Heparin
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Thrombocytopenia and thrombus in an elderly patient: case report A 75-year-old woman developed thrombocytopenia during cardiac surgery, and developed a thrombus in her cerebral artery during catheter angiography, in association with heparin therapy. The woman, who was enrolled in a study on the prevalence of heparin-induced thrombocytopenia in cardiovascular patients, underwent aortic valve replacement, mitral valve plasty, and right coronary artery bypass surgery, using heparin anticoagulation [dosage not stated]. Immediately after surgery, her platelet count decreased from 159 to 40 × 103 cells/µL. The woman underwent a platelet transfusion, and her platelet count returned to 168 × 103 cells/µL. Her warfarin therapy was restarted on postoperative day 7. She suddenly developed right conjugate deviation, sensory disturbance of the left side of her body, and left hemiplegia 2 days later. The INR of her prothrombin time was 1.52. An occlusion of the horizontal portion of her right middle cerebral artery was shown on cerebral angiography 3 hours later. She underwent mechanical clot disruption using a microcatheter tip and wire with heparin-included media [dose not stated]. A long threadlike thrombus suddenly formed within the whole infracallosal segment of her right anterior cerebral artery 30 minutes later. After a further 30 minutes, the thrombus occluded her right anterior cerebral artery. The angiography was stopped immediately. An MRI scan revealed hyperintense lesions in her right middle and anterior cerebral arteries. Heparin-induced thrombocytopenia was suspected as the cause of her thrombus formation and heparin was discontinued; argatroban was initiated. Cardiac thrombi were not evident on transoesophageal echocardiography 2 days later. Positive heparin-induced thrombocytopenia antibodies were detected in blood samples obtained before and after surgery and on the day of her stroke. Author comment: "The different clinical features of [heparin-induced thrombocytopenia] seen in the two episodes (thrombocytopenia during cardiac surgery and thrombosis without thrombocytopenia after stroke) might be a result of the different heparin doses and routes of administration . . . [W]arfarin therapy given with no direct thrombin inhibitor might also have contributed to the events." Kawano H, et al. Thrombus formation during cerebrovascular catheterization in heparin-induced thrombocytopenia. Neurology 67: 361-362, No. 2, 25 Jul 2006 801043316 Japan
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Reactions 26 Aug 2006 No. 1116
