322 Published by DiscoverSys | Bali Med J 2019; 8(1): 322-327 | doi: 10.15562/bmj.v8i1.1466 CASE REPORT ABSTRACT Open access: www.balimedicaljournal.org and ojs.unud.ac.id/index.php/bmj Utilization of modifed digital subtraction angiography in a child with cerebral venous sinus thrombosis presenting with autism spectrum disorder symptoms: A novel approach Ardianto Pramono 1,2* , Ristaniah Soetikno 1 , Achmad Hussein Sundawa Kartamihardja 1 , Tinni Trihartini Maskoen 1 , Terawan Agus Putranto 2 , Erwin Setiawan 1,2 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 modifed 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 fow 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 modifed DSA method, which was later termed as IAHF procedure, to increase the cerebral blood fow. 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. Keywords: autism spectrum disorder, cerebral venous sinus thrombosis, digital subtraction angiography, intra arterial heparin fushing Cite this Article: Pramono, A., Soetikno, R., Kartamihardja, A.H.S., Maskoen, T.T.M., Putranto, T.A., Setiawan, E. 2019. Utilization of modifed 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 1 Department of Radiology, Universitas Padjajaran 2 RSPAD Gatot Soebroto. Department of Interventional Radiology * Correspondence to: Ardianto Pramono; Department of Radiology, Universitas Padjajaran; ardianto@rspadgs.net Bali Medical Journal (Bali Med J) 2019, Volume 8, Number 1: 322-327 P-ISSN.2089-1180, E-ISSN: 2302-2914 Received: 2018-02-11 Accepted: 2018-02-26 Published: 2019-04-01 322 INTRODUCTION Currently, Autism Spectrum Disorder (ASD) is widely known as a complex problem, which is primarily found in children. We would like to report a case of a child who sufers from ASD symptoms since he was 18 months old. Tis case was interesting because brain Magnetic Resonance Imaging (MRI) examination showed decreased blood fow in the internal jugular vein, transverse and straight sinus, which was concluded as Cerebral Venous Sinus Trombosis (CVST). Tis case may provide more insight into the possibility of CVST that could lead to ASD presentation in pediatric patients since CVST with ASD presentation is rarely reported, especially in Indonesia. Te incidence rate of CVST in the pediatric population is 0.67 per 100,000 children per year. 3 Te reported incidence rate is 0.34 per 100,000 children per year when neonates are excluded. 4 Te clinical presentation in neonates is usually seizures or lethargy, while in older infants and children (similar to adults), the common presentations are seizures, altered levels of consciousness, headache with papilledema, isolated intracranial hypertension, or focal neurological defcits. Te known etiology of CVST in the pediatric population varies. In neonates, it could be caused by acute systemic illnesses such as shock or dehydration. However, in older children, local infection such as mastoiditis and coagulopathy could be the cause of CVST. In older children and adolescents, systemic lupus erythematosus, nephrotic syndrome, leukemia or lymphoma with l-asparaginase treatment, and trauma have been reported as causes of CVST. 5,6 Iron defciency anemia is also an established risk factor for CVST. 7 Unlike adult CVST, long-term outcomes of neonatal CVST have been estimated to be severe with disabilities. Te possibility of CVST as a predisposing risk factor for the developmental delay might be considered as up to 58% of patients had developmental delay, 28% had cerebral palsy,