Cerebral Sinovenous
Thrombosis (CSVT) is a serious complication of L-
asparaginase chemotherapy for
leukemia in children. Clinical features of
headache, altered consciousness, focal neurological deficit, and
seizures developing during or immediately
after treatment with L-
asparaginase should alert the treating physician to the possibility of CSVT. Immediate imaging of the brain should be done using CT and MRI and the veins should be visualized noninvasively by CT and MR venography. We report two children on induction
therapy for acute
leukemia who presented with
seizures,
headache, and altered consciousness. Venous
infarcts with and without
hemorrhage were seen on CT in one patient and the
empty delta sign was seen after contrast injection; however, the early changes were missed by CT. MRI detected dural
sinus thrombosis relatively earlier in another patient, while the CT findings were equivocal; in this patient, contrast-enhanced MRI showed the
empty delta sign and MR venography confirmed absent flow in the superior sagittal sinus, which was diagnostic of
sinus thrombosis. Rapid anticoagulation was started with
heparin and maintained with
warfarin. The child with a unilateral small nonhemorrhagic
infarct made a complete recovery while the other, with bilateral hemorrhagic
infarcts, did not survive. We stress the importance of early diagnosis of CSVT using CT and MRI in children with
leukemia being treated with L-
asparaginase; this will permit timely treatment.