Utilization of modified digital subtraction angiography in a child with cerebral venous sinus thrombosis presenting with autism spectrum disorder symptoms: A novel approach

Ardianto Pramono , Ristaniah Soetikno, Achmad Hussein Sundawa Kartamihardja, Tinni Trihartini Maskoen, Terawan Agus Putranto, Erwin Setiawan

Ardianto Pramono
Department of Radiology, Universitas Padjajaran RSPAD Gatot Soebroto, Department of Interventional Radiology. Email:

Ristaniah Soetikno
Department of Radiology, Universitas Padjajaran

Achmad Hussein Sundawa Kartamihardja
Department of Radiology, Universitas Padjajaran

Tinni Trihartini Maskoen
Department of Radiology, Universitas Padjajaran

Terawan Agus Putranto
RSPAD Gatot Soebroto. Department of Interventional Radiology

Erwin Setiawan
Department of Radiology, Universitas Padjajaran RSPAD Gatot Soebroto, Department of Interventional Radiology
Online First: April 01, 2019 | Cite this Article
Pramono, A., Soetikno, R., Kartamihardja, A., Maskoen, T., Putranto, T., Setiawan, E. 2019. Utilization of modified digital subtraction angiography in a child with cerebral venous sinus thrombosis presenting with autism spectrum disorder symptoms: A novel approach. Bali Medical Journal 8(1): 322-327. DOI:10.15562/bmj.v8i1.1466

Background: The limited number of case reports about Cerebral Venous Sinus Thrombosis (CVST), especially in the pediatric population who also present with Autism Spectrum Disorders (ASD) symptoms, prompted the authors to be the pioneer in reporting of pediatric CVST with ASD symptoms case in Indonesia. In this study, we would like to report a case of an 8-year-old patient with ASD who was diagnosed with CVST after undergoing Magnetic Resonance Imaging (MRI) examination. After the diagnosis was established, the patient underwent a modified Digital Subtraction Angiography (DSA) method, which was later termed as Intra Arterial Heparin Flushing (IAHF) as its treatment option.

Case presentation: An 8-year-old-boy was brought by his parents to Gatot Soebroto Hospital with speech and communication problems, and also cognitive and behavioral problems such as the inability to count, read words, follow orders and maintain emotional stability. After a thorough standard examination by the attending physician, further examination using Magnetic Resonance Imaging with MR perfusion was suggested to establish a diagnosis. The imaging results showed a decrease in blood flow in the transverse sinus and straight sinus, and also in the internal jugular vein. The patient was diagnosed with CVST. The patient underwent anticoagulation therapy, which was administered through a modified DSA method, which was later termed as IAHF procedure, to increase the cerebral blood flow.

Conclusion: After the patient underwent the IAHF procedure, good clinical outcomes were immediately seen, even at six months follow up. The parents reported that there were improvements in the patient’s cognitive and behavioral status.


Moulton E, Bradbury K, Barton M, Fein D. Factor Analysis of the Childhood Autism Rating Scale in a Sample of Two Year Olds with an Autism Spectrum Disorder. J Autism Dev Disord. 2016. DOI: 10.1007/s10803-016-2936-9.

Sébire G, Tabarki B, Saunders DE, Leroy I, Liesner R, Saint-Martin C, et al. Cerebral venous sinus thrombosis in children: risk factors, presentation, diagnosis and outcome. Brain. 2005;128:477–89. DOI: 10.1093/brain/awh412.

Piazza G. Cerebral venous thrombosis. Circulation. 2012;125(13):1704-9. DOI: 10.1161/CIRCULATIONAHA.111.067835.

Carmeliet P. Angiogenesis in health and disease. Nat Med. 2003;9(6):653-60. DOI: 10.1038/nm0603-653.

Putranto TA, Yusuf I, Murtala B, Wijaya A. Intra arterial heparin flushing increases Manual Muscle Test–Medical Research Councils (MMT-MRC) score in chronic ischemic stroke patient. Bali Med J. 2016;5(2):216-220.

Tsai FY, Nguyen B, Lin WC, Hsueh CJ, Yen A, Meng K, Kostanian V. Endovascular procedures for cerebrovenous disorders. Acta Neurochir Suppl. 2008;101:83–86.

Barnes C, Newall F, Furmedge J, Mackay M, Monagle P. Cerebral sinus venous thrombosis in children. J Paediatr Child Health. 2004;40(1-2):53–55. DOI: 10.1111/j.1440-1754.2004.00291.x.

deVeber G, Andrew M, Adams C, Bjornson B, Booth F, Buckley DJ, et al. Cerebral sinovenous thrombosis in children. N Engl J Med. 2001;345(6):417–423. DOI: 10.1056/NEJM200108093450604.

Kenet G, Kirkham F, Niederstadt T, Heinecke A, Saunders D, Stoll M, et al. Risk factors for recurrent venous thromboembolism in the European collaborative paediatric database on cerebral venous thrombosis: a multicentre cohort study. Lancet Neurol. 2007;6(7):595–603. DOI: 10.1016/S1474-4422(07)70131-X.

Maguire JL, deVeber G, Parkin PC. Association between iron-deficiency anemia and stroke in young children. Pediatrics. 2007;120(5):1053–1057. DOI: 10.1542/peds.2007-0502.

Roach ES, Golomb MR, Adams R, Biller J, Daniels S, Deveber G, et al. Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke. 2008;39(9):2644–2691. DOI: 10.1161/STROKEAHA.108.189696.

Huisman TA, Holzmann D, Martin E, Willi UV. Cerebral venous thrombosis in childhood. Eur Radiol. 2001;11(9):1760-5. DOI: 10.1007/s003300100822.

Wasay M, Dai AI, Ansari M, Shaikh Z, Roach ES. Cerebral venous sinus thrombosis in children: A multicenter cohort from the United States. J Child Neurol. 2008;23(1):26–31. DOI: 10.1177/088307807307976.

Johnson MC, Parkerson N, Ward S, de Alarcon PA. Pediatric sinovenous thrombosis. J Pediatr Hematol Oncol. 2003;25(4):312-5.

Saposmik G, Barinagarrementeria F, Brown RD Jr, Bushnell CD, Cucchiara B, Cushman M, et al. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(4):1158-1192. DOI: 10.1161/STR.0b013e31820a8364.

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