2023 Volume 48 Issue 3 Pages 284-289
Although the therapeutic strategy for this drug is not well established, it causes well-known thrombotic complications, which can occasionally induce serious cerebral sinus thrombosis. L-asparaginase (L-Asp) is one of the many important drugs in multidisciplinary chemotherapy regimens for acute lymphoblastic leukemia (ALL). We present the case of a 17-year-old boy with ALL who received L-Asp chemotherapy in a multidisciplinary setting. The patient developed mild left hemiplegia 27 days after starting chemotherapy. Laboratory results revealed some abnormal values: fibrinogen, <50 (200-400 mg/dl); FDP, 18.0 (<5.0 µg/ml); antithrombin activity, 58 (80-130%); D-dimer, 5.0 (≤1.0 µg/ml); TAT, 8.1 (<4.0 ng/ml); protein C, 53 (82-112%); and protein S, 37 (67-164%). Diffusion-weighted images from magnetic resonance imaging revealed several high-intensity spots. We suspected thromboembolism and began anticoagulation therapy with heparin, as well as antithrombin and fresh frozen plasma replenishment. However, the patient developed generalized seizures and was in a comatose state 36 h after onset. A massive hemorrhage in the right parietal lobe was discovered using computed tomography, along with a midline shift and “empty delta sign” in SSS. We then determined that the patient had a hemorrhagic infarction caused by cerebral sinus venous thrombosis. In SSS, we performed external and internal decompression before performing endovascular mechanical thrombectomy. Following surgery, he received anticoagulant therapy as well as barbiturate coma therapy under normothermia. His neurological condition was given a score of 2 on the modified Rankin scale at his 6-month follow-up, with mild hemiparesis and independent daily activities. L-Asp metabolizes asparagine to aspartic acid and ammonia, eventually resulting in asparagine depletion. Because all cells lack asparagine synthase, asparagine depletion inhibits protein synthesis, causing the cells to undergo selective apoptosis. L-Asp has become an effective and important drug for treating ALL because of this mechanism. However, inhibiting protein synthesis also inhibits coagulation and fibrinolytic factor synthesis in the liver, which may cause thromboembolic side effects. As a result, careful monitoring and prompt correction of these factors are required. While cerebral sinus venous thrombosis caused by L-Asp has frequently been reported, few cases have been reported in patients who underwent surgical treatments for serious, major sinus occlusions. As a result, no treatment strategies for these cases have been developed. Because cerebral major sinus venous thrombosis has a poor prognosis, early diagnosis and aggressive treatment may be critical.
