To report an adult patient with intracerebral hemorrhage (ICH) and delayed-onset of cerebral venous thrombosis (CVT) after pegaspargase therapy for B-cell acute lymphoblastic leukemia (ALL.) 

Asparaginase in treatment of ALL has been associated with venous thromboembolism, including CVT. Pegaspargase is a modified form of L-asparginase created by conjugation with polyethylene glycol, prolonging both half-life and decreasing immunogenicity. Pegaspargase might therefore cause late thrombosis and/or bleeding.

A 46 year-old-female with ALL underwent intrathecal methotrexate administration followed after four days by intravenous pegaspargase. Two days later she developed a new generalized tonic-clonic seizure and was found to have a large right intracranial hemorrhage with thrombocytopenia. MRI and MR venogram did not reveal CVT or cause of hemorrhage. Two and a half weeks later she developed sudden headache and aphasia due to contralateral parietal ICH. Evaluation revealed a new thromboses of the left cerebral transverse sinus and a deep vein in the calf. She was not thrombocytopenic at this time, nor did she have further chemotherapy between the first and second ICH. The second ICH was attributed to CVT due to the single dose of pegaspargase. Anticoagulation was started but she transitioned to hospice care.

Pegaspargase-related coagulation disorders can be associated with ICH and late CVT despite pegaspargase discontinuation.