPECT CVT Study Group. Safety and Efficacy of Dabigatran Etexilate vs. Dose-Adjusted Warfarin in Patients with Cerebral Venous Thrombosis: A Randomized Clinical Trial. JAMA Neurol. 2019; 76(1457–1465).

  16. Ferro J, et al. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis-endorsed by the European Academy of Neurology. European Stroke Organization. Eur. J. Neurol. 2017; 24(1203–1213).

  17. Ghoneim A, et al. Imaging of cerebral venous thrombosis. Clin Radiol. 2020; 75(4).

[1] Mendoza, O. Campozano V, Naranjo R, Montenegro X, Bolaños O. Trombosis venosa cerebral puerperal: implicaciones neurocríticas de un caso clínico. Critical Care & Emergency Medicine, 6(2).
https://doi.org/10.58281/ccem.v6i2.10
PDF

Licencia

© 2025 Critical Care & Emergency Medicine by Ediciones Prado. This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0) .

Licencia Creative Commons CC BY 4.0

The copyrights of the articles published in Critical Care & Emergency Medicine belong to Ediciones Prado. The contents of the articles that appear in the Journal are exclusively the responsibility of the authors and do not necessarily reflect the opinions of the Editorial Committee of the Journal. It is allowed to reproduce the material published in Critical Care & Emergency Medicine without prior authorization for non-commercial use.

ISSN

2992-6785

eISSN: 2992-6785
DOI: 10.3989/ccem

Indexación

Patrocinadores

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