2 cases of pegylated asparaginase-associated cerebral venous sinus thrombosis in children - clinical analysis and literature review

Sep 30, 2026

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Background Cerebral venous sinus thrombosis (CVST) is a serious complication in children with acute lymphoblastic leukemia (ALL) receiving pegylated asparaginase (PEG-Asp). This study investigates risk factors, clinical characteristics, and prognosis based on two affected pediatric cases and a systematic literature review. Methods Retrospective analysis covered symptoms, laboratory and imaging findings, treatments, and outcomes during induction remission therapy. Results Both patients developed CVST about two weeks after the first PEG-Asp dose with seizures, normal platelets, low fibrinogen and antithrombin III, and MRI/MRV-confirmed thrombosis with hemorrhage. Conclusion Regular coagulation monitoring and prompt MRI plus MRV for unexplained neurologic symptoms are critical.

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CategoryHealthcare

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Abstract

Introduction

Literature review methods

Chen et al. Thrombosis Journal (2026) 24:5 Thrombosis Journal [https://doi.org/10.1186/s12959-025-00822-9](https://doi.org/10.1186/s12959-025-00822-9) CASE REPORT Open Access 2 cases of pegylated asparaginase-associated cerebral venous sinus thrombosis in children: clinical analysis and literature review Meijun Chen1,2, Guanwen Lu3, Yongxian Huang2 and Zhengbin Hu2,4* Abstract Background Cerebral venous sinus thrombosis (CVST) is a serious complication in children with acute lymphoblastic leukemia (ALL) undergoing chemotherapy with pegylated asparaginase (PEG-Asp) . This study aims to investigate its risk factors, clinical features, and prognosis. Methods We retrospectively analyzed the clinical manifestations, laboratory findings, imaging characteristics, treatment, and outcomes of two pediatric ALL patients who developed CVST during induction remission therapy at our center. Additionally, a systematic literature review was conducted to contextualize our findings. Results Both children were treated per the CCCG-ALL-2020 protocol and developed CVST approximately two weeks after the first PEG-Asp dose, presenting with generalized tonic-clonic seizures. Notably, platelet counts were normal at presentation. Coagulation tests primarily showed decreased fibrinogen (FIB) and antithrombin III (AT-III) . Head magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) confirmed venous sinus thrombosis with hemorrhage. Management included fresh frozen plasma and fibrinogen infusion, mannitol for intracranial pressure reduction, and rivaroxaban for anticoagulation. Both patients recovered without recurrence of thrombosis upon subsequent PEG-Asp exposure. Conclusion During ALL chemotherapy involving PEG-Asp, regular monitoring of coagulation parameters (especially FIB and AT-III) is crucial. Unexplained neurological symptoms should raise suspicion for CVST, warranting prompt MRI + MRV. Anticoagulation with rivaroxaban was effective in these cases, yielding favorable outcomes. CVST complicating the induction phase of ALL requires heightened clinical awareness for early prevention, diagnosis, and treatment. Keywords Child, Acute lymphoblastic leukemia, Pegylated asparaginase, Cerebral venous sinus thrombosis, Rivaroxaban *Correspondence: Zhengbin Hu [hu_zhengbin2021@126.com](hu_zhengbin2021@126.com) 1Department of Pharmacy, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China 2Department of Hematology and Oncology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou 510623, China 3Department of Radiology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou 510623, China 4Guangzhou City Rescue Management Station Downtown Branch, Guangzhou 510599, China © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit [http://creati](http://cr

FAQs

When does CVST typically appear after pegylated asparaginase in these children?

In both reported cases, CVST developed approximately two weeks after the first PEG-Asp dose during induction remission therapy.

What laboratory and imaging findings supported the CVST diagnosis?

Platelet counts were normal at presentation. Coagulation tests showed decreased fibrinogen (FIB) and antithrombin III (AT-III), and MRI plus MRV confirmed venous sinus thrombosis with hemorrhage.

How were the children treated, and what was the outcome?

Management included fresh frozen plasma and fibrinogen infusion, mannitol for intracranial pressure reduction, and rivaroxaban for anticoagulation. Both children recovered without recurrence of thrombosis after subsequent PEG-Asp exposure.

Sep 30, 2026

Uploaded by Ben