Symptomatic upper-extremity deep vein thrombosis induced by reverse S-shaped distortion of a peripherally inserted central catheter due to post-craniotomy epilepsy following traumatic brain injury: a case report.

BACKGROUND: Upper-extremity deep vein thrombosis (UEDVT) is not uncommon in neurocritical patients with indwelling peripherally inserted central catheters (PICCs). Pharmacological anticoagulation following UEDVT poses a clinical challenge for these patients. Here, we present a rare mechanism contributing to UEDVT: distortion and deformation of a PICC line. A stepwise anticoagulation strategy was implemented while the PICC remained in situ.

CASE REPORT: A 79-year-old man underwent an urgent craniotomy to remove a massive traumatic subdural hematoma. A 4 Fr single-lumen PICC was inserted after surgery via the right basilic vein using ultrasound guidance. The catheter tip was correctly positioned, and the PICC line remained stable for the 1 week. In the 2 week, the patient experienced recurrent seizures. Subsequently, progressive swelling of the right upper limb developed, attributed to the formation of right UEDVT due to a reverse S-shaped distortion of the proximal PICC, which further induced systemic hypoalbuminemia and generalized gravity-dependent pitting edema. The PICC was patent and left in place. A cautious anticoagulation strategy was adopted, starting with nadroparin calcium at 4,100 IU once daily, then twice daily, and later switched to enoxaparin at 6,000 IU twice daily. Upon recanalization of the thrombus, the regimen was sequentially transitioned to rivaroxaban 20 mg once daily and maintained until discharge. No intracranial bleeding was observed during the anticoagulation therapy.

CONCLUSIONS: Epilepsy after traumatic brain injury can cause unexpected PICC distortion, markedly increasing UEDVT risk. If the catheter is still required and keeps patent, maintaining it in situ with carefully escalated anticoagulation may be a safe management strategy.