2 Cases of Pegylated Asparaginase-Associated Cerebral Venous Sinus Thrombosis in Children: Clinical Analysis and Literature Review

Abstract Objective To investigate the risk factors and prognosis of cerebral venous sinus thrombosis (CVST) occurring in children with acute lymphoblastic leukemia (ALL) during chemotherapy with pegylated asparaginase (PEG-Asp). Methods The clinical manifestations, laboratory findings, imaging characteristics, treatment, and prognosis of two pediatric ALL cases complicated by CVST during induction remission therapy at Guangzhou Women and Children's Medical Center were retrospectively analyzed, and relevant literature was reviewed. Results (1) Both children were treated according to the CCCG-ALL-2020 protocol and developed CVST during the induction remission phase. CVST occurred approximately two weeks after the first PEG-Asp administration in both cases. The presenting symptom was generalized tonic-clonic seizure. Platelet counts were within the normal range. Coagulation tests showed insignificant prolongation of APTT, with decreased fibrinogen (FIB) and decreased antithrombin III (AT-III) being the main abnormalities. Head magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) revealed venous sinus thrombosis with hemorrhage. After treatment with infusion of fresh frozen plasma and fibrinogen to improve coagulation function, mannitol to reduce intracranial pressure, and rivaroxaban for anticoagulation, no further thrombosis occurred. CVST symptoms did not recur upon subsequent PEG-Asp administration. Conclusion During chemotherapy for ALL, especially when using PEG-Asp, regular monitoring of coagulation function is essential. Unexplained neurological symptoms often indicate possible CVST, warranting prompt cranial contrast-enhanced MRI and MRV for early diagnosis. Anticoagulation with rivaroxaban is effective for children developing CVST, resulting in a favorable prognosis without severe permanent neurological deficits. Greater clinical attention should be paid to CVST complicating the induction remission phase of ALL to enable early prevention, diagnosis, and treatment.