Objective:

To describe the clinical course and management of a patient with myeloproliferative disorder presenting with multiple, concurrent neurovascular complications.

Background:

Patients with myeloproliferative disorders are at increased risk for both thrombotic and hemorrhagic events due to underlying coagulopathy. The simultaneous occurrence of subdural hemorrhage, arteriovenous fistula (AVF) with pseudoaneurysm, and dural venous sinus thrombosis (DVST) is rare and presents significant diagnostic and therapeutic challenges.

Design/Methods:

N/A

Results:

A 63-year-old male with myeloproliferative disorder on Jakafi presented with acute-on-chronic headache, nausea, and vomiting. Imaging revealed a 16 mm left holohemispheric subdural hemorrhage with 12 mm midline shift, requiring emergent decompressive hemicraniectomy and hematoma evacuation. Further evaluation identified a left middle meningeal artery AVF with pseudoaneurysm, treated with coiling and embolization. MRI showed a left occipital acute infarct, and CTV demonstrated left transverse and sigmoid sinus thrombosis. The patient’s prothrombotic state likely contributed to DVST, while chronic vascular injury and coagulopathy may have facilitated AVF and pseudoaneurysm formation. During his hospitalization, he remained alert and oriented but experienced delirium, visual hallucinations, and a seizure. The delirium resolved spontaneously and he was placed on Keppra for seizure prevention. Subsequently, he developed pulsatile tinnitus due to a new symptomatic left dural arteriovenous malformation, for which he underwent elective embolization of a left-sided dural AVF arising from the left occipital artery with venous drainage into the sigmoid sinus. The patient continues to receive multidisciplinary care, including anticoagulation and antiepileptic therapy, and remains clinically stable.

Conclusions:

 This case underscores the complex interplay of hemorrhagic and thrombotic neurovascular events in myeloproliferative disorders. Early recognition and coordinated multidisciplinary management are essential for optimizing outcomes in such multifaceted presentations.